A Case of Osteomyelitis of the toe caused by Coccidioidomycosis in a 17 year-old with Diabetes Insipidus

Abstract

We report a case of a 17-year-old male who presented with pain in his right first toe. His pain and swelling had worsened and x-rays of his foot revealed erosive changes of the great toe distal phalanx suggesting possible osteomyelitis. His co-morbidities were morbid obesity and diabetes insipidus. He was admitted to the hospital, blood cultures were drawn, and he was started on vancomycin for presumed bacterial osteomyelitis. He underwent incision and drainage of the fluctuant abscess of the toe, where a culture of the wound was taken. Preliminary results grew fungi. Being located in an endemic area, he was started on anti-fungal treatment for presumed disseminated coccidioidomycosis; culture was positive for Coccidiodes immitis. He also had serology positive for coccidioidomycosis titers. He had uneventful hospital stay and was discharged on long-term oral antifungal therapy.

Coccidioidomycosis Osteoarticular Dissemination

“…One complicating factor in the diagnosis of vertebral coccidioidomycosis is that patients do not always present either symptom of pulmonary coccidioidomycosis nor do they display a significant past medical history of elevated rates of respiratory infections [29,34,36,38]. Although some reports describe the presence of primary lung infection in patients with vertebral coccidioidomycosis [29], a retrospective review study by Szeyko and colleagues [27], showed that the pulmonary disease, even when present, did not correlate with the severity of vertebral infection.…”

“…The clinical studies reporting neurologic symptoms in patients with vertebral coccidioidomycosis cases have also highlighted the necessity of surgical management to prevent further spread in addition to pharmacological therapy [33][34][35]40] due to the fatal nature of coccidioidal infection in the brain. Some rare reported cases of coccidioidal osteomyelitis included infection of the first toe in a young patient with a medical history of diabetes insipidus and obesity [38], the facial bone involvement such as the jaw osteomyelitis in an infant [31], infection of the patella (anterior bone of the knee) in immunocompetent males [41], and orbital bone osteomyelitis with associated periorbital abscess [42]. Coccidioidal osteomyelitis in those rare sites highlights the importance of considering C. immitis and C. posadasii as potential pathogens during the diagnosis of patients with bone diseases, especially patients living in endemic region or patients with a travel history to endemic regions, whether they are immunocompetent or immunocompromised.…”

Coccidioidomycosis Osteoarticular Dissemination

“…One complicating factor in the diagnosis of vertebral coccidioidomycosis is that patients do not always present symptoms of pulmonary coccidioidomycosis, nor do they display a significant past medical history of elevated rates of respiratory infections [39,44,46,48]. Although some reports describe the presence of primary lung infection in patients with vertebral coccidioidomycosis [39], a retrospective review study by Szeyko and colleagues [37] showed that the pulmonary disease, even when present, did not correlate with the severity of vertebral infection.…”

“…Some rare reported cases of coccidioidal osteomyelitis included infection of the first toe in a young patient with a medical history of diabetes insipidus and obesity [48], facial bone involvement such as the jaw osteomyelitis in an infant [41], infection of the patella (anterior bone of the knee) in immunocompetent males [51], and orbital bone osteomyelitis with associated periorbital abscess [52]. Coccidioidal osteomyelitis in those rare sites highlights the importance of considering Coccidioides spp.…”