Disseminated coccidioidomycosis in a patient managed with adalimumab for Crohn's disease

Background. A 50-year-old man presented with a 2-3month history of left lower quadrant abdominal pain, right periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain, and a 32kg weight loss over the past year. He had a 34-year history of complicated Crohn's disease that was notable for surgical stricture repair and partial colectomy for bowel perforation. The patient was receiving mesalazine and 6-mercaptopurine and, 2 months before admission, had stopped a 4-month therapy course with the biologic agent adalimumab for treatment of Crohn's disease.Investigations. Physical examination, brain and elbow MRI scans, chest CT scan, routine blood analyses, assessment of coccidioidomycosis antibody levels, immunodiffusion and complement fixation studies in serum and cerebrospinal fluid, full-body technetium-99m nuclear bone scan, hematoxylin and eosin staining of resected tissue specimens.Diagnosis. Disseminated coccidioidomycosis with meningeal, bone, soft tissue and pulmonary involvement.Management. The patient underwent treatment with amphotericin B liposomal complex and oral fluconazole and right elbow surgical debridement and irrigation. All immunosuppressive therapy was stopped.