Background
- Dimorphic fungus found in the soil, two main species:
- C. imitis in SW US esp California
- C. posadasii in northern Mexico and other parts of Central and South America
- Cocci meningitis first described by Ophuls in 1905
- is increasingly diagnosed in endemic areas btw 1997 & 2006 incidence quadrupled to 91 per 100,000 with
60% of cases coming from Arizona
- 60% of infections are asymptomatic, the remainder have mainly pulmonary symptoms
- 1-5% of symptomatic pts have extra pulmonary infxn wks to months after the initial infection
- skin & soft tissues, bones/joints, CNS (meningitis in 0.15% to 0.75% of
cases)
- CSF eosinophilic pleocytosis identified in 70% of pts in one study, but other authors report this finding
to be uncommon
- Neuroimaging abnormalities seen in up to 75% of patients, those w/abnormalities have higher mortality rate
(32%) vs 8% for those without
- most commonly see diffuse meningeal enhancement, but focal enhancement of basal cisterns, Sylvian
fissures, craniocervical junction or pericallosal regions can be seen
- may also see hydrocephalus, acute deep cerebral infarcts/edema, massess/abscesses
Treatment: If untreated, meningitis is lethal for 95 percent of patients within two years
- Polyenes (Ampho B .01 to 1.5 mg and newer lipid formulations) used for more serious forms of disease,
ineffective for meningitis if given IV has to be given intrathecal
- intrathecal AMB can cause meningeal irritation > fever, headache, pain in abd or back
- reservoirs for IT insulation of AMB can be placed
- lipid formulations have cured CM animals when given IV, no human studies
- relapse rate ~30%
- Azoles: Voriconazole used more often in life threatening mycoses
- in one study 79% of pets responded to 400 mg oral fluconazole
- itraconazole 200 mg TID or BID, doesnt penetrate CSF well but has been shown to be able to treat
CM, likely due to penetration into inflamed meninges
- 400 mg Posaconazole BID highly active against Cocci in vitro, used successfully in one study to treat
62% of patients w/refractory infection or those intolerant of other drugs
- high risk of relapse after azole discontinuation studies ~78% so need to continue treatment for life
- focal neurologic complications may emerge during tx, esp within the first 2 years, it is useful to perform
MRI of both the head and spinal cord at baseline and in follow-up
T1 weighted image
showing disease
involving basilar cisterns
References:
1) Blair JE. Coccidioidal Meningitis: update on Epidemiology, Clinical Features, Diagnosis, and Management. Current
Infectious Disease Reports. 2009. 11:289-295.
2) Hector RF and Laniado-Laborin R. Cocidiomycosis-A Fungal Disease of the Americas. PLoS Medicine. 2005.
3) Galgiani JN, Ampel NM, Catanzaro A, Johnson RH, Stevens DA, et al. (2000) Practice guidelines for the treatment of
coccidioidomycosis. Clin Infect Dis 30: 658661.
4) Goldstein EJ, Johnson RH, and Einstein HE. Clin Infect Dis. 2006 42 (1):103-107.
5) Drake KW and Rodney AD. Coccidiodal meningitis and brain abscesses: Analysis of 71 cases at a referral center.
Neurology. 2009. 73(21):1780-6.