Pain Management

Background: Coccidioidomycosis is caused by Coccidioides immitis and by C posadasii, approximately 60-65% of cases are asymptomatic, however, it may present with fever, sore throat, cough, headache, fatigue, and pleuritic chest pain. Here we present a case of back pain who was found to have an aneurysm, he was later found to have coccidioidomycosis. The only other risk factor that could have possibly contributed to this presentation was hypertension. Case: This is a 59-year-old male who presented with acute worsening chronic back pain which apparently started after he twisted his back while playing golf. On admission his blood pressure was elevated at 175/99 mm Hg, he was afebrile with a temp of 97.7°F, pulse was 59/min, respiratory rate was 16/min and SpO2 was 99% on room air. Physical exam was remarkable for Paraspinal tenderness at L4-L5 level. Labs were significant for initial troponin of 0.09. Initial EKG showed T wave inversion in the inferior leads. So the decision was made to start heparin, aspirin and carvedilol. Cardiology performed cardiac catheterization which showed mild, nonobstructive CAD with EF of 60% as well as an ascending aortic aneurysm without dissection. So we ordered computed tomography (CT) angiogram which showed ascending aorta pulmonary artery measuring 5.3 x 5.2 cm. There was no previous CT chest for comparison. Cardiothoracic surgery recommended outpatient follow up with CT in three months. Two days after the discharge of the coccidioidomycosis antibody test was positive with titer reactive at 1:2. A prescription for four weeks of fluconazole was then provided in the view of the diagnostic results. Discussion: The various etiological factors of ascending aortic aneurysms include Marfan syndrome, type IV Ehlers-Danlos syndrome, atherosclerosis, bacterial [mycotic or syphilitic], arteritis (i.e., giant cell, Takayasu, Kawasaki, Behçet), and trauma. Coccidioidomycosis has never been reported to have caused thoracic aneurysm making this a rare case. Even though underlying hypertension increases the risk of an aneurysm, the presence of coccidioidomycosis at the time of its discoverymakes it a possible etiological factor in this patient.