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Roentgenographic
Features
Coccidioidomycosis
BY
MAJOR
MURRAY
K.
STEPHEN
COLONEL
DALINKA,
MAJOR
H.
From
the
Departments
Tins
report
is
a
its fourteerr
lesiotrs
diagnnosis.
of
of Radiology
descriptions
cases
usually
ins less
capable
producirng
systennic
disease
patient
Anry
turd fever
setnninrated
lesions
irave
osseous
connmon
lilipirro
evens
were
than
ins tine
is tens times
is
recorded
coccidioidomycosis
tine
of
tire
of
in black
twelve
whose
should
be
eosinopinilia,
form
connmons
to
the
primary
osseous
differential
most.
localized
infectious
forns
is
form is progressive.
It occurs
20 per cenrt of patiemrts
witir
organism
monsth
loss,
tine
people
patienrts
is no
tinere
accordinng
tire
of their
inn in itis,
Tire
of
A ntonio
.
otre
Weigirt
Eigint
San
a.spects
disease.
to
Apparently
FORCE,
FORCE,
Base,
a discussions
Coccidioides
dissenninrated
more
greater.
black.
i3,
AIR
A ir Force
tine disseminsated
j)proximately
errdemic
persist
for lonsger
coccidioidomycosis.
are
by
lesionss
in regionrs
dissennninration
and
systemic
bersigtr
arid self-limited,
but
than
0.5 per cent of cases
FORCE,
AIR
STATES
roenstgenographic
is caused
of
UNITED
Lackland
of coccidioidonrycosis
Coccidioidomycosis
all fumrgi
tire
AIR
STATES
TEXAS
Orthopedics,
of
STATES
UNITED
CORPS,
ANTONIO,
and
UNITED
CORPS,
MEI)ICAL
SAN
PENNSYLVANIA,
CORPS,
MEI)ICAL
HOPKINS,
Diagnosis*
PHILADELPHtA,
MEI)ICAL
GREENDYKE,
RALPH
Differential
M.D.t,
DtNNENBERG,
WILLtAM
AND
and
of Osseous
reports,
hr
sex
or
but
respiratory
symptoms
suspected
as havinrg
ieukocytosis,
anrd
disease.
Feise
and
tire hazard
tinat
our
age
series
stated
tirat
for the
whose
race
j)redilection
dissenninsation
disskins
for
is more
was
primarY
connmon
in
tnnens.
Tire
to
funrgus
Censtral
Coccidioides
America,
Pampa
region.
zotre,
a
soil,
Tins
desert
inigir
disease
civilian
of an
ins a large
fractions
disease
may
arid
refractile
mycelia
S
and
Presenrted
by
each
to
at the Eighteenth
Las Vegas,
Nevada,
June
t Department
of Radiology,
vania 19130.
l)epartment
of Orthopedics,
land
Air Force
Base,
San
Antonio,
VOL.
53-A,
NO.
San
receive
1971
tire
Unrited
States,
Grand
Ciraco-
to the lower
Soniorani
life
exclusively
in areas
of poor
sufficient
an
body
via
.
Annual
in
The
an
Symposium
produce
leaves
adult,
tract.
It
(average
regions.
the
area
ultimately
26#{149}
(spores)
in
is derived
becomes
thirty
a doubly
micrometers),
break
completing
of the Society
arsd
endemic
forms
spherules
the chlamydospore,
size
active
military
to
individual
endospores
into
to
increased
confined
respiratory
micrometers
develops
of
not
exposed
the
exposure
Because
t7
is
after
the
out
of the
cycle.
of Air Force
Clinsical
Sur-
8, 1970.
Thomas
Wilford
Texas.
of Radiology,
Wilford
Antonio,
Texas.
