Figure 1. Computed tomography (CT) scan of the head with intravenous (IV) contrast, showing focal hemorrhage versus enhancing mass (blue arrow) involving the genu of the corpus callosum measuring 1.1 × 1.8 × 3.9 cm.
| Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access |
| Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc |
| Journal website https://www.journalmc.org |
Case Report
Volume 14, Number 3, March 2023, pages 81-87
A Rare Case of Coccidioidomycosis Meningitis
Figures
Tables
| Spinal fluid | Patient value (units) | Reference range |
|---|---|---|
| µL: microliter, dL: deciliter, mg: milligram, RBCs: red blood cells; WBCs: white blood cells; CSF: cerebrospinal fluid. | ||
| Glucose, CSF | 81 mg/dL | 40 - 70 mg/dL |
| Protein, CSF | 146 mg/dL | 15 - 45 md/dL |
| RBC, CSF | 10,000 µL | 0 µL |
| WBC, CSF | 4 µL | 0 µL |
| Coccidioides, CSF | 1:1 | < 1:1 |
| Opening pressure, CSF | 43 mL | |
| Reference | Age | Sex | Geographic location | HIV status | Comorbid conditions | Initial presentation | Plasma titer | CSF titer | Treatments | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| F: female; M: male; LA: Los Angeles; CA: California; USA: United States of America; CSF: cerebrospinal fluid; GA: Georgia; N/a: not available; IV: intravenous; PO: oral QD: daily; BID: twice daily; TID: three times a day; LAmB: liposomal amphotericin. | ||||||||||
| [7] | 49 | F | LA, CA, USA | Negative | None | Headaches, fevers, vomiting, and maculopapular rashes (1.5 × 1.5 cm) on the face and back | N/a | N/a | IV fluconazole (800 mg intravenously daily), IV ceftriaxone (4 g q24h), and IV mannitol (125 mL intravenously q8h). | Recovered |
| [8] | 66 | M | N/a | Negative | None | Facial pain, fever | 1:128 | 1:32 | PO fluconazole 400 mg daily. IV liposomal amphotericin, high-dose fluconazole, intrathecal (IT) amphotericin B and voriconazole. IV isavuconazole (372 mg every 8 h for six doses, then every 24 h thereafter) (35-day therapy). | Recovered |
| [8] | 33 | F | N/a | Negative | None | Found down | N/a | 1:8 | Intravenous high-dose fluconazole 400 mg twice daily. High-dose fluconazole, IV LAmB and concomitant IT amphotericin B. IV isavuconazole (372 mg every 8 h for six doses, then every 24 h thereafter) (23-day therapy). | Comatose |
| [8] | 22 | M | N/a | Negative | None | 3 months of headaches | N/a | 1:8 | PO posaconazole 300 - 600 mg QD (34-day therapy). PO voriconazole 300 mg BID (17-day therapy). PO fluconazole 600 mg BID (11-day therapy). IV voriconazole 300 mg BID (13-day therapy). PO itraconazole suspension 200 mg TID (204-day therapy). PO isavuconazole 372 mg QD (55-day therapy). PO fluconazole 600 mg BID, IV amphotericin B 5 - 10 mg/kg QD, IT amphotericin B (295-day therapy). | Recovered |
| [9] | 36 | M | Central Valley, CA, USA | Negative | None | Headache, nausea, vomiting | 1:256 | 1:8 | PO 1,200 mg daily fluconazole and IV liposomal amphotericin-B 5 mg/kg QD, followed by a PO dexamethasone for 15 days and PO fluconazole 800 mg daily. IV liposomal amphotericin-B 5 mg/kg QD and PO voriconazole 400 mg BID, IV dexamethasone 3 mg IV every 6 h, with a 5-day taper to 1 mg IV every 12 h, IV posaconazole 300 mg QD. | Expired |
| [10] | 42 | M | Hobbs, New Mexico, USA | Negative | None | 3-week history of headache, malaise, low-grade fevers, photophobia, phonophobia, and vomiting | N/a | N/a | IV acyclovir 900 mg every 8 h, IV vancomycin 2 g every 8 h, IV ceftriaxone 2 gram every 12 hours, and IV dexamethasone 10 mg × 1 dose. PO isoniazid 3 mg daily, PO rifampin 100 mg daily, PO ethambutol 1,600 mg daily, PO pyrazinamide 2,000 mg daily, IV dexamethasone 8 mg every 8 h, IV LAmB 200 mg daily. PO fluconazole 800 mg daily, dexamethasone taper. | Recovered |
| [11] | 26 | M | Southwest, USA | Negative | None | Persistent fevers, headache, nausea, and vomiting | High | N/a | IV fluconazole 1,200 mg daily. IV LAmB 10 mg/kg daily, dexamethasone. fluconazole was replaced with IV voriconazole with loading dose of 6 mg/kg IV BID for two doses; then maintenance dose of 4 mg/kg IV BID. Lifelong triazole therapy. | Recovered |
| [12] | 53 | M | N/a | Negative | Coccidioidal meningitis diagnosed 3 years prior | New onset diplopia secondary to a right-sided CN VI palsy that followed 2 weeks of progressively severe worsening headaches | 1:16 | 1:4 | PO fluconazole 800 mg daily. IV LAmB 5 mg/kg/day × 14 days, then transitioned to PO voriconazole 200 mg QD. | Recovered |
| [12] | 27 | M | N/a | Negative | 5-year history of coccidioidal meningitis | Severe headache, meningismus, and normal mentation | N/a | 1:4 | 5-year history of PO fluconazole 1,000 mg QD. IV LAmB 5 mg/kg/day × 14 days, then transitioned to PO voriconazole 200 mg QD. | Recovered |
| [13] | 39 | M | Central Valley, CA, USA | Negative | 21 years of heavy alcohol use | Weight loss, night sweats | Negative | Positive | PO fluconazole 400 mg daily. | Recovered |
| [14] | 53 | F | N/a | Negative | Coccidioidal meningitis | Gait instability, confusion, and headache | N/a | N/a | IV fluconazole, then switched to PO fluconazole. | Recovered |
| [15] | 55 | M | Mexico | Negative | None | Bilateral upper extremities weakness | 1:128 | Positive | High-dose steroids, IV LAmB. | Expired |
| [16] | 30 | F | San Joaquin Valley, CA, USA | Negative | 14 weeks’ gestation | Headaches, nausea, vomiting, joint pain, fevers, circular erythematous lesions on her right thumb and back | N/a | N/a | intravenous LAmB, intrathecal amphotericin B, and intrathecal hydrocortisone. | Recovered |
| [17] | 59 | M | Atlanta, GA, USA | Positive | HIV, epididymitis | Headache, photophobia, neck stiffness, fevers, chills, weight loss, dyspnea, cough, scant hemoptysis | N/a | N/a | Four-drug therapy (PO isoniazid daily, PO rifampin daily, PO ethambutol daily, PO pyrazinamide daily) and dexamethasone for tuberculous meningitis. | Expired |