Objective:

To present a case of subacute coccidioidal meningitis in a patient initially presumed to have ALS, highlighting the impact of socioeconomic factors and recognizing atypical presentations of meningitis.

Background:

Coccidioidal meningitis is a rare but serious complication of Coccidioides infection, typically presenting with systemic symptoms like fever, headache, and neck stiffness. However, in subacute cases, presentations may be atypical, with focal neurological deficits overshadowing systemic signs. This can complicate the diagnosis. In such cases, imaging and serological testing are critical for distinguishing between progressive neurological diseases and treatable infections.

Design/Methods:

N/A

Results:

A 58-year-old male with type 2 diabetes and previously diagnosed ALS presented with worsening confusion and inability to walk after a year of progressive bilateral lower extremity weakness.The patient had been diagnosed with ALS at an outside facility approximately 6 months previously. Upon admission, due to progression and atypical features (urinary retention and a sensory level at T4), he was re-evaluated. Brain and spine MRI revealed leptomeningeal enhancement and communicating hydrocephalus, suggesting meningitis despite absent systemic symptoms. Further testing confirmed subacute coccidioidal meningitis (positive Coccidioides EIA IgG, CF titer 1:16).  Complex socioeconomic factors, including undocumented status and lack of insurance, had led to patient’s inability to follow-up initial recommendations, which contributed to the delayed diagnosis. Treatment with amphotericin and lifelong fluconazole was initiated.

Conclusions:

This case highlights the diagnostic challenges in patients with complex socioeconomic issues and underscores the importance of considering atypical presentations of CNS infections like coccidioidal meningitis. In this instance, initial ALS concerns were not fully evaluated and the patient’s symptoms progressed. Revaluation revealed leptomeningeal enhancement on imaging and atypical neurological finding. This study underscores the importance of health care coverage in our American healthcare system as well as complete evaluation of atypical symptoms to allow for early intervention and treatment.