Coccidioidal meningitis and brain abscesses: Analysis of 71 cases at a referral center

OBJECTIVE: Coccidioides species are the most common etiologic agents of chronic meningitis in regions endemic for coccidioidomycosis. Occasionally, even short-term travel to endemic regions results in the acquisition of meningeal disease, so awareness of this complication of coccidioidomycosis is important even in nonendemic areas. The prognosis depends on the early recognition and treatment of the disease, so it is important to be familiar with the varied clinical manifestations, risk factors associated with meningeal involvement, diagnostic challenges, and therapeutic modalities. METHODS: We performed a retrospective analysis of 71 cases with coccidioidomycosis involving the CNS seen from 1996 to 2007 at a referral medical center in southern Arizona. RESULTS: The only presenting symptom found in the majority of patients was headache. Those who were immunocompromised (most commonly HIV/AIDS and chronic steroid therapy) were at increased risk, but diabetics were not at increased risk. There was a preponderance of males (2:1) and people of Hispanic, African, and Asian (especially Pacific Isles) background. CSF anticoccidioidal antibody and culture were frequently negative on presentation, but in these cases, the serum antibody test was usually positive. Imaging studies were helpful in two thirds of cases, most commonly demonstrating basilar meningitis or hydrocephalus, which frequently required ventriculoperitoneal shunting. Most were treated with fluconazole, and prognosis was good for most of those who remained on treatment. CONCLUSIONS: Coccidioidal meningitis remains a diagnostic challenge, but the diagnosis can usually be made successfully when coccidioidal serum and CSF antibodies and cultures are combined with appropriate imaging studies.