Disclosures: Brian M. Dena, DO: Nothing to disclose

Case Description: A 29-year-old veteran with no relevant medical history suddenly developed seizure while en route to deployment to the Middle East. Initial workup revealed meningitis, hydrocephalus, and concern for cervical epidural abscess with cord involvement at the C5 level with fluid culture positive for coccidiomycosis. He underwent CSF shunt placement, C5 level laminectomy, and was treated with broad spectrum antibiotics. He was treated with aggressive anti-fungal treatment and his clinical picture stabilized. He was discharged from acute care on lifelong anti-fungal treatment at a decreased dose. At that time, he had persistent cognitive deficits as well as right upper extremity proximal weakness thought to be related to his spinal lesion.

Setting: United States Veterans Affairs hospital.

Patient: A 29-year-old man with disseminated coccidiomycosis.

Assessment/Results: Over the first week of residential brain injury rehabilitation admission, he developed progressive left upper extremity proximal weakness. EMG was obtained, which revealed chronic bilateral C5 cervical radiculopathy, worse on right, with findings of acute denervation and reinnervation changes in bilateral C5 innervated muscles. Cervical MRI showed the prior C5 laminectomy, dural adhesions, leptomeningeal thickening spanning C2-C5, and cord abnormalities at these levels. He was readmitted to acute care for continued workup. The weakness along with his imaging findings were attributed to worsening of his indolent coccidiomycosis, for which he was placed on more intensive anti-fungal treatment. His weakness gradually improved though full strength did not return.

Discussion: We present a case of recrudescence of disseminated coccidiomycosis leading to progressive focal weakness during a rehabilitation admission, with resulting MRI findings consistent with focal spinal cord involvement leading to EMG findings more consistent with radiculopathy, potentially representing involvement of lower motor neuron cell bodies in the spinal cord.

Conclusion: This case highlights coccidiomycosis infection as a unique etiology of bilateral upper extremity weakness with unusual MRI and EMG findings.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/disseminated-coccidiomycosis-with-delayed-progressive-focal-weakness/