Abstract
Coccidioidomycosis is an invasive fungal disease caused by Coccidioides species, posing a significant risk of disseminated infection. Vertebral involvement, though rare, can lead to instability, epidural abscess, and neurological deficits. In such cases, the integration of antifungal therapy and surgical intervention becomes critical, yet no standardized surgical protocol exists. A 27-year-old pregnant woman presented with four months of progressive axial neck pain, neck stiffness, a left-sided cervical mass, and neurological deterioration consistent with upper cervical myelopathy. Workup revealed vertebral coccidioidomycosis at the craniocervical junction with ventral C1 displacement and spinal instability. Biopsy of the cervical mass confirmed Coccidioides infection, and she was started on fluconazole, amphotericin B, and steroids. Due to worsening neurological function (ASIA B) and imaging showing cervical cord compression, occipitocervical fixation with foramen magnum decompression and partial C1 resection was performed. Despite technically successful decompression and rigid fixation, her neurological function remained unchanged postoperatively. She also experienced preterm labor soon after surgery, and the neonate did not survive. The patient was eventually discharged on lifelong antifungal therapy, maintaining American Spinal Injury Association (ASIA) Impairment Scale grade B status at the short-term follow-up. Vertebral coccidioidomycosis involving the craniocervical junction is a rare but serious entity that can cause rapid neurological decline. While prolonged antifungal therapy remains essential, timely surgical decompression and stabilization are vital when spinal instability or neurological deficits are present. This case underscores the importance of early diagnosis and intervention for improved outcomes in spinal coccidioidomycosis, especially in high-risk patients such as pregnant women.