6, SEPTEMBER
corresponds
almost
found
population
endosporulations
and
soutirwesterts
particularly
a bipirasic
organism-it
Tine infectious
form,
the
geomrs,
§ Department
Air Force Base,
area
tire
eighty
grows
tine
irumidity.
years
enters
ten
to
America,
coccidioidomycosis
occur
and
reproduces
spherules,
of
is
in culture.
spirerule
winch
low
iminitis
a mycelium
is ensdemic
of Soutir
endemic
inowever,
Coccidioides
tissue
and
residents
Systennic
I)arts
distributions
rouginly
arid tine orgamnisnr
is
regions,
travel,
frons
to
temperature,
Tire
imnnitis
arid
Jefferson
Hall,
I1ali,
University
Medical
Medical
Hospital,
Corps,
Corps,
United
United
Philadelphia,
States
States
Air
PennsylForce,
Air Force,
Lack-
Lackland
1157
1158
i.
K.
S. DINNENBERG,
DALINKA,
W.
H.
GREENDYKE,
TABLE
DISTRIBUTION
OF
BONE
LESIONS
FOURT
IN
EEN
CASES
17
15
4
14
Clavicle
2
Sternum
Humerus
Scapula
2
2
2
2
2
2
2
Femurt
1
2
Calcaneus
1
2
Metatarsals
1
1
2
2
1
1
1
1
1
1
1
1
bonet
Fibula
vertebral
lesions;
Lesions
7
Ulna
Tibia
Radius
individually.
t Symmetrical
involvennent
included
was
HOPKINS
CoCCmDIomDoMYcosns
5
Phalanges
Contiguous
OssF:ous
OF
Cases
Spine5t
Ribs
Innominate
R.
I
Site
S
AND
as
a
single
but
lesion
skip
lesiomis
were
counrted
also had symmetrical
A coccidioidin
three
to
six
seminated
skins
weeks
disease
to
patients
two
lesions
had
of the pubis,
test.
symmetrical
ischial
inas beets
become
positive
is present.
i,2i
lesions
rami,
and
developed
aird,
Serologic
to
due
disease,
higher
in
titers
titers
parallel
tine
which
activity
aitlrough
there
are
disseminated
of
tine
Symmetrical
lesions of ischium,
iliac
also has symmetrical
lesions of femoral
the left sacral
alae can also be identified.
aid
are
did
ratiner
bomres
inn diagtsosis,
arrergy,
iliac
titers
cases
not
tinan
lesions
THE
omse of these
but
is unrrelinrble
of
primary
occur.
it takes
wirens
tue
dis-
imnnportanrt
the
have
JOURNAL
degree
slightly
OF
lesions
witir
Connplennnenst-fixationr
of innmnrumrity
bones, and symphysis
pubis are demonstrated.
neck which are not seen in this roentgenogram.
The
titi(l
reliable
irsdicators
of the
effect
to be itrdicative
of tire presemrce
of
reported
lesionrs
disease
to
iliac
necks.
complement-fixations
in the diagnosis
of disseminrated
disease
and
of tinerapy.
A titer of 1 to 64 or inigher
is thought.
disseminated
of the
femoral
sclerotic
BONE
This patient
A lesion in
borders.
AND
JOINT
SURGERY
ROENTGENOGRA1’HIC
FEATURES
OF
OSSEOUS
1159
COCCtDIO1DOMYCOSIS
II
2
FIG.
Fig.
2: Poorly
nrew-botie
defused
formirat
Fig.
shaft
soft-tissue
swelling
of the index
finger.
phalamix
of the
proxinsal
phalanx
and
small
sequestrum
our fourteen
patiensts
rvith
foci. Tise distrihutionr
of lesions
ins the
well
were
sponrgiosa
and
denrarcated.
the
of our patients
..trid to irave
piralairgeal
lesions
osseous
lesions,
it was
it was
m2
occasiots
to
(Fig.
poorly
showed
are
and
be
atropiry
denser
usually
aird
3,6
etrds
of long
majority
borders
tine
and
tins
nsay
VOL.
