171. Continuous Intrathecal (IT) Amphotericin B (AB) for Relapsed Coccidioides (C) Meningitis (M)
Session: Poster Session: Fungi
Friday, October 5, 2007: 12:00 AM
Room: Poster Halls G-H
A 19-year-old African American man with CM was treated with fluconazole (FZ) 800 mg daily. Worsening hydrocephalus, hemiparesis, cognitive impairment and seizure-like activity with cerebral lesions occurred after 1 mo. (8/00); dexamethasone was added (8/24-9/23/00) and a ventriculo-peritoneal shunt (VPS) placed. Noncompliance with FZ > 1 mo. resulted in headache and vomiting 9/01. C was cultured from ventricular CSF during new VPS placement, which was complicated by peritoneal adhesions. Vomiting persisted and FZ resumed. AmBisome 4350 g was given IV 10/9-11/12/01. Vomiting, cognitive and gait abnormalities persisted, and CSF total protein and CF titers increased. On 11/16, a catheter was placed in the basilar cisterns and connected subcutaneously to a Medtronics programmable pump for continuous intrathecal (IT) infusion of 1mg/ml AB, at initial rate 0.05 mg/day, from an 18 ml reservoir. When the residual reservoir solution was replaced 11/29 the AB level was 0.2 mg/ml with inhibitory & killing levels (I&KL) vs. patient’s isolate 1:256. The infusion was increased to 0.25 mg/day. By 12/26, he had received 12.6 mg AB and the 27 day old residual reservoir AB solution was assayed at 0.06mg/ml with I&KL 1:32.
LUMBAR CSF RESULTS
DateWBC/mm3Eosinophils, %Protein, mg/mlGlucose, mg/mlCF TiterI&KLAB, mcg/ml
10/8/01135401024221:128
11/9220371746241:5121:160.076
12/265244435161:32<1:4<0.06
2/21/02205678241:8
6/7/0690511:2

There was no evidence of AB toxicity during continuous IT infusion + high dose FZ . Device malfunction was detected 2/21/02 and FZ continued. He remains well and attends college 4 years later.
Continuous IT infusion provided biologically active AB without neurological toxicity. The 18 ml reservoir provided continuous therapy for a month without reloading, lessening the risk of infection. A rapid escalation in dose in this case of fulminant CNS fungal infection was achieved by adjusting the rate of IT infusion.
C Berry, MD1, D Stevens, MD2, D Pappagianis, MD3, E Hassid, MD4, E Happs, RN1, K Sahrakar, MD1 and  C.D. Berry, None; E. Hassid, Medtronics, Company / Companies, Speaking and Teaching; Honorarium, What was received, Speaking and Teaching; K. Sahrakar, None; D. Pappagianis, None; E. Happs, None; D.A. Stevens, None., (1)TPMG, Sacramento, CA, (2)Sta. Clara Valley Medical Ctr., San Jose, CA, (3)Univ Calif Davis, Davis, CA, (4)Inst. for Restorative Health, Davis, CA


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