Desert Screening Dilemma

A 43-year-old man with HIV returns to clinic in Tucson, Arizona, after several months of inconsistent antiretroviral therapy adherence. He has lived in southern Arizona for the last 5 years and works as a delivery driver. He reports no recent travel outside the U.S. Southwest.

He feels well and denies fever, cough, pleuritic chest pain, dyspnea, rash, headache, focal bone pain, or weight loss. Nine months earlier, screening serologies for Coccidioides IgM and IgG were negative.

Current laboratory studies show HIV RNA 68,400 copies/mL and CD4 count 172 cells/mm^3. CBC, liver enzymes, and creatinine are unremarkable. He asks whether he should take an antifungal medication now because "everyone here talks about valley fever."

Four months later, after partial ART re-engagement, his HIV RNA remains detectable and CD4 count is 188 cells/mm^3. Routine repeat screening now shows newly positive Coccidioides EIA IgM and IgG. Confirmatory immunodiffusion and complement fixation tests are sent.

He remains afebrile and continues to deny cough, dyspnea, chest pain, rash, headache, or focal musculoskeletal symptoms. Examination is unrevealing, chest radiograph shows no focal or diffuse infiltrates, and there are no laboratory abnormalities suggesting active extrapulmonary disease.