Patient outcomes and surgical complications in coccidioidomycosis-related hydrocephalus: an institutional review

Abstract

Object Coccidioidomycosis is a common fungal infection in the southwestern US. Hydrocephalus is a serious complication of cranial coccidioidomycosis, and the surgical management of coccidioidomycosis-related hydrocephalus has unique challenges. The authors reviewed their institutional experience with hydrocephalus in the setting of coccidioidomycosis. Methods The authors retrospectively identified 44 patients diagnosed with coccidioidomycosis-related hydrocephalus at their institution since 1990, who underwent a total of 99 shunting procedures. The authors examined patient demographics, type of shunt and valve used, pressure settings, failure rates, medical treatment, ventricular response to shunting, and other variables. Results The majority of patients were young (average age 37 years) men (male/female ratio 28:16) with a mean follow-up of 63 months. Patients of Asian and African descent were overrepresented in the cohort compared with regional demographic data. The overall shunt failure rate during follow-up was 50%, and the average number of revisions required if the shunt failed was 2.5 (range 1–8). Low to moderate draining pressures (mean 88 mm H2O) were used in this cohort. Fourteen patients received intrathecal antifungals, and a trend of initiating intrathecal therapy after need for a shunt revision was observed (p = 0.051). The majority of shunt failures (81%) were due to mechanical blockages in the drainage system. Most patients (59%) had at least partial persistent postoperative ventriculomegaly despite successful CSF diversion. Four patients (9%) died due to coccidioidomycosis during the follow-up period. Conclusions Coccidioidomycosis-related hydrocephalus more often affected young males in the study's cohort, especially those of African and Asian descent. Despite the best medical therapy, there was a high rate of shunt failure due to clogged catheters or valves due to the underlying disease process. Many patients continued to have ventriculomegaly even with adequate CSF diversion. The morbidity and mortality of this chronic disease process must be recognized by the treatment team, and patients should be appropriately counseled.

The Rise of Valley Fever: Prevalence and Cost Burden of Coccidioidomycosis Infection in California

“…In some cases, shunts may be used for administration of medication. These types of shunts commonly fail, and many patients require one or more surgical revisions [26].…”

2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis

“…Thereafter a new shunt can then be placed. With organisms of low pathogenicity or if Coccidioides species is the only organism involved, a single-stage approach (removal of the shunt with simultaneous reimplantation with a new shunt) can be considered [147,148]. Exploration of the nonfunctioning shunt is done by evaluating proximal and distal flow intraoperatively so that revision can be tailored to the particular area of failure.…”

A Case of Rapidly Progressive Coccidioidal Meningitis in an Immunocompetent Patient

“…Due to hydrocephalus, our patient required a VP shunt. According to neurosurgery literature, there is a high likelihood that a VP shunt used for coccidioidomycosis will become clogged with debris and protein [ 11 ]. These difficulties can be manifested by a recurrence of headache, nausea, vomiting, gait disturbance, or mental status changes [ 12 ].…”