Sclerotic vertebral bodies: an unusual manifestation of disseminated coccidioidomycosis.

Abstract

Dense Vertebral bodies are well known in conditions such as metastatic carcinoma, lymphoma, osteopetrosis, Paget's disease, and various forms of granulomatous osteitis. They are also known to occur in primary osteosarcoma of the spine, osteoid osteoma, osteosclerotic form of multiple myeloma, hyperparathyroidism, and occasionally as an isolated finding with no evidence of disease. However, there are no known reports of this finding occurring in coccidioidomycosis unless accompanied by marked destruction of the vertebra. Recently, a patient presented with this abnormality as one manifestation of disseminated disease. Case Report A 29-year-old Negro female, who had been born and lived a number of years in southern Texas, noted lower back pain and a lump on the sternum early in 1964. In June 1964 the lesion ruptured spontaneously and failed to heal. This lesion, along with an extensive retromanubrial sinus tract, was excised in December. Examination of the specimen revealed coccidioidomycosis. The patient was treated with amphotericin B from December 1964 to September 1965. The chest film had been normal, but a pleural effusion developed in January 1965. At this time sclerotic changes in the vertebral bodies of T-10, T-11, and L-4 were first noted. There was an associated paraspinal mass (Fig. 1). The pleural effusion cleared in July, but in October additional destructive changes of the manubrium and sterno-clavicular joints became evident. Because of toxi-city, the amphotericin-B therapy was temporarily discontinued. The patient was readmitted in January 1966 for resection of the manubrium and proximal ends of both clavicles. During subsequent months the serum complement fixation titer for coccidioidomycosis remained at 1: 256. A total of 5 g of amphotericin B had been administered since December 1964. In June 1966 draining abscesses developed in the neck and over the upper lumbar region. On culture, these were positive for coccidioidomycosis. At this time there was also a diffuse nodular infiltrate in both lungs and partial consolidation of the right middle and lower lobes. The serum titer was 1: 1024, and amphotericin-B therapy was reinstituted. The sclerotic vertebrae remained unchanged. By the end of December 1966, an additional 3.7 g of amphotericin-B had been given. The chest film was normal, the draining sinuses had healed, and the serum titer was 1:256. The patient was maintained on amphotericin B as an outpatient. By April 1968 the paraspinal mass was nearly gone, but the vertebrae remained dense. A strontium-85 bone scan was positive over the abnormal bones. The chest remained clear. In April 1969 the vertebrae had returned to nearly normal density, the para-spinal mass was gone, and the chest remained clear.