Controversies in the Management of Central Nervous System Coccidioidomycosis

Thompson, George R.; Ampel, Neil M.; Blair, Janis E.; Donovan, Fariba M.; Fierer, Joshua; Galgiani, John N.; Heidari, Arash; Johnson, Royce H.; Shatsky, Stanley A.; Uchiyama, Christopher M.; Stevens, David A.

doi:10.1093/cid/ciac478

Cited by 8 publications

(10 citation statements)

References 56 publications

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“…9 The experts recommended placement of an MRI-compatible VP shunt as the only permanent management approach, with other approaches like repeated CSF removal via LP or external ventricular drain (EVD) as temporary treatments. 9,10 The experts also agreed that shunt placement should not be delayed with concern that delays in shunting lead to worse patient outcomes. 8,11 However, published guidelines do not specify optimal timing for a shunt in the management of hydrocephalus with increased ICP for minimally symptomatic patients.…”

Section: Discussionmentioning

confidence: 99%

Non-shunt Management of Communicating Hydrocephalus in an Immunocompetent Host With Disseminated Central Nervous System Coccidioidomycosis

Menghani

Takamatsu

Ibrahim

et al. 2023

Journal of Investigative Medicine High Impact Case Reports

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Disseminated coccidioidomycosis is associated with significant morbidity and mortality. Involvement of the meninges is often fatal if untreated, typically requiring lifelong antifungal therapy and neurosurgical intervention. We present the case of a young male without any known immunocompromising conditions who opted exclusively for medical management of newly diagnosed coccidioidomycosis meningitis with communicating hydrocephalus and discuss the controversy associated with this approach. This case highlights the importance of shared decision-making between patient and clinician, even if the plan diverges from available guidelines. Furthermore, we discuss clinical considerations in approaching the close outpatient monitoring of patients with central nervous system coccidioidomycosis with hydrocephalus.

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Section: Discussionmentioning

confidence: 99%

Non-shunt Management of Communicating Hydrocephalus in an Immunocompetent Host With Disseminated Central Nervous System Coccidioidomycosis

Menghani

Takamatsu

Ibrahim

et al. 2023

Journal of Investigative Medicine High Impact Case Reports

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“…Moreover, we did not systematically assess fluconazole adherence by therapeutic drug monitoring during the entire study period. Therapeutic drug monitoring of fluconazole has not generally been recommended given the >90% bioavailability of fluconazole, although some experts use such levels to assess patient medication adherence [19]. It is noteworthy that all fluconazole levels were therapeutic for the patients in the study when assessed.…”

Section: Discussionmentioning

confidence: 99%

Fluconazole Failure in the Treatment of Coccidioidal Meningitis

Gupta

Ampel

Klanderman

et al. 2022

JoF

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Introduction: Coccidioidal meningitis (CM) is the most lethal form of disseminated coccidioidomycosis. Current guidelines recommend fluconazole as initial therapy but there has been a paucity of data regarding failure of fluconazole and optimal fluconazole dosage in the treatment of CM. We conducted this study to understand risk factors for fluconazole failure. Methods: We conducted a single-center retrospective chart review of patients diagnosed with coccidioidal meningitis between 1 January 1988 and 15 May 2021. Relevant demographic and clinical variables were collected, along with outcomes including treatment failure and death at any point. Univariate tests were conducted using the chi-squared goodness of fit test and analysis of variance. Results: Among 71 patients who began treatment for CM with fluconazole, 22 (31%) developed worsening meningitis at a median time of 206 days. Longer time from symptom onset to diagnosis of CM was a risk factor for fluconazole failure. Although the absolute failure rate of fluconazole starting dose of 400 mg daily was higher than that of 800 mg daily, the differences did not achieve statistical significance (p = 0.39). Conclusion: Fluconazole failure is not uncommon in the treatment of CM. A dose of 800 mg daily was not superior to a dose of 400 mg daily. All patients on fluconazole for CM require close monitoring.

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“…Meningitis is recognized as the most serious type of dissemi nated coccidioidomycosis and if not treated is lethal. 1 This form of the disease requires prompt diagnosis and proper management by experts, which reduces the risk of serious complications such as hydrocephalus, vasculitic infarctions, cranial neuropathy, arachnoiditis, and death. 2 The Infectious Diseases Society of America's cocci dioidal guidelines indicate analyzing cerebral spinal fluid (CSF) for initial diagnosis if meningeal symptoms are pres ent and recommend initial therapy with fluconazole 400 to 1200 mg. 3 The current medical treatment is thought to only suppress the disease.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Asymptomatic Coccidioidal Meningitis Relapse: A Demon in Disguise

Kooner

Heidari

Johnson

2023

Journal of Investigative Medicine High Impact Case Reports

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Coccidioides spp is a soil-dwelling, dimorphic fungus that causes coccidioidomycosis. It is endemic to the western hemisphere. Although primarily a respiratory disease, it can also cause a myriad of clinical manifestations, from asymptomatic disease to meningitis. In fact, Coccidioides species is probably the most common etiologic agent of long-term meningitis in California and Arizona. Early diagnosis and treatment are critical to avoid fatal complications. With treatment, the cerebral spinal fluid analysis may return to normal. Relapse of coccidioidal meningitis is usually suspected with recurrence of meningitis symptoms. The patient is a 53-year-old man with a 2-decade history of coccidioidal meningitis who was diagnosed with an asymptomatic relapse of coccidioidal meningitis.

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Controversies in the Management of Central Nervous System Coccidioidomycosis

Cited by 8 publications

References 56 publications

Non-shunt Management of Communicating Hydrocephalus in an Immunocompetent Host With Disseminated Central Nervous System Coccidioidomycosis

Non-shunt Management of Communicating Hydrocephalus in an Immunocompetent Host With Disseminated Central Nervous System Coccidioidomycosis

Fluconazole Failure in the Treatment of Coccidioidal Meningitis

Asymptomatic Coccidioidal Meningitis Relapse: A Demon in Disguise

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