• Diagnosis and Initial Management of Musculoskeletal Coccidioidomycosis in Children

      Ho, Aaron K.; The University of Arizona College of Medicine - Phoenix; Shrader, M. Wade (The University of Arizona., 2013-03)
      Coccidioidomycosis is an invasive fungal infection caused by the inhalation of aerosolized spores of Coccidioides spp., which reside in the arid soil of the southwestern United States and northern Mexico. Dissemination of coccidioidomycosis is rare, and can lead to extrapulmonic diseases including meningitis, osteomyelitis, and skin and soft-tissue involvement. The purpose of this study is to report our experience with musculoskeletal coccidioidomycosis in children. We retrospectively reviewed the charts of patients with musculoskeletal infection with Coccidioides spp. at our institution from 1997 to 2010. Demographic and clinical data were collected from medical records, including the age of the patient, gender, white blood cell count, immunocompetence, length of stay, location of involvement, and initial treatment. In total, we identified 20 children with musculoskeletal coccidioidomycosis. The mean age was 12.3 years (range: 2 to 17) at time of diagnosis. Diagnostic criteria included positive imaging tests (usually MRI), serological positive titers, and/or biopsy with positive cultures. The most common presenting symptom was bone pain (100%) and just 3 (15%) patients had accompanying signs/symptoms of pulmonary infection. Only 2 (5%) patients had a white blood cell count > 15×109/L (5%). Locations of infection included the foot (24%), knee (14%), spine (19%), forearm (10%), lower leg (7%) and other sites (26%). Fluconazole was the most common antifungal agent used (75%). Surgical intervention was required in 12 (60%) of patients. This is the first series that has described musculoskeletal coccidioidomycosis exclusively in children. This study suggests that the initial presentation of this disease can be nonspecific and difficult to recognize in children. Clinicians should consider this diagnosis when faced with a musculoskeletal infection in children from the southwestern United States and northern Mexico.