Longitudinal Neuroimaging in Pediatric Coccidioidomycosis: Full Spectrum of Brain, Spine and Head and Neck Findings.

Coccidioidomycosis is an endemic mycosis in some regions of the Americas including the southwestern United States with recognized potential for extra-pulmonary dissemination. Nevertheless, its neuroradiologic spectrum in children, particularly with respect to longitudinal evolution and head and neck involvement, remains incompletely characterized. We retrospectively reviewed n=16 pediatric patients with definitive or probable infection evaluated at a single quaternary care center in an endemic region, analyzing clinical/laboratory data and serial neuroimaging findings. Most children were previously healthy. Neuroimaging abnormalities represented the initial manifestation in more than one-third of cases and were frequently multifocal and temporally dynamic, including both clinically silent and delayed lesions. Craniospinal meningitis and related complications such as hydrocephalus, stroke, intracranial vasculopathy and chronic arachnoiditis were the most common and severe findings of central nervous system involvement. Parenchymal granulomas were more common than previously described, while cerebrovenous thrombosis and diffuse white matter signal abnormalities could also occur. Head and neck involvement was identified in 56% of patients, most commonly craniofacial osteomyelitis, but also temporomandibular joint septic arthritis, necrotic cervical lymphadenopathy/lymphadenitis, cutaneous lesions, and chorioretinitis, suggesting these features may be more prevalent in children than previously recognized. These findings expand the known imaging spectrum of pediatric coccidioidomycosis and underscore the importance of neuroradiologist familiarity with these patterns to facilitate early disease recognition within the appropriate clinical and epidemiologic context followed by timely initiation of antifungal therapy. A low threshold for neuroimaging, coupled with comprehensive, multi-compartment evaluation over time, is essential for accurate delineation of disease extent and for monitoring therapeutic response.