- John N Galgiani, MD
John N Galgiani, MD
- Professor of Medicine
- University of Arizona
Coccidioidomycosis is caused by the dimorphic fungi of the genus Coccidioides (C. immitis and C. posadasii), which are endemic in desert regions of the southwestern United States and Central and South America. (See "Primary coccidioidal infection", section on 'Epidemiology' and "Primary coccidioidal infection".)
Coccidioidal meningitis will be reviewed here. Primary infection, extrapulmonary infection outside of the central nervous system, laboratory diagnosis, pulmonary sequelae, and infection in immunocompromised hosts are discussed separately. (See "Primary coccidioidal infection" and "Coccidioidomycosis: Laboratory diagnosis and screening" and "Manifestations and treatment of extrapulmonary coccidioidomycosis" and "Coccidioidomycosis in compromised hosts".)
Coccidioidomycosis has protean manifestations, and primary infection is frequently unrecognized. However, disseminated infection can occur. Meningitis is the most lethal complication of coccidioidomycosis, and thus it is crucial to recognize this serious complication. If untreated, meningitis is lethal for 95 percent of patients within two years . This contrasts sharply with most nonmeningeal infections, which are either self-limited respiratory syndromes or cause chronic focal morbidity within or beyond the lungs. (See "Primary coccidioidal infection" and "Coccidioidomycosis in compromised hosts".)
Precise statistics about the incidence of meningitis due to this fungus are not available. The Arizona Department of Health Services found that, in 2007, 8 percent of reported new coccidioidal infections were disseminated and, of these, 17 percent involved the central nervous system . Applying these statistics to the total number of 4900 reported cases in Arizona provides an annual estimate of about 60 cases in Arizona or 100 cases in the United States. Since it is estimated that there are more than 150,000 infections with Coccidioides spp annually, these estimates suggest that the proportion of patients with meningitis is less than 0.1 percent of all exposures.
The treatment of coccidioidal meningitis has evolved to include oral therapies that have largely supplanted the need to instill antifungal agents directly into the cerebrospinal fluid. Nonetheless, the management of coccidioidal meningitis remains difficult and often requires the orchestration of several medical subspecialties to optimize the clinical response.
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- CLINICAL MANIFESTATIONS
- Signs and symptoms
- Imaging findings
- Initial approach to diagnosis
- Routine examination of CSF
- Approach when cultures and antibody tests are negative
- Specific diagnostic tests
- - Culture
- - CSF antibody testing
- - CSF coccidioidal antigen levels
- Antifungal therapy
- Management of increased intracranial pressure
- Monitoring treatment response
- SUMMARY AND RECOMMENDATIONS