Disseminated Musculoskeletal Coccidioidomycosis in an Immunocompetent Host: A Rare Case Requiring Extensive Spinal and Pelvic Surgery.

Coccidioidomycosis, also known as "Valley Fever," is an endemic fungal infection caused by Coccidioides species, typically presenting as a respiratory illness. Disseminated disease, particularly with extensive skeletal involvement, is rare and typically seen in immunocompromised individuals. We report a unique and severe case of disseminated musculoskeletal coccidioidomycosis in a previously healthy immunocompetent 33-year-old African American man, involving multiple spinal levels, pelvic bones, and the right chest wall. The patient required multiple orthopedic surgeries, including anterior and posterior spinal decompression and fusion, bilateral sacroiliac joint debridement, and pelvic fixation. The diagnosis was confirmed via bone biopsy demonstrating Coccidioides spherules. Despite antifungal therapy, his disease progressed, necessitating escalation of treatment from fluconazole to isavuconazole and liposomal amphotericin B, followed by initiation of fosmanogepix as part of the approved treatment regimen. This case highlights the importance of high clinical suspicion, aggressive surgical intervention, and multidisciplinary management in complex disseminated coccidioidomycosis, even in immunocompetent hosts.