An 11-year-old African American male presented in March 1993 with a 4-month history of progressive thoracic pain radiating along the right flank anteriorly, associated with malaise, anorexia, low grade fever, and a five pound weight loss. Exam revealed intact neurologic function, with pain elicited on straight leg raising and on motor testing of the iliopsoas muscles. Deep tendon reflexes were increased at the knees bilaterally. Initial white blood cell count was 8100 per cmm with 32 percent eosinophils. The erythrocyte sedimentation was increased at 107 mm/hr. The chest radiograph revealed diffuse interstitial infiltrates, a large thoracic paraspinous mass, and destruction of T10. MRI confirmed destruction of the T10 vertebral body, with a paraspinous collection from T8 to T11, and anterior epidural extension at T10 with compression of the dural sac. At thoracotomy, the patient was also noted to have partial destruction of the inferior aspect of T9 and the superior aspect of T11. Debridement of the paraspinous collection revealed a thick-walled abscess with multiple cavities containing approximately 20cc of pus. The patient underwent T10 corpectomy with partial corpectomy of T9, discectomies of T9-T10 and T10-T11, and decompression of the dural sac. Stains of pus and tissue revealed spherules consistent with Coccidioides immitis, which subsequently grew from the operative specimen. The initial serum complement fixation titer was 1:16, with a positive IgM immunodiffusion test (performed by D. Pappagianis). The cerebrospinal fluid formula was benign with negative complement fixation and immunodiffusion studies. Amphotericin Tvas initiated for a total dose of two grams. Six weeks postoperatively, the patient underwent transthoracic reconstruction with partial corpectomy of T9 and T11 for extensive softening of tile vertebral bodies, discectomies of T8-9 and T11-12, and placement of a fibular strut graft. Followup studies have revealed decompression of the abscess with fusion of the graft. Following completion of a two-gram course of amphotericin, the patient was changed to itraconazole on which he remains to date. Re has done well clinically with resolution of pain, spinal stability, normalization of eosinophilia and erythrocyte sedimentation rate, and a progressive decline in complement fixation titer to 1:4. He remains anergic to sphaleron.
Full conference title:
Coccidioidomycosis - Centennial Conference