Transient Ischemic Attack as a Presenting Manifestation of Coccidioidal Meningitis: A Review of Four Cases
Safa Mousavi1, Divanshu Sharma1, Shikha Mishra2, Bianca Torres1, Jigar Patel2, Michelle Fang3, Carlos DAssumpcao2, Rasha Kuran2, Katayoun Sabetian4, Royce Johnson2
1Valley Fever Institute, Kern Medical, 2Department of Medicine, Division of Infectious Disease, 3Department of Pharmacy, 4Department of Neurology, Kern Medical
Objective:

To identify transient ischemic attack (TIA) as a presenting symptom or complication of coccidioidal meningitis (CM)

Background:

Meningitis is the feared manifestation of disseminated coccidioidomycosis. It commonly presents with headache and may be accompanied by altered mental status, gait disturbance, and focal neurological deficits. TIA is a rare presentation of CM, with only a single case reported to date.

Design/Methods:

A retrospective review (2011–2023) was conducted using ICD-9/10 codes and positive CSF Coccidioides IgG/IgM. Confirmed CM, TIA, and available neuroimaging were included; MRI evidence of CVA were excluded.

Results:

Case 1

A 40-year-old Latino man with pulmonary coccidioidomycosis presented with headache and transient right facial and limb numbness. Lumbar puncture (LP) showed 520 WBCs (44% lymphocytes), glucose 22 mg/dL, protein 249 mg/dL, and coccidioides complement fixation (CF) 1:4. Fluconazole 1000mg/day was continued with daily LP until ICP normalized.

Case 2

A 64-year-old Latino man with chronic pulmonary coccidioidomycosis presented with headache, transient right facial droop, and left-sided weakness. LP showed 240 WBCs (34% lymphocytes), glucose 38 mg/dL, protein 127 mg/dL, and CF 1:4. Fluconazole was increased to 1000mg/day with adjunctive dexamethasone.

Case 3

A 52-year-old Latino man with pulmonary coccidioidomycosis diagnosed with CM three months prior presented with transient slurred speech, right-sided weakness, and left lower facial droop. LP showed 210 WBCs (74% lymphocytes), glucose 27 mg/dL, protein 218 mg/dL, and CF 1:32. Fluconazole 1000mg/day was continued.

Case 4

A 42-year-old Latino woman with chronic CM had a relapse presenting as headache. Six months later, she presented with headache, right facial numbness, and transient leg weakness. LP showed 28 WBCs (68% lymphocytes), glucose 36 mg/dL, protein 52.7 mg/dL, and CF 1:1. Voriconazole 400mg/day was continued.

Conclusions:

Even in an endemic zone for coccidioidomycosis, TIA is a rare presentation of CM. It is a diagnostic consideration, particularly for patients with previously identified non-CNS coccidioidomycosis.

10.1212/WNL.0000000000215702
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