53-A,
NO.
with
coccidioidomycosis,
ins Table
I. Tirey
of lesionrs
were
w’ere
present
interpreted
as an
was
usually
confirmed
destructive
periosteal
lesions
nine
almost
lytic.
of tire
mad multiple
always
occur-
The
in multiple
extensions
iras
bones,
and
moderate
in our
lesions
sites
usually
of involvement
from
the
horse
focus
and
on
a tendency
our
patients
ends
explain
6. SEPTEMBER
of the
the
long
localization
1971
bones
in
degree,
according
to
published
patients.
to involve
horse
showed
pirenonnenon
is unknown.
Cockshot
believed
the red nnarrow,
and,
tirerefore,
lesions
occur
ext.rennities,
with
1). Lesions
in the small
bones
of the hands
and feet
defined
borders
and our one patient.
with
nnetatarsal
tins (Fig. 2) . If there was soft-tissue
swelling
near
an
although
this
Coccidioidomycosis
tine
finger
than tine surrounding
soft tissue
(Fig.
3). Sequestra
are said
and only
occurred
once
in this series
(Fig.
3). Regional
bone
is frequent
reports
great
Sclerotic
ins two
oftenr
little
Findings
osseous
is given
Of
red
of the
associated
Roentgenographic
horse
3
FIG.
of the
1011.
3: 1 )etrse
middle
lesion
retain
of the
this
prominences
predilection.
that
the organisms
where
red marrow
some
lesions
red
marrow
in part.
Tire
(Fig.
4) and
cause
of this
are parasitic
remains.
In
even
irs adult
in
the
life,
1160
M.
K.
DALINKA,
Well
Tine
feet
spared,
series.
to
extenrsion
If
tine
into
articular
joints
There
involvement.
of the
sides
H.
involved
and
is not
one
of our
AND
process
nnainly
thougirt
is rio selective
of the unfused
olecranon
slnowed
is involved,
synovium,
GREENDYKE,
the
patierrts
cartilage
involvement.
both
19,
W.
involving
of our
reports
bone
insvolving
lesion
one
With
Lesionr
DINNENBERG,
is frequently
2) and
accordinrg
5). Direct
demarcated
diapinysis
(Fig.
18,20
S.
in
this.
the
Tine
patienrti
proximal
of the
boires
HOPKINS
ulna.
of tine
epipinyseal
exemplified
iiatids
I)lates
tins
ttre
process
ansd
trot
(1”ig.
to be common
annd r’as trot seems inn this
it is by extetssiots
from
tue
adjtu’ent
preservation
marginal
H.
of w’eigint-bearinrg
erosiorrs
t.ibial
THE
of cartilage
epiphyseal
JOURNAL
plate
OF
BONE
cartilage
may
and
AND
occur.
sparing
JOINT
the
.
Two
joint.
SURGERY
ROENTGENOGRAPHIC
FEATURES
OF
OSSEOUS
1161
COCCIDIOIDOMYCOSIS
I
FnG.
Lytic
lotrg-bone
cases
lesiotr
with
periosteal
lesion
which
did not
of
svnroviai
osseous
involvensenst
cinatsges.
( Figs.
Sclerosis
eari’
finsdinrg
nrerst
of tire
r’as
two sites
disease
with
Lesiotrs
our
series
patieirts
urn early
at
arid Uris may be the
with older
onres.
reasons
itnvolving
tine
conrfirnred
appeare(l
of
is said
sclerosis
ribs
reportedly
earlier
are
of otiners.
extrapleural
ribs in our patiernts
w’as eitiner
lytic or sclerotic
titis.
Four
of our patienrts
sirowed
synnmetrical
Tire
mass
mr our
usually
marginral
central
(Fig.
and
bone
rib
8).
was
Tine
involvennent,
tuberculosis
22,
syphilis
cryptococcosis
12
6,
histiocytosis,
sickle-cell
lack
tinani
25,
in
four
r’as
past,
as coninpared
and
locations
lesions
an
treat-
its the
series
of
patients
moderts
ins one
involvement
irot. associated
tionral
patienst,
involvement
nr’as nearly
symmetrical
(Fig.
symmetry
of boise lesions
occurred
in four separate
locatiorns
seers this pirenromenon
occur
in biastomycosis,
and similar
genital
Tire
only
of tine
lesions
inealirsg
r’as so infrequerrt
of
ins tw’o
patienrts.
