Disseminated coccidioidomycosis-related cervical intramedullary lesion causing quadriplegia in an immunocompetent host

Description

A 41-year-old man with a history of crystal methamphetamine and alcohol abuse had progressive fever, nausea, headache, gait difficulties and seizures over 4 weeks while living in California and Mexico. He was diagnosed with meningitis, treated with antibacterials and discharged to a rehabilitation facility. One month later, he had recurrent symptoms with weakness of both arms and legs. Neuroimaging revealed extensive basilar pachymeningitis, leptomeningitis, hydrocephalus (figure 1A), cervical epidural enhancement (figure 1B) and a non-enhancing central cervical intramedullary lesion spanning C1 through C6 (figure 1C). He was started on fluconazole 800 mg daily due to his travel history, although a serum antibody test was negative by double immunodiffusion (<1:1). A ventriculoperitoneal shunt was placed for hydrocephalus and he was discharged but remained quadriplegic. Two weeks later, he developed confusion and was found to have bilateral subcortical strokes on MRI with evidence of arteritis...

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