314 Coccidioides immitis or C. posadasii can cause coccidioidomycosis, which remains a clinical concern in the southwestern United States, including Arizona, California, New Mexico, Texas, and Washington (1). It is a common disease with an annual incidence rate of 43/100,000 in Arizona and an estimated 150,000 cases, including asymptomatic cases, in the United States. However, coccidioidomycosis is rare in Japan, with only a few cases reported annually. An increasing incidence of coccidioidomycosis and an expanding endemic range have been reported in the United States (2). Approximately 60% of infected individuals become asymptomatic, while the rest show symptoms that vary from flu-like symptoms to pneumonia. Up to 1% of cases lead to disseminated disease, whereas most symptomatic cases are self-limiting; therefore, supportive care is the mainstay in mild cases without overt immunosuppression (3). However, approximately 5% of patients with primary disease exhibit residual pulmonary nodules or peripheral thin-walled cavities, which can provide a site for subsequent diseases such as other microbes and neoplasms. The prevalence of nontuberculous mycobacteria (NTM) in Japan is considerably higher than that reported in most other countries, and a constant and steady increase in NTM-related mortality has been reported (4). In Japan, the incidence of pulmonary NTM increased from 5.7/100,000 in 2007 to 14.7/100,000 in 2014, a 2.6-fold increase (5). Due to the limited effectiveness of antibiotics, especially in fibrocavitary- type cases, macrolide-resistant NTM infections, and recurrent cases after antimicrobial withdrawal, pulmonary resection may be performed in carefully selected patients (6). Herein, we report the case of a Japanese mine supervisor who was pretreated for NTM and eventually diagnosed with coccidioidomycosis following Short Communication Pulmonary Coccidioidomycosis Complicated by Nontuberculous Mycobacterial Pulmonary Diseases with a Literature Review Hiroki Ashizawa 1,2 , Naoki Iwanaga 1,2 * , Hirokazu Kurohama 3,10 , Yuya Ito 1 , Nobuyuki Ashizawa 1,4 , Tatsuro Hirayama 5 , Kazuaki Takeda 1 , Shotaro Ide 1,6 , Yohsuke Nagayoshi 2,7 , Masato Tashiro 4 , Takahiro Takazono 1,8 , Tsutomu Tagawa 9 , Kiyoyasu Fukushima 7 , Masahiro Ito 10 , Shigeki Nakamura 11,12 , Koichi Izumikawa 4,8 , Katsunori Yanagihara 13 , Yoshitsugu Miyazaki 12 , and Hiroshi Mukae 1 1 Department of Respiratory Medicine, 3 Department of Pathology, 4 Department of Infection Control and Education Center, 6 Infectious Diseases Experts Training Center, and 13 Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki; 2 Department of Respiratory Medicine, 9 Department of Thoracic Surgery, and 10 Department of Pathology, National Hospital Organization, Nagasaki Medical Center, Nagasaki; 5 Department of Pharmacotherapeutics and 8 Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki; 7 Division of Respiratory Medicine, Japanese Red Cross Nagasaki Genbaku Isahaya Hospital, Nagasaki; 11 Department of Microbiology, Tokyo Medical University, Tokyo; and 12 Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan ABSTRACT: Following an endobronchial examination, a young mine supervisor was treated with antibiotics for a pulmonary nontuberculous mycobacterial infection for approximately one year. However, a review of the radiological findings revealed a different possibility. Accordingly, pulmonary resection was performed, and histopathological analysis revealed numerous yeast-like fungi. Since the patient had stayed in the southwestern United States for two months in 2009, eight years previously, coccidioidomycosis was strongly suspected. The diagnosis of coccidioidomycosis was subsequently confirmed by serology and polymerase chain reaction testing of the excised specimen. Here, we report an educational case that emphasizes the importance of meticulous medical history-taking and awareness of endemic mycoses in other countries in the context of globalization. Received February 14, 2023. Accepted April 25, 2023. J-STAGE Advance Publication May 31, 2023. DOI: 10.7883/yoken.JJID.2023.073 *Corresponding author: Mailing address: Department of Respiratory Medicine, Nagasaki University Hospital, 1-7- 1 Sakamoto, Nagasaki City 852-8501, Japan. Tel: +81- 95-819-7273, Fax: +81-95-848-7285, E-mail: niwanaga@ nagasaki-u.ac.jp Jpn. J. Infect. Dis., 76, 314-318, 2023