Objective:

To describe a rare case of disseminated coccidioidomycosis affecting the central nervous system, complicated by mainstem pulmonary embolism, cauda equina syndrome, and non-cortical myoclonus.

Background:

Coccidioidomycosis, endemic to the Southwestern United States, often presents with nonspecific constitutional symptoms that delay diagnosis and treatment. Disseminated disease occurs in 1% of cases and carries a mortality rate of up to 25%

Design/Methods:

n/a

Results:

26-year-old male with no significant past medical history, with recent military service in Yuma, Arizona, and Coalinga, California, presented to our Emergency Department with a 2-month history of headache, weakness, nausea/vomiting, night sweats, productive cough, and multiple verrucous, violaceous plaques on his forehead, forearm, and back. CT head without contrast revealed severe communicating hydrocephalus and transependymal edema. Cerebrospinal fluid studies were significant for xanthochromia, pleocytosis, increased protein, hypoglycorrhachia, and elevated Coccidioides IgG/IgM antibodies. A ventriculoperitoneal shunt was placed, and he was started on amphotericin B induction, transitioned to fluconazole maintenance. While compliant on fluconazole, he developed worsening encephalopathy, areflexic quadriplegia, and neurogenic bladder requiring foley. He was transferred to neuro ICU for neurological deterioration, recurrent fevers, tachycardia, and tachypnea. CTA chest revealed bilateral mainstem pulmonary emboli, and MRI spine revealed an epidural abscess spanning C6-T3, requiring urgent anticoagulation, transluminal thrombectomy, and conservative neurosurgical management under broad-spectrum antibiotics. Interval brain imaging revealed progression of basal, nodular, leptomeningeal enhancement, prompting resumption of amphotericin B and replacement of fluconazole with posaconazole. After discharge to rehabilitation, he was re-admitted to the ICU for respiratory distress requiring intubation. He developed episodes of paroxysmal sympathetic hyperactivity with multifocal segmental myoclonus, treated with clonazepam and baclofen. Continuous EEG demonstrated no electrographic correlates. 

Conclusions: