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Disseminated Coccidioidomycosis of the Spine 2011

General Spine

Asif, Abdullah, M.D.
Husam, Semaan, M.D., Non ASSR Member
Hassan, Semaan, M.D., Non ASSR Member
Haitham, Elsamaloty, M.D., Non ASSR Member
Ahmad, Aouthmany, M.D., Non ASSR Member
Yogesh, Patel, M.D., Non ASSR Member

Excerpta

Coccidioides immitis is a dimorphic fungus that resides as a saprophyte in arid, alkaline soils. It is endemic to the American Southwest and Central and South America. Its reported disease prevalence is increasing. There are approximately 100,000 new infections diagnosed each year, of which one-third are symptomatic. Of the symptomatic individuals approximately 5-10% will develop a serious pulmonary infection and of those that have a serious infection less than 1% will develop chronic pulmonary disease and/or extrapulmonary dissemination. The main organs of involvement disseminated coccidioidomycosis are the skin, lymphoid tissue, the central nervous system, and the musculoskeletal system. Imaging plays a central role in defining the extent of dissemination. We describe an extremely rare case of disseminated coccidioidomycosis of the spine in a 26-year old immunocompetent patient.

Purpose

To report a rare case of disseminated coccidioidomycosis in an immunocompetent patient.

Methods & Materials

Patient was a 26-year old man, who had lived in Arizona previously, presented with facial lesions as well as neck and back pain. He noticed a skin lesion six months ago that has been getting worse. Physical examination showed marked spinal stiffness and tenderness to palpation at C2, C5 spinous processes as well as at thoracic and lumbar levels. The remainder of the physical examination including the neurological evaluation was within normal limits. Laboratory tests showed elevated C-reactive protein and white blood cell count. Magnetic resonance imaging studies demonstrated extensive paravertebral abscesses involving the cervical, thoracic, and lumbar spine as well as involvement of the vertebral bodies and posterior elements. A CT-guided drainage of the left paravertebral C6 level fluid collection was performed and the cultures confirmed coccidioidomycosis. Patient was treated with radical surgical debridement, spinal stabilization with corpectomy at C5 level with concomitant local and systemic chemotherapy.

Results

An initial x-ray of cervical spine showed C5 vertebral plana with prevertebral soft tissue swelling. Subsequent CT of cervical spine demonstrated near complete destruction of C5 vertebral body, severe kyphosis, epidural as well as retropharyngeal soft tissue involvement. MR imaging demonstrated a pathologic fracture with the complete destruction of the C5 vertebral body and inflammatory involvement of adjacent C4-C5 intervertebral disc. C5 retropulsion with mass effect on the spinal cord with cord edema was seen. Extensive prevertebral soft tissue involvement was seen at C4 through C6 levels. C1 through C4 posterior elements as well adjacent soft tissue demonstrated an abscess cavity with adjacent inflammatory changes. Extensive involvement of thoracic vertebral bodies as well as paravertebral soft tissue was noted. The right scapula demonstrated high signal intensity lesion on T2W images consistent with inflammatory involvement. Mediastinal adenopathy was also appreciated. Osseous involvement of multiple lumbar vertebral bodies as well multiple paraspinous fluid collection was seen. Extensive involvement of the sacrum and iliac bones was also appreciated. A whole body nuclear medicine scan demonstrated multiple areas of increased activity in the cervical, thoracic, upper lumbar spine, right ischium, and the left acetabulum. In light of patient's history, these findings were most consistent with multiple foci of infection.

Conclusion

The prevalence and distribution of Coccidioidomycosis is increasing as is the likelihood of seeing its often unique and bizarre clinical manifestations and complications. Most patients are asymptomatic and disseminated form of disease is rare. The symptoms of disseminated disease develop insidiously and delay in diagnosis of several months is not a rarity. If included in the differential diagnosis, the disease can be recognized earlier and the likelihood of numerous complications can be avoided. Once spinal involvement is diagnosed, a regimen of aggressive surgical debridement as well as consistent chemotherapy must be employed if remission and/or eradication of the illness are sought. Lesions are usually well-circumscribed but may present with an ill-defined border and permeative type of bone destruction, especially in the spine. Plain radiographs are useful in the initial evaluation, nuclear medicine bone scan can identify disseminated disease, and CT and MRI are effective in determining soft tissue involvement and spinal abnormalities. Radionuclide scanning can identify disseminated lesions that are clinically unsuspected. False-negative bone scans in disseminated disease have not been reported. Therefore, when disseminated disease is suspected, skeletal scintigraphy should be the initial mode of examination, followed by magnetic resonance imaging.

References/Financial Disclosures

1. Galgiani J, 2005. Coccidioides species in: Principals and practices of infectious disease by Mandell, Bennett, and Dolin: Philadelphia: Elservier 2005; 3040-3050. 2. Crum, NF, Lederman, ER, Stafford, CM, et al. Coccidioidomycosis: A descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine (Baltimore) 2004; 83:149 3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol 2006;55:929â