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A 79-year-old man with type 2 diabetes and neuropathy presented to a Minneapolis hospital with 3 months of headaches and right ankle redness, swelling and pain. MRI of the ankle showed bony erosions (figure 1). Ankle synovial fluid had 30 000 white blood cells/mm3 (93% neutrophils); synovial fluid culture was positive for Coccidioides spp., confirmed by DNA probe. Serum complement-fixing anti-Coccidioides antibodies were positive at a titre of 1:128. Brain MRI was unremarkable. Cerebrospinal fluid (CSF) analysis revealed pleocytosis and an elevated CSF protein supporting a diagnosis of meningitis; CSF Coccidioides antigen, anti-Coccidioides antibody testing and fungal cultures were negative. Additional history revealed that the …
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