To describe the clinical presentation, neuroradiology findings, treatment, and outcomes in paralyzed patients with Coccidioidal meningitis
Coccidioidal meningitis (CM) is a life-threatening condition and a diagnostic challenge. It is associated with infarction, aneurysms, hydrocephalus, intracranial hemorrhage, transient ischemic attacks, syrinx, and arachnoiditis. Untreated, it is fatal within 2 years.
We conducted a retrospective case review (2011–2023) identified by ICD-9/10 codes and positive Coccidioides IgG/IgM in CSF. Confirmed CM, paralysis, and available neuroimaging were included. Patients under 18 years or those with insufficient data were excluded.
Thirty-four patients were identified; mean age was 45.5 years (range: 21 to 64 years old). Twenty-four patients were male, and most were White Hispanic. Twenty-nine patients developed paralysis on therapy for CM, while 5 presented with paralysis as the initial manifestation of CM.
Headache was the most common initial symptom. Paralysis developed after a median of 18 months (range: 6 days–19 years) from initial CM diagnosis. Twenty-one patients were treated initially with fluconazole, 16 of whom were transitioned to broad-spectrum triazoles at the onset of paralysis: 1 to itraconazole, 7 to voriconazole, 2 to posaconazole, and 6 to isavuconazole. At paralysis onset, along with azole therapy, adjunctive therapy included intravenous liposomal amphotericin B, intrathecal amphotericin B, in combination with dexamethasone. Twelve patients had ventriculoperitoneal (VP) shunts placed: 7 at the time of CM diagnosis and 5 at the onset of paralysis.
Neuroradiologic findings at paralysis onset included basilar arachnoiditis (16/34), hydrocephalus (11/34), vasculitic infarctions at various locations (19/34), spinal arachnoiditis (16/34), syrinx (3/34), and subarachnoid hemorrhage (3/34). One patient had a right middle cerebral artery aneurysm.
Twenty-eight patients survived with the significant morbidity, and 6 patients died.Paralysis in patients with CM is associated with significant morbidity and mortality. Antifungal therapy with adjunctive glucocorticoids reduces mortality rate.