Vertebral coccidioidomycosis: presentation and multidisciplinary management

Am J Med. 2012 Mar;125(3):304-14. doi: 10.1016/j.amjmed.2011.10.018.

Abstract

Background: Vertebral involvement is a severe complication of infection caused by Coccidioides species.

Methods: We conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009.

Results: We identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy.

Conclusion: Vertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Antifungal Agents / therapeutic use
  • Arizona
  • Black or African American / statistics & numerical data
  • Coccidioidomycosis / diagnosis*
  • Coccidioidomycosis / ethnology
  • Coccidioidomycosis / therapy*
  • Combined Modality Therapy
  • Female
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Factors
  • Spinal Diseases / diagnosis*
  • Spinal Diseases / ethnology
  • Spinal Diseases / microbiology*
  • Spinal Diseases / therapy*
  • Steroids / therapeutic use
  • Treatment Outcome
  • White People / statistics & numerical data

Substances

  • Antifungal Agents
  • Steroids