Objective:

To present a case of Coccidioides meningitis complicated by vasculitis and multiple ischemic strokes.

Background:

Coccidioides, a soil-dwelling fungus endemic to the western U.S., can cause rare central nervous system complications such as meningitis, vasculitis, hydrocephalus, and stroke, all linked to high morbidity.

Design/Methods:

NA

Results:

A 68-year-old male, with recent travel to Arizona, presented with a two-month history of worsening headaches. MRI showed ischemic stroke in left cerebellum, and dilation of bilateral ventricles, suggesting hydrocephalus. However, the absence of neurological deficits and infarct localization suggested a different etiology for the headaches. Discharged the next day, he returned four days later with altered mental status, nausea, and extreme fatigue. Elevated LP opening pressure, neck pain, and CSF antigen confirmed Coccidioides meningitis. He started on fluconazole, then switched to itraconazole. A month later while hospitalized, he suffered a right basal ganglia stroke due to parainfectious vasculitis and was treated with dexamethasone. Discharged to rehab, he developed worsening right-sided weakness and facial droop several days later. Readmission MRI revealed new infarcts in the left thalamus and corona radiata, hemorrhagic stroke conversion, and worsening vasculitis, causing hemiplegia and incontinence. Despite CSF profile improvement (1511/uL to 97/uL Total Nucleated Cells), his condition deteriorated over the next month, likely due to an immunologic response rather than untreated infection, and ultimately elected to pursue comfort care.

Conclusions:

This case highlights the challenge of managing vasculitis-related stroke in Coccidioides meningitis. We identified two potential causes for the recurrent strokes: infection-related and immune response-related vasculitis. Early recognition is crucial, especially as the disease spreads to regions historically unaffected. Non-endemic regions constitute just 2% of cases, but climate change and increased travel has worsened the distribution and burden of disease.