29 Sep 2020

7/16/20 Coccidoidal Meningitis

For our first Goldstein Morning Report of the 2020-2021 academic year, PGY3 Darren Morris presented a very interesting case of a 71 yo F with history of HTN who presented with 3 weeks of encephalopathy and a subsequent fall. On neurologic exam, the patient was AAOx0, cranial nerves intact, unable to follow commands and had diffuse weakness. The remainder of the examination was unremarkable.

Metabolic, basic infectious (UA, blood cultures, CXR), and endocrine workup did not yield an obvious etiology.

MRI of the brain had the following findings:

Lumbar Puncture:

  • Xanthochromic, slightly cloudy
  • RBC: 2/cumm
  • WBC: 428/cumm
  • Nucleated Cells: 15%
  • Lymph: 57%
  • Monocytes/Histiocytes: 17%
  • Plasma Cells: 12%
  • Glucose: 29 mg/dL
  • Protein: 677 mg/dL

Given concern for TB vs fungal meningitis, patient was started on RIPE and fluconazole.

Then, the CSF Cocci Antibody resulted at 1:64 (elevated)

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Treatment:
Patient was started on liposomal amphotericin, and then transferred to Neuro ICU for Ommaya to continue with IT amphotericin. RIPE was discontinued.

Take home points:

  1. Cocci Meningitis should be on differential when considering meningitis in Los Angeles.
  2. Cocci normally manifests with pulmonary symptoms, but it can also present in other ways. It can be associated with CNS vasculitis and present with stroke.
  3. First line treatment is Fluconazole but if patient has worsening neurologic symptoms or persistent pleocytosis on CSF despite first line therapy, IT amphotericin should be initiated. Treatment will require maintenance azole therapy for life.

Sentinel Article:
Disseminated Coccidioidomycosis Treated with Interferon-γ and Dupilumab

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