889. Voriconazole in Coccidioidal Meningitis following Failure of Response to Fluconazole
Session: Poster Abstract Session: Antifungal Therapy
Saturday, October 22, 2011
Room: Poster Hall B1
  • Poster_889_IDSA_49_Vorincon in flocon failure_Arash_Heidari.pdf (316.5 kB)
  • Background: Coccidioidal Meningitis (CM) remains a challenging disease despite its discovery over a century ago. Fluconazole, and intrathecal amphotericin B have been useful in management and provided favorable responses. Published experience with voriconazole has been limited to small case reports. Kern Medical Center in Bakersfield California provides a specialty clinic for serious cases of CM. Our objective was to evaluate experience with voriconazole in a large case series over 7 years.

    Methods:  Medical records of patients with CM, a history of refractory response to fluconazole, and subsequent treatment with oral  voriconazole were evaluated for clinical and laboratory disease variables over a 7 year period. Those with <6 months of records or who were lost to follow-up were excluded. Cases were evaluated for response utilizing the Mycoses Study Group Scoring system for CM (MSG Score).  A decrease in score of 40% is considered a favorable response. Evaluation was also performed utilizing cerebrospinal fluid pleocytosis. A decrease to 50 cells or less or stable number of <50 cells was considered a favorable response.

     Results:  33 evaluable cases were identified with 6 to 18 months of complete data. 78% were male. Hispanics were most prevalent (78%) followed by Caucasians (21%) and African American (9%). 8 (24%) had diabetes and 19 (57%) required a shunt for hydrocephalus. A history of seizure was documented in eight (24%).25 cases had a baseline MSG Score of 6 or greater. A 40% drop in score was observed 12 of the 25 (48% response rate). In 8 cases with a score of < 6 a stable score (remaining at < 6) was observed in 7 (87%). An overall favorable response utilizing the scoring system was therefore identified in 19 of 33 cases (57%). Pleocytosis of >50 cells at baseline was noted in 17 cases.  In 15 of these, pleocytosis decreased to < 50 (88%). In 14 cases with <50 cells, 12 remained <50 (85%). A 87% overall favorable response (27 of 31) was therefore observed in pleocytosis. 17 (51%) experienced photodermatitis which was much higher than expected from the literature.

     Conclusion:  Voriconazole is a useful oral agent for controlling the symptoms and laboratory indices of Coccidioidal Meningitis  in patients with refractory responses to fluconazole.

    Subject Category: M. Mycology including clinical and basic studies of fungal infections

    Arash Heidari, M.D.1, John Caldwell, Pharm.D.2, Aelita Chappell, M.D.2, Bahareh Ghafarizadeh, M.D.2 and Royce H. Johnson, M.D., F.A.C.P.1, (1)Infectious Diseases, Kern Medical Center/UCLA, Bakersfield, CA, (2)Internal Medicine, Kern Medical Center/UCLA, Bakersfield, CA


    A. Heidari, Ortho-McNeil: Grant Investigator, Research grant
    Pfizer: Grant Investigator, Research grant

    J. Caldwell, Ortho-McNeil: Grant Investigator, Research grant
    Pfizer: Grant Investigator, Research grant
    Artisan Pharma: Grant Investigator, Research grant

    A. Chappell, None

    B. Ghafarizadeh, Ortho-McNeil: Grant Investigator, Research grant

    R. H. Johnson, Pfizer: Grant Investigator, Research grant
    Ortho-McNeil: Grant Investigator, Research grant
    Bio-K plus International Inc.: Scientific Advisor and Speaker's Bureau, Speaker honorarium
    Allermed Lab. Inc.: Grant Investigator, Research grant
    Forest Pharmaceuticals: Speaker's Bureau, Speaker honorarium

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