1820. Coccidioidal Meningitis, Clinical and Therapeutic Challenges in a Single Institution
Session: Oral Abstract Session: Fungal Infections
Saturday, October 5, 2013: 2:15 PM
Room: The Moscone Center: 300
Background: Coccidioidomycosis is endemic to the southwestern United States.  Forty percent of infections are symptomatic; of this 5-10% will develop serious pulmonary infections.  Of those, less than 1% will develop chronic pulmonary disease and/or extra-pulmonary dissemination.  Patients with coccidioidal meningitis present a unique therapeutic dilemma

Methods: Available data from patients with coccidiodal meningitis treated in a single tertiary referral hospital, between January 2005 and March 2013 was retrospectively collected. Charts were reviewed to obtain demographics, clinical presentation, anatomical site of involvement, treatment, and clinical outcomes.

Results: We identified 130 cases of coccidioidal meningitis. Eighty seven had available data.  The mean age at presentation was 41.2, with 64.3% males.  Races included Black (20.5%), Caucasian (47.4%), Hispanic (21.8%), Asian (6.4%), and Native American (3.8%).  Clinical presentation included:  Cephalgia (52.9%), encephalopathy (31.0%), hydrocephalus (50.5%), CVA (20.1%), cerebritis (3.4%), fever (12.6%), and seizures (4.5%). Outpatient follow up occurred in 35.6% (31/87), from 0-6 years. Initial therapy was fluconazole in all patients, with 39.7% failure rate (clinical, serological, and/or radiographic progression after at least 3-6 months on fluconazole). Rescue therapy consisted of voriconazole (n=33), posaconazole (n=11), intravenous (IV) amphotericin B (n=13), and intrathecal (IT) amphotericin B (n=19) [usually in combination with an azole drug]. Failure rates were 21.2%, 45.5%, 46.2%, and 10.5%, respectively.  Itraconazole was used in four patients successfully.  Mortality occurred in 8% of the patients.

Conclusion: We report a large case series of coccidioidal meningitis with a diverse clinical presentation, and therapeutic response.  Disease control was achieved in the majority with oral azoles, including fluconazole, voriconazole, and posaconazole.  The use of IV amphotericin B was associated with higher failure rates when compared to azoles and IT amphotericin B.  While fluconazole remains the first line therapy, other azoles show acceptable success rates in refractory cases. In more severe cases the use of intrathecal amphotericin B in combination with an azole has the highest success rate.

Brian Beck, MD1, Ana Moran, MD2,3, Yashar Kalani, MD, PhD4, Kris Smith5, Nicholas Theodore, MD4, Peter Nakaji, MD4, Marie Grill, MD6 and Omar Gonzalez, MD2,3, (1)Neurology, Barrow Neurological Institute, Phoenix, AZ, (2)Arizona Pulmonary Specialists, Phoenix, AZ, (3)Infectious Diseases, Barrow Neurological Institute, Phoenix, AZ, (4)Neurosurgery, Barrow Neurological Institute, St. Joseph Hospital, Phoenix, AZ, (5)Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, (6)Neurology, University of California San Francisco, San Francisco, CA

Disclosures:

B. Beck, None

A. Moran, None

Y. Kalani, None

K. Smith, None

N. Theodore, None

P. Nakaji, None

M. Grill, None

O. Gonzalez, None

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