the
of our
ins cirrotric
of our
was
because
ins four
marnifestatiors
B pronnotes
that
This
series
present
nnairrly
irs oire
annphotericitr
diaphysis.
our
was
to occur
itsvolvemetst
a large,
from
formationr
roeistgenographic
winch
tine experienrce
as
excluded
nrew-botse
of boise,
6
formation
mr the humeral
the end of the bone.
were
Periosteal
1 tinsti 6). Tins
patiensts.
new-hotne
ilrvolve
of
witir
and
of our
the
perios-
in an
addi-
1). In one patienst,
the
(Fig. 3) . We Irave also
changes
may
occur
in
anemia,
scurvy,
and
con-
1162
M. K. DALINKA,
Lesion
Spinal
There
S. DINNENBERG,
arising
from
involvement
the
was
w’as relative
sparing
was
seen
in
two
were
of
not
our
central
in our
disc
(Fig.
in our
Bone
disease.
Destruction
bearing
portion
frequently
In contrast,
of one
the
culosis
w’hile
commonly
iliac
seen
8)
.
by
cavity.
parts
Bone
of entry
.
others
The
the
and
when
States
for
bone prominences
monly
accompanying
has
of the
different
and
lesions
tend
The
the
a greater
of
findinng,
turd
are
rarely
tine
weight-
bone
pelvis
joints
frequently
located
Solitary
to
of
8.
the
to the
in
soft-tissue
may
Rib
two
and
inrfection,
diseases
to
are
seers
tire
and
via a cecal
is usually
is helpful
and
western.
addition
.
ins tuberlesiorrs
be involved
insvolvennent.
southeastern
southwestern
involvement
inflammation
bone lesions
tendency
the
in tins
of the
to be centrally
The pelvis
involved
is endemic
not
it occurs,
for the sacro-iliac
lytic arid more
secondary
8
prornounrced
and facial bones
is frequently
usually
is introduced
tinrough
spine.
epidemiology
epiphyseal
23#{149}
a late
involvement
coccidioidomycosis.
not in coccidioidomycosis.
discrete
Blastomycosis
United
indicated.
involvennenrt
more
Tuberculous
is usually
than
extremities
lesions
The
irave
21
was
frequently
is common,
Rib
in
and
rather
them.
a tendency
Blastomycosis
are
spared.
ischium.
marginal
involvement
extension
from
Blastoinycosis:
of
as
right.
Diagnosis
joints
is usually
tuberculosis
is regional
the
indiscriminrate
collapse
Involvement
of the mandible
because
the infectious
organism
differentiating
shows
11
but
Vertebral
atrophy
or more
and
are
in
disease
destruction
portal
on
series.
muscle
joint
wing
these
Actinomycosis:
oral
rib
produces
sclerotic
lesions
with
a predilection
coccidioidal
lesions
of the pelvis
are usually
involve
in this
and
of the
R. HOPKINS
first
patients
cartilages
Differential
Tuberculosis:
of the
AND
other
bone elements
of the spine.
Ofters multiple
spinal
masses
were frequent.,
and contiguous
rib involvement
patients
present
portion
frequent
of the
the vertebral
bodies
and the
lesions
w’ere found.
Paraspinal
fistulae
W. H. GREENDYKE,
in
midwestern
Blastomycosis
producirrg
lesions
of
and ulceration
of overlying
soft tissues
comcan simulate
coccidioidomycosis
quite closely.
to produce
fistulae
and to erode
into joints
15#{149}
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
ROENTGENOGRAPH1C
1)estructiotr
of
l)ro(ess.
Note
tisimimiimrg
of tire
Tire
disc
the
the
tine
head
of the
of
disc
OF
FnG.
