BACKGROUND AND PURPOSE: Coccidioides immitis is a dimorphic fungus endemic to the Southwest United States and Mexico, and at our institution, it is a relatively common pathogen presenting with a broad spectrum of associated spine diseases. We describe the various spinal manifestations resulting from coccidioidal infection and provide MR imaging examples from 41 pathologically proved cases. MATERIALS AND METHODS: Retrospective electronic medical record and PACS searches were performed. Patients found to have both MR imaging findings positive for infection and confirmative biopsy and/or CSF studies were included. Abnormal MR imaging findings were identified, categorized, and quantified. Patient demographics and associated intracranial involvement if present were also recorded. RESULTS: Forty-one patients were included. Positive findings were categorized as leptomeningeal enhancement (26 patients, 63%), arachnoiditis (22 patients, 54%), osteomyelitis-discitis (14 patients, 34%), cord edema (11 patients, 27%), and true syrinx (3 patients, 7%). Thirty patients had documented brain involvement (73%), most commonly in the form of basilar meningitis. Four patients were positive for HIV (10%). Fifteen patients had pulmonary manifestations at presentation (37%). CONCLUSIONS: C immitis results in various spinal manifestations, most commonly leptomeningeal enhancement and arachnoiditis/ adhesive disease followed by osteomyelitis, which may resemble tuberculous or pyogenic infection on MR imaging. ABBREVIATION: T1ϩC ϭ T1-weighted images with contrast Coccidioides immitis is a dimorphic fungus well-known to be endemic to the Southwest United States and Mexico. 1,2 At our institution, we experience C immitis as a relatively common pathogen, presenting with variable pulmonary, intracranial, and spinal diseases regardless of immune status. The spectrum of spine disease reported in the literature is extensive, with involvement of the leptomeninges, epidural/paraspinal space, vertebral bodies both with and without disc involvement, and, rarely, the spinal cord. Although previous case reports and articles have discussed the imaging appearance of spinal coccidioidomycosis, to our knowledge, there has not been a comprehensive review of both intrathecal and vertebral/paraspinal involvement of this magnitude. 3-9 We describe the spinal MR imaging findings from 41 patients with pathologically proved Coccidioides infection.