Overview
Coccidioidal meningitis (CM) is a severe fungal infection caused by Coccidioides immitis or Coccidioides posadasii, often complicated by vasculitis, hydrocephalus, and neurological deficits 125.Diagnosis
Clinical Presentation: Includes headache, fever, altered mental status, and signs of meningeal irritation 125.
Laboratory Tests: CSF analysis typically shows pleocytosis, elevated protein, and low glucose levels 13.
Imaging: Neuroimaging often reveals asymmetric hydrocephalus, cerebral vasculitis, and infarcts 125.
Serological Tests: Confirm coccidioidal infection through serological markers 1.Management
First-Line Treatment: Amphotericin B or lipid-associated formulations of amphotericin B are recommended 14.
Adjunctive Therapy: Fluconazole for consolidation therapy post-Amphotericin B 14.
Vasospasm Management: Percutaneous transluminal angioplasty (PTA) may be considered in severe cases 2.
Vasculitis: No established therapies; corticosteroids use is controversial 4.Special Populations
Pediatrics: Higher risk of hydrocephalus; outcomes assessed by HOQ and mRS; frequent shunt surgeries required 1.
Comorbidities: Vasculitic complications can lead to cerebral arteritis and infarction, complicating management 45.Key Recommendations
Initiate empirical antifungal therapy with amphotericin B in suspected cases of coccidioidal meningitis (Evidence: Strong 14).
Monitor for and manage complications such as hydrocephalus and cerebral vasculitis through appropriate neuroimaging and interventions (Evidence: Moderate 125).
Consider adjunctive use of fluconazole for consolidation therapy following initial amphotericin B treatment (Evidence: Moderate 14).
Evaluate and treat intracranial vasospasm with endovascular techniques like PTA when clinically indicated (Evidence: Weak 2).
Close follow-up in pediatric patients due to higher morbidity and need for repeated neurosurgical interventions (Evidence: Moderate 1).References
1 De la Cerda-Vargas MF, Candelas-Rangel JA, Navarro-Dominguez P, Sandoval-Bonilla BA, Meza-Mata E, Muñoz-Hernandez MA et al.. Neurococcidiomycosis in children with hydrocephalus: assessment of functional outcome, quality of life and survival in relation to neuroimaging findings. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2024. link
2 Hu YC, Newman CB, Bristol R, McDougall CG, Albuquerque FC. Percutaneous transluminal angioplasty in a patient with vasospasm secondary to coccidioidal meningitis: case report and review of the literature. Journal of neurointerventional surgery 2011. link
3 Williams PL, Leib SL, Kamberi P, Leppert D, Sobel RA, Bifrare YD et al.. Levels of matrix metalloproteinase-9 within cerebrospinal fluid in a rabbit model of coccidioidal meningitis and vasculitis. The Journal of infectious diseases 2002. link
4 Williams PL. Vasculitic complications associated with coccidioidal meningitis. Seminars in respiratory infections 2001. link
5 de Carvalho CA, Allen JN, Zafranis A, Yates AJ. Coccidioidal meningitis complicated by cerebral arteritis and infarction. Human pathology 1980. link80013-x)