Coccidioidomycosis and erythema nodosum in pregnancy

Introduction: Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, viral, bacterial or fungal infections such as coccidioidomycosis. Other causes include sarcoidosis, inflammatory bowel disease, cancers, pregnancy/hormone related, idiopathic, and medication side effects. Diagnosing the primary cause of this skin manifestation may help a clinician find the underlying disease. Case Report: A 24­year­old, gravida 1, para 1, 8 weeks pregnant Mexican­ American female living in Phoenix Arizona presented with symptoms of shortness of breath of 2 weeks duration. She complained of shortness of breath, pleuritic chest pain, and persistant productive cough. She also developed new painful lesions on her lower extremities that were found to be erythema nodosum. Coccidioidomycosis IgM and IgG serologies were positive. She was started on amphoteracin B 5 mg/kg IV three days/week for four weeks and her skin lesions and respiratory symptoms subsided within a few days. At the start of her second trimester of pregnancy she was switched to fluconazole 400 mg PO for four more weeks. Conclusion: Coccidioidomycosis during pregnancy shows a more favorable outcome when erythema nodosum is present. Therapy for this fungal infection remains to be based on expert opinion. Amphoteracin B is considered relatively safe in pregnancy, and there is insufficient evidence for the safety of fluconazole. Keeping high clinical suspicion of coccidioidomycosis for patients who present with erythema nodosum in the south­west United States, especially in pregnant patients with respiratory symptoms, will help clinicians not miss this commonly seen fungal disease.