2024 American Academy of Neurology Abstract Website

Objective:

Background:

Coccidiodal meningitis is caused by a fungus in the soil found in the southwestern United States and portions of Central and South America. It has an indolent course but can result in complications including hydrocephalus, vasculitis, infarctions and pseudosubarachnoid hemorrhage. Mortality is high and treatment is lifelong antifungal therapy.

Design/Methods:

Results:

A 41-year-old immunocompetent female who traveled from Mexico presented with headaches, photophobia, vomiting, fever and night sweats for five days. Four months back she had findings concerning for erythema nodosum that were then resolved. Lumbar puncture revealed lymphocytic pleocytosis, low glucose and elevated protein. Bacterial and fungal cultures were negative. MRI showed few scattered T2/FLAIR hyperintense foci. Her symptoms were managed with supportive therapy for presumed aseptic meningitis. She was discharged home.

Two weeks later she presented in clinic with worsening headache, neck stiffness, fever and blurry vision with bilateral papilledema. Repeat lumbar puncture showed elevated opening pressure, worsened lymphocytic pleocytosis, and low glucose. A lumbar drain was placed. Her serum coccidiodal Ab came back positive (1:512) with elevated CSF coccidiodal Ab (1:32). CT head showed hydrocephalus and hyperdensities within the suprasellar region, interpeduncular cisterns, the bilateral ambient cisterns, and the bilateral sylvian fissures.

Fluconazole 800mg daily was started. Two weeks later at follow up she reported improved headache and fever. Repeat opening pressure was normal.

Conclusions:

An immunocompetent status in a non-endemic region lowered the initial concerns for coccdiodal meningitis and delayed treatment. We highlight the importance of taking a travel history, note the importance of low CSF glucose and association of fungal infections, and recommend a high index of suspicion for a coccidiodal infection even in immunocompetent individuals with meningitis to avoid delay in diagnosis and treatment.