Senior Staff Physiatrist NIH Bethesda, Maryland, United States
Case Diagnosis: Thoracic epidural abscess, pathological vertebral fracture, and severe spinal cord compression secondary to disseminated Coccidioidomycosis.
Case Description: A previously healthy 20-year-old presented with thoracic spinal cord compression (T5–T6) secondary to disseminated Coccidioidomycosis. Imaging revealed diskitis-osteomyelitis, severe cord compression, and kyphotic deformity. Despite surgery and antifungal therapy, he developed a shoulder abscess, mediastinal phlegmon, seizures, encephalopathy, hemothorax, and bilateral lower extremity weakness (0/5) with sensory loss below T4, bowel/bladder dysfunction, and complete dependence for mobility and self-care. Neurosurgery recommended a TLSO and deferred stabilization surgery given the extent of the infection. The physiatrist instead recommended CTLSO to stabilize the spine, protect the cord, and enable early rehabilitation. Fabrication was challenging due to fluctuating abscesses; once fitted, the brace allowed upright positioning. Rehabilitation included mobility exercises, spasticity management, and FES among other interventions. Within a year, he regained bowel/bladder function, improved trunk control, achieved independence in bed mobility and transfers, stood with a walker, reached modified independence at wheelchair level, returned to college, and adaptive sports.
Discussions: Spinal involvement from disseminated Coccidioidomycosis is rare and often results in severe neurologic deficits. Early orthotic intervention, directed by the physiatrist, enabled timely rehabilitation despite delayed surgical stabilization, preventing prolonged immobilization and its complications. The physiatrist also coordinated other multidisciplinary interventions, including mobility training, spasticity management, and FES, to promote neurologic recovery. This case highlights the critical role of physiatry in bridging medical, surgical, and rehabilitation care to optimize function in patients with complex spinal infections.
Conclusions: Early, structured rehabilitation—guided by physiatry and supported by customized bracing—can enable safe mobilization, functional recovery, and improved quality of life in severe Coccidioidomycosis-related spinal cord injury, even when definitive surgical stabilization must be delayed.
