Musculoskeletal manifestations of lower-extremity coccidioidomycosis: a case series

Background: Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal manifestations are uncommon and seen in disseminated disease. While the involvement of the axial skeleton has been well described, the literature is limited on diseases involving the lower extremity. Methods: We identified three patients, at two regional academic medical centers in southern Arizona, who demonstrated different manifestations of osteoarticular coccidioidomycosis involving the lower extremity. Results: Case 1 is a 41-year-old male, with a history of HIV/AIDS and vertebral coccidioidomycosis, who presented with abscesses in the left hemipelvis and left proximal femoral osteomyelitis. He was treated with staged surgical debridement, including the use of amphotericin B impregnated beads. He remains on indefinite oral posaconazole suppression. Case 2 is a 46-year-old female, who presented with suspected right knee osteoarthritis. An MRI revealed septic arthritis and osteomyelitis. Necrotic bone was debrided, and synovial fluid cultures were positive for Coccidioides. She underwent a resection of the native knee joint with the insertion of an amphotericin B and voriconazole impregnated spacer. She continues oral itraconazole and awaits a total knee arthroplasty. Case 3 is a 76-year-old male, who presented with a draining right heel ulcer. Radiographs revealed bony destruction consistent with Charcot arthropathy. Irrigation and debridement revealed the gelatinous destruction of the talus and calcaneus, and cultures confirmed Coccidioides infection. A polymethyl methacrylate voriconazole spacer was placed. He subsequently underwent arthrodesis and remains on lifelong fluconazole. Conclusion: Lower-extremity osteoarticular coccidioidomycosis has various debilitating presentations that frequently mimic non-infectious etiologies. Treatment warrants surgical debridement, and prolonged antifungal therapy should be considered.