Metacarpal Coccidioidal Osteomyelitis

​Coccidioidomycosis is a rare fungal infection primarily of the lungs.    It is endemic to the southwest United States, Mexico, Central America, and South America.  Coccidioidomycosis can disseminate to bone. Common sites include spine, patella, metacarpals, metatarsals, carpal bones, and diaphysis of long bones.  Bone infections of the hand most commonly occur in children.
 
The case report in this journal is of an African American man with coccidioidal osteomyelitis of the fifth metacarpal.  The patient initially fell and was diagnosed with a left 5th metacarpal fracture.  Two weeks later he developed abscess on anterior shoulder, which was drained.  He was also treated with intravenous antibiotics.  Three weeks after casting, the patient noticed drainage but did not seek medical attention for an additional week.  On exam. a granulomatous ulceration was found over the dorsal fifth metacarpal head.  Small finger MCP joint lacked full flexion and extension.  The ESR and CRP were significantly elevated.  Initial x-rays showed evidence of bone changes consistent with possible osteomyelitis.  Radiographs 4 weeks later showed erosion of the fifth metacarpal neck and head.  The patient was empirically started on IV vancomycin and oral levofloxacin.  The patient was ultimately taken to surgery and the metacarpal head was resected.  Coccidioides immitis was found with intra-operative cultures.  Fluconazole was started once cultures were final.  At four-month follow-up wound was completely healed with no evidence of infection.