A Rare Case of Coccidioidomycosis Spinal Meningitis Resulting in Paraplegia: A Case Report

Case Description: A 35-year-old man with history of Coccidioidomycosis spinal meningitis (CSM) presents with myelopathy. Program Description: Patient was first diagnosed and treated for CSM in 2006 after presenting with 1 month history of headache and fever. The patient began having progressive lower extremity weakness in 2010 and was found on imaging and cerebral spinal fluid microscopy to have recurrent Coccidioidomycosis arachnoiditis localized at the thoracolumbar junction. Patient underwent neurosurgical decompression and was placed on lifelong oral Fluconazole. His weakness improved and he was ambulatory until 2013 when he presented with rapid onset bilateral lower extremity weakness with bowel and bladder incontinence. Setting: Acute Rehabilitation Hospital. Results or Clinical Course: Repeat magnetic resonance imaging revealed arachnoid cyst formation within the anterior thecal sac of the spinal cord extending from T10 to L1. The cyst measured 6mm in diameter at T12 causing moderate posterior cord compression. Clinical deficits included bilateral leg weakness, impaired sensation and neurogenic bowel and bladder. Patient had emergent T11 - L1 laminectomy, intradural adhesion lysis and fenestration of arachnoid cyst under constant neural monitoring. Despite making adaptive functional gains with physical and occupational therapy, he showed no improvement of his neurological deficits during postoperative rehabilitation. He was unable to self ambulate and required daily bowel and bladder programs. Discussion: A literature review revealed that most cases of spinal cord compromise due to disseminated coccidioidomycosis are caused by vertebral osteomyelitic destruction resulting in extradural compression. Transient paraparesis has been documented as a result of intrathecal amphotericin B, no longer routinely utilized. However, this patient had no osseous involvement and received all antifungal medications orally or intravenously but never intrathecally. Despite daily oral Fluconazole his disease progressed causing functional neurologic deficits. Conclusions: This rare case report of CSM resulting in paraplegia demonstrates the potential chronicity and progression of coccidioidomycosis despite medical intervention.