Pediatric Musculoskeletal Coccidioidomycosis in Central California: A Single Center Experience

Abstract

Background: Published literature on musculoskeletal coccidioidomycosis is sparse and limited to case reports and case series. This is one of the largest case series to describe the clinical presentation, diagnosis, medical and surgical management and outcomes of pediatric musculoskeletal coccidioidomycosis at a tertiary care hospital. Method: A retrospective case review was performed on patients ≤ 21 years old who were followed at a tertiary care center with a diagnosis of musculoskeletal coccidioidomycosis from January 1, 2007, to December 31, 2020. Descriptive data are expressed as medians and interquartile range (IQR) for continuous variables or as frequency and percentage for categorical variables. Categorical values were compared using the χ2 test. Results: Forty-one patients were identified. The median age was 12.8 years, and most were male (71%), Latinx (66%) and healthy (71%). Limb swelling (66%), bone pain (54%) and joint pain (46%) were the most common presenting symptoms. Multiple bone involvement was present in 29% while 12% had the joint disease, and craniofacial (n = 10) and metacarpal/metatarsal bones (n=9) were the most commonly involved sites. Elevated Coccidioides complement fixation (CF) titers ≥1:32 were seen in 90% of the patients. Thirty-three patients (81%) required surgical interventions and of these 16 (48%) required additional surgical procedures. Eleven patients (27%) had disease relapse. Children >13 years of age were more likely to have > 1 organ involvement (16 vs. 7, P = 0.04), multiple bone involvement (10 vs. 2, P = 0.004) and maximum Coccidioides CF titers >1:128 (13 vs. 6, P = 0.02). Conclusions: In endemic areas, musculoskeletal coccidioidomycosis causes a substantial disease burden in children and should be considered in the differential diagnosis of those presenting with bone and joint pain or swelling. Early diagnosis and treatment are essential to minimize long-term morbidity and mortality.

Coccidioidomycosis Osteoarticular Dissemination

“…Higher rates of severe disease, including higher rates of dissemination, are associated with certain ethnic groups, notably those of African, Asian (especially Filipino), and Hispanic descent [5,13,[16][17][18]. Some of the increased susceptibility may be explained by environmental and socioeconomic factors; however, differences in rates of severe and disseminated disease emerge even when controlling for these factors [19], suggesting that underlying host genetic factors play a role in disease susceptibility.…”

“…Skeletal sites of infection do not have a location bias, as any bone could be involved in dissemination, but the reported sites with the most severe disease manifestation have been in the axial skeleton, including the skull, sternum, ribs, and vertebrae [4,37,41,42], with the latter being slightly favored (especially the lumbar and thoracic areas), where Coccidioides spp. frequently disseminate [5,18,37,41]. Most clinical cases describe vertebral coccidioidomycosis as osteomyelitis (limited to the vertebral bodies) and discitis (intervertebral disc space involvement), with symptoms including vertebral body compression and height loss, worsening back and neck pain, lower extremities weakness, weight loss, night sweats [37,39,[43][44][45][46][47], epidural enhancement and abscess [37,39,45,47], paraspinal abscess [47], complete vertebral body destruction with focal kyphosis, and retropharyngeal abscess [44].…”

Coccidioidomycosis in Northern Arizona: an Investigation of the Host, Pathogen, and Environment Using a Disease Triangle Approach

“…Finally, despite decades of research, a vaccine does not exist ( 19 , 20 ). Currently, the best tool to combat VF is improved awareness for patients and health care professionals, so that correct treatment can be initiated ( 21 – 23 ).…”