The man beat cancer years ago. Why was there a mass in his lungs?
Visit to the Dude ranch
The patient was a slim, energetic man who looked younger than his 62 years, Azar noted when he met the man the following week. Informed by the biopsy results, the infectious disease specialist asked the patient the same questions the CDC asked about his recent travel. Has he been to the Midwest or South in the last year? Maybe around the Mississippi or Ohio river valleys?
Yes, answered the patient, but not for decades. But, he added, he spent a few days at a dude ranch in Arizona a few weeks before he got sick. The pneumonia had been terrible, but he felt fine now. Azar felt a moment of satisfaction: He was in Arizona just before he got sick? This was probably coccidioidomycosis. And yet the CDC thought it was a blast. Azar had to be sure what he was treating. Blastomycosis was a much more serious disease than coccidioidomycosis and required much longer treatment. He sent a tissue sample taken from the man’s lung to the CDC for genetic identification of the yeast. Meanwhile, Azar gave the man an antifungal drug, itraconazole, which worked against both types of yeast.
It took weeks for the results to come back. But they finally had a definitive answer: it was coca.
Relieved to be cleared of a possible cancer diagnosis, the patient hopped on the Internet to read about Valley Fever. It was all over Arizona. His sister-in-law later reminded him that there was a sick card in the rooms of the dude ranch they visited every year for the last 30 years or so. He quickly found the Valley Fever Center of Excellence at the University of Arizona-Tucson College of Medicine, just a few miles from the dude ranch. It was set up to teach doctors and patients about the infection. Two-thirds of all coke patients got it right there in Arizona. They were real coke experts, the patient told Azar. You should call them. Azar wasn’t sure what he could learn from these people. But he had some questions. So when the patient brought it up again, he called.
He read the guidelines on the treatment of this disease — written, it turned out, by the doctor who ran the Center of Excellence — and their recommendation was to stop treatment if the patient had no symptoms. Is that correct? “I learned so much,” Azar admitted to the patient. Most importantly: the man did not need medication. His body had already neutralized the bug.
It’s amazing, Azar told me, that something can be so common in one part of the country and so rare in every other place. If that patient had gone to the emergency room in Tucson, it’s more likely they would have recognized what he had as valley fever. If he had symptoms, they would treat him; if it wasn’t, they wouldn’t. But they certainly wouldn’t order a biopsy. And you wouldn’t think for a second that he had cancer.
Lisa Sanders, MD, is a contributing writer for the journal. Her latest book is “Diagnostics: Solving the Most Perplexing Medical Mysteries”. If you have a solved case to share, email her at [email protected]
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