LAUSR

A 31-year-old man presented with 8 months of progressive upper back pain and 2 weeks of fever and leg weakness. He was born in Mexico and later moved to Salinas, CA, where he worked in agriculture. He denied injection drug use. Neurologic exam showed 4/5 left leg strength, hyperreflexia, and upward Babinski. There were no sensory changes. Magnetic resonance imaging showed C7–T4 osteomyelitis/discitis, T3 vertebra plana (complete vertebral body compression), and epidural fluid collection with cord compression (Fig. 1). He underwent spinal decompression with instrumentation. Pathology showed granulomatous inflammation with spherules (Fig. 2) and cultures grew Coccidioides immitis.]–>]–> Coccidioidomycosis typically presents as a self-limited illness with fever, fatigue, and respiratory symptoms. Rarely, the infection spreads hematogenously to the skin, bones (especially vertebrae), and CNS. Risk factors for extrapulmonary dissemination include immunocompromise (suppressed cellular immunity), African or Filipino descent, and pregnancy. 2 Endemic areas include the southwestern United States, Mexico, and parts of Central and South America. In California, incidence is highest in the San Joaquin Valley and Central Coast. Uncomplicated pulmonary coccidioidomycosis is managed with supportive care, but extrapulmonary cases warrant oral azoles. Severe vertebral disease with cord compromise requires amphotericin induction therapy and surgical decompression.