989. Intrathecal Amphotericin Treatment in the Management of Neuro-invasive Coccidiomycosis Infection: Single Institutional Experience
Session: Poster Abstract Session: CNS Infection
Friday, October 9, 2015
Room: Poster Hall
Background: Coccidioidomycosis is a mycotic infection endemic to the Southwest. Only a small percentage of infections are extra-pulmonary, though disseminated central nervous system infection is associated with significant morbidity and mortality. While azole-based therapy is considered first-line treatment in the current era, amphotericin may be used in severe or refractory cases. There is a paucity of literature reviewing intrathecal (IT) amphotericin use in Coccidioidal meningitis and treatment response remains unclear.

Methods: Patients with Coccidioidal meningitis admitted to our hospital 1990-2013 were identified retrospectively and prospectively. Patients with severe disease not responsive to optimized azole therapy and/or intravenous (IV) amphotericin were treated with IT amphotericin deoxycholate. Dosage, administration, and monitoring were per literature- and experience-derived institutional protocol. Treatment response was defined as improvement in clinical, lab, and/or radiologic parameters.

Results: Twenty-five of 87 patients with CNS coccidioidomycosis were treated with IT amphotericin. Mean age at diagnosis was 38 years (range 16-74), and 17 were men. Group race included 11 white, 4 black, 4 Hispanic, and 2 Native American. Eighty percent were immunocompetent. Nineteen had hydrocephalus, 17 had leptomeningeal enhancement, and 7 had strokes on neuroimaging. Ommaya reservoirs were placed at the cisternal level. Once IT amphotericin was titrated up to maximum tolerated dose (<= 1mg), treatment frequency ranged from 1-3 times weekly. Duration of therapy in most ranged from 3-6 months. The most common side effects were related to chemical meningitis (headache, nausea); these improved with decreased dose and pre-medication except for 1 unable to tolerate treatment (1 of 5 who also received IV amphotericin). Of the 25, 23 (92%) achieved treatment response, though ultimately 6 of 21 (29%) followed up died.

Conclusion: We present a large series of patients with CNS coccidioidomycosis treated with IT amphotericin. Our experience suggests that IT amphotericin remains an important and generally well-tolerated treatment option for severe neuro-invasive Coccidioidal disease, though mortality from infection remains high.

Marie Grill, MD1, Ana Moran, MD2,3,4, Annette Cordova, MS, R.Ph5, Brian Beck, MD6, Yashar Kalani, MD, PhD7, Kris Smith, M.D.8, Peter Nakaji, MD7, Nicholas Theodore, MD7 and Omar Gonzalez, MD3, (1)Neurology, Mayo Clinic, Phoenix, AZ, (2)Infectious Disease, St. Joseph Hospital, Phoenix, AZ, (3)Arizona Pulmonary Specialists, Phoenix, AZ, (4)Infectious Diseases, Barrow Neurological Institute, Phoenix, AZ, (5)St. Joseph's Hospital, Dignity Health, Phoenix, AZ, (6)Neurology, Barrow Neurological Institute, Phoenix, AZ, (7)Neurosurgery, Barrow Neurological Institute, St. Joseph Hospital, Phoenix, AZ, (8)Neurosurgery, Barrow Neurological Institute, Phoenix, AZ


M. Grill, None

A. Moran, None

A. Cordova, None

B. Beck, None

Y. Kalani, None

K. Smith, None

P. Nakaji, None

N. Theodore, None

O. Gonzalez, None

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