To study the clinical presentation, radiological findings and management of spinal arachnoiditis in Coccidioidal Meningitis (CM).

Spinal arachnoiditis complicates approximately 12% CM patients. Spinal imaging is often delayed due to variable symptom onset and severity. Intrathecal amphotericin B deoxycholate (IT ABd) has been speculated to cause arachnoiditis in CM patients. IT ABd has been historically linked to the worsening of neurological symptoms in such cases.

Charts of 78 CM patients aged > 18 years who underwent MRI of at least one spinal segment were analyzed. We excluded incarcerated patients, those without spinal cord abnormalities on imaging and cases with insufficient data (n=25). 53 CM cases were included and reviewed for spinal arachnoiditis. Data were collected on their demographics, clinical presentation, imaging and management.

Spinal arachnoiditis (SA) was suspected clinically after a median time of 24 months (40 days to 32 years) from CM onset. Mean age at SA diagnosis was 49 years (range 19-74). 72% (n=38) patients were men. 77% (n=41) identified as Hispanic. 85% had ambulatory difficulties secondary to motor weakness and ataxia (n=44). 

137 MRI segmental scans were analyzed (48 cervical, 49 thoracic, and 43 lumbar). "Leptomeningeal enhancement"(75%) and "arachnoid cysts/adhesions"(27%) were seen throughout the spinal cord. "Cord edema, myelitis, and myelomalacia"(44%), and "syringomyelia"(16%) were identified exclusively within the cervical and thoracic segments. "Conus medullaris enhancement"(44%), "Nerve root clumping/enhancement" (26%) and "solid cauda equina"(18%) were observed in the lumbar region. 38% patients documented IT ABd use (n=20). Spinal arachnoiditis developed in CM patients treated with and without IT ABd. 

High occurrence of intraspinal abnormalities in CM supports a low threshold for spinal cord imaging. Contrary to previous literature, our study showed that neurological deterioration long speculated to be due to IT ABd may actually reflect the natural progression of infection rather than a treatment-related complication.