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INTRODUCTION: Coccidioidomycosis is an infection caused by the dimorphic environmental fungus Coccidioides immitis. Rapid progression of coccidioidoidal pneumonia is unusual in an immunocompetent host. We present the case of a 46-year-old agricultural worker who presented with fever, lymphadenopathy, and abnormal outpatient chest X-ray, who was found to have coccidioidomycosis which developed into a necrotizing pneumonia with Acinetobacter baumannii coinfection. CASE PRESENTATION: Patient is a 46-year-old male with previous cigarette smoking who presented after one week of left flank pain, fever, chills, drenching sweats, 10-pound weight loss in 1 month, and abnormal outpatient CXR. The patient was born in Mexico and had not returned for 15 years. He had occupational exposure to agricultural pesticides, as well as a remote history of incarceration and methamphetamine abuse. He was HIV-negative and was not on immunosuppressant drugs. He had no improvement in symptoms with outpatient amoxicillin-clavulanate and came to the emergency room. Admission CT chest showed mediastinal and left hilar lymphadenopathy and left lower lobe consolidation. He went for bronchoscopy with endobronchial ultrasound guided fine needle aspiration, transbronchial biopsies, and bronchoalveolar lavage. Respiratory cultures grew A. baumannii and the patient was started on meropenem. Station 7 lymph node FNA and LLL biopsy showed mild chronic inflammation and no malignancy. Patient had positive QuantiFERON-Gold with all AFB stains and cultures negative. He failed to improve after 5 days, and repeat CT chest showed rapidly evolving necrotizing features of the LLL consolidation. He went for thoracotomy with left lower lobectomy, left upper lobe wedge resection, and partial pericardial resection. Pleural biopsies and resected lung tissue grew C. immitis. Initial bronchoscopy BAL and station 7 lymph node FNA also later grew C. immitis. The patient was started on fluconazole and completed meropenem, with clinical improvement. Other cultures and fungal serologies were normal. He was eventually discharged home to complete a course of fluconazole, along with plans for later treatment of latent tuberculosis.

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