S
rib
with
left
the
miitrth
betweemi
early
OSSEOUS
(‘omrtiguous
thoracic
vem’tei)ra
nrinsth
amsd teirth
the
I)aravertebral
atid
1163
COCCIDIOIDOMYCOSIS
involvemenrt
of
oh
amid
the
right
thoracic
triasses
tire
(usc
transverse
cartilage
Vertebrae.
frequently
comst.iguously
i5
Bonse
are
lesionis
inrdistinsguisirable
Metastalic
1)I’innarY
lesionss,
nirsth
is itsvolved
ribs
be
the
we(lgimrg
cartilage
Cr’yptococcosis:
ntti(l may
of
lateral
cartilage
imrvolve
FEATURES
seemi in 10 per
roenstgensograpinically
Boric
carcinoma:
metastases
boric
tunnor.
Tire iristorv
arid
tire roentgensograpinic
may,
of a PrinnarY
features
cenit
of tine
frons
coccidioidomycosis
ons occasiotn,
neoplasns,
of tine lesions
tine
dissennitsated
simulate
cases
‘#{176}
1624
infections
distributionr
are usually
or
of tine
sufficient
bone
for
diagnosis.
Bacterial
with
joinst.
tinis
disease
infection:
destructions
frons
The
rapidity
atid
early
of clrarnge
pen’iosteal
seenr
ins bacterial
nsew-bonie
osteomyelitis
irelp
formations
along
differentiate
coccidioidomycosis.
Comments
Borne
involvemenrt
lnennatogenous
insated disease
tations
of delayed
arid
is associated
for
tine
horse
53-A,
NO.
The
OL.
in
coccidioidomycosis
is
ins origins, anrd in approxinnately
bone lesionss develop
.
Osseous
disseminsatiois
with
findings
prominelsces
arsd
1971
always,
cent
irsvolvement
commonrly,
t4#{149}
widespread
roentgensographic
6, SEPTEMBER
More
almost
20 per
borne
if
of patients
may
be the
involvement
riot
always,
w’itis dissemfirst manifesis multiple
disease.
of
multiple
metaplryses,
osseous
relative
lesions
disc
with
cartilage
a predilection
sparing
with
1164
n.
K.
indiscriminate
tive of fungus.
endemic
S. DINNENBERG,
DALINKA,
H.
involvement
of the appendages,
This is particularly
true if the
area.
suggestive.
The
further
association
Roent.genographic
the
defines
W.
degree
extent
and
patient
of lesions
evidence,
and
GREENDYKE,
AND
R.
symmetrical
is not white
of skin
however,
is
HOPKINS
lesions
are suggesand if he lives in an
or lung,
more
or both,
often
is highly
adjunct
an
which
of involvement.
References
1.
G. L., and
BAUM,
SCHWARZ,
Coccidioidomycosis:
JAN:
A Review.
Am.
J. Med.
Sci.,
230
: 82-97,
1955.
2.
C. D., and
1942.
H. A.: Coccidioidal
663-666,
3.
CARTER,
738,
4.
E.
R.:
Granuloma:
Coccidioidal
Roentgen
Infection
Diagnosis.
in
Am.
Bonse.
Radiology,
J. Roentgennol.,
38:
25 : 715-
1931.
R. A. : Infectious
Granulomas
of Bone
and
23 : 1-16, 1934.
W. P. : Personal
communication,
1970.
V. P. : Bone Involvement
in Cryptococcosi.s
CARTER,
cidioidal
5.
6.
MILLER,
BENNINGHOVEN,
Granuioma.
COCKSHOT,
COLLINS,
102-112,
Joints,
with
Special
Reference
to
Coc-
Radiology,
(Torulosis).
Am.
J.
Roemstgemrol.,
63:
1950.
J. P. ; BnDDLE,
MARJORIE;
and MCKEEvER,
F. M.: Osseous
Coccidioidal
Gramrulomnra.
An Attempt
to Measure
the Prognosis.
J. Bone and Joint Surg., 41-A : 1109-1122,
Sept.. 1959.
8. COPE,
V. Z. : Actinomycosis
of Bone with Special
Reference
to Infectiotr
of the
\em’tebral
Column.
J. Bone and Joint Surg.,
33-B : 205-214,
May
1951.
9. C0ITNER,
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