Working Diagnosis:
Coccidioidomycosis of the right knee.

Treatment:
Infectious disease consultant initiated treatment with fluconazole 800mg daily for 2 months. It was recommended the patient obtain a chest radiograph and chest CT to evaluate for pulmonary involvement which the patient declined to do.

Outcome:
The athlete completed a course of physical therapy post arthroscopy and completed in the following football season. He has not had a recurrence of his knee effusion.

Author's Comments:
Common atraumatic etiologies of effusion include infection, rheumatologic disease, tumors, and osteoarthritis. Initial work up and MRI lead to a diagnosis of lipoma arborescens, a rare benign lesion, accounting for less than 1% of lipomatous lesions, characterized by normal synovium undergoing villous proliferation with mature fat cells. However, the pathology results for our athlete demonstrated coccidiodiomycosis demonstrating the importance of obtaining tissue diagnosis to direct therapy.

References:
1. Taxy J, Kodros S. Musculoskeletal Coccidiodiomycosis Unusual Sites of Disease in a Nonendemic Area. Am J Clin Pathol 2005;124:693-696
2. Rettig AC, Evanski PM, Waugh TR, Prietto CA. Primary coccidioidal synovitis of the knee: a report of four cases and a review of the literature. Clin Orthop 1978;132:187-192
3. Taljanovic M, Adam R. Musculoskeletal Coccidioidomycosis. Am J Clin Pathol 2005;124:693-696
4. Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis. Infect Dis Clin North Am. 2003;17:41-57

Acknowledgments:
This case highlights the importance of taking a thorough patient history. The athlete's time in the southwest (Arizona) was an important clue to his eventual diagnosis.

Return To The Case Studies List.