A paradigm for the evaluation and management of spinal coccidioidomycosis

BACKGROUND: Coccidioidomycosis is a fungal infection that is endemic to parts of the Southwestern United States. When infection involves the spine, the treatment strategies can be challenging. We have devised a management protocol for spinal coccidioidomycosis based on a review of the literature and our experience. METHODS: The electronic literature search of National Library of Medicine for publications from 1964 to 2014 was performed using the following keywords: Coccidioidomycosis and spine. The search yielded 24 papers. Treatment strategies were summarized into a treatment protocol. RESULTS: A total of 164 cases of spinal coccidioidomycosis were identified, ranging in age from <10 to >80 years. Males (n = 131) and African-Americans (n = 79) were strikingly over-represented. Medical therapy: Once a diagnosis of spinal coccidioidomycosis is established, antifungal therapy should always be started. Antifungal therapy with amphotericin B or azoles like fluconazole. Medical therapy needs to be continued for many years and sometimes indefinitely to reduce disease recurrence or progression. Surgical management is indicated in cases with mechanical instability, neurologic deficit, medically intractable pain, or progression of infection despite antifungal therapy. CONCLUSIONS: This work provides a working protocol involving assessment and reassessment for the management of spinal coccidioidomycosis. Medical management with antifungal agents in some cases can provide satisfactory disease control. However, in patients with mechanical instability, neurologic deficit, medically intractable pain or disease progression disease control may only be achieved with surgical debridement and stabilization.