Discussion of epidural involvement in spinal coccidioidomycosis infections

Introduction: Coccidioidomycosis is an infection caused by the dimorphic fungus Coccidioides immitis, which is endemic to the southwestern United States. Although primarily manifesting as pulmonary disease, it can disseminate to other sites. While cocci vertebral osteomyelitis has been discussed within the literature, less is known regarding spinal epidural abscesses (SEA).

Methods: A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the PRISMA guidelines. Included manuscripts were methodically scrutinized for quality; patients with confirmed cocci SEA; disease management; outcome. Additionally, we describe our institution's experience.

Results: Six studies with six male patients (average age 37 years) were included in the review. Two patients had a history of disseminated disease. While four patients underwent surgical intervention in addition to medical management, two patients were solely managed medically. Of those managed surgically, all patients had subjective improvement in their clinical status. One patient who was managed medically remained paraplegic at the time of discharge. At our own institution, there were two patients with cocci SEA who were both males, aged 19 years old, who underwent surgical intervention. While one patient had a complicated history of disseminated disease, the other patient’s cocci diagnosis was made with his SEA presentation. Both patients had clinical arrest of disease and resolution of neurologic symptoms at 10-month follow-up. Compiling all eight cases, management included IV amphotericin B in combination with an -azole. Additionally, those of African American descent were affected most frequently (4/8 cases). No patients had documented immunocompromised status.

Conclusion : Similar to previous cocci literature, there was a predominance of males affected as well as those of African American descent. Although the disease cannot be cured, surgical intervention can stop local disease progression. Disseminated disease and immunocompromised were not associated with disease severity. Further studies will be needed to better assess risk factors and optimal medical management.