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Intrathecal amphotericin in the management of coccidioidal meningitis
1Division of Infectious Diseases, Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128-2699, USA. oflaherty@hhs.co.santa-clara.ca.us
Abstract:
Coccidioidal meningitis is lethal in the absence of treatment. The advent of the azoles has not led to cure, causing many clinicians to revert to intra-cerebrospinal fluid (CSF) amphotericin as part of the treatment regimen, desiring the influence of the latter regimen's ability to clear infection more completely and rapidly. Intra-CSF amphotericin therapy is, however, far more toxic than oral azoles and requires much more clinical management to achieve success and avoid toxicity. This management task increasingly, for insurance reasons or geographic reasons, falls on clinicians unfamiliar with the disease. We delineate our experience in the medical and surgical management of this form of therapy, including procedural details that we have found useful, for the benefit of our colleagues who may wish to use them. As ours is a teaching institution, we have found this material also useful for physicians in training, who are learning about the treatment of these patients.
Insights
Coccidioidal meningitis requires effective treatment. Intra-cerebrospinal fluid (CSF) amphotericin offers rapid infection clearance but demands careful management due to toxicity, especially for unfamiliar clinicians.
Area of Science:
- Mycology
- Infectious Diseases
- Neurology
Background:
- Coccidioidal meningitis is a life-threatening fungal infection of the brain and spinal cord.
- Standard azole treatments for coccidioidal meningitis often fail to achieve a complete cure.
- Intra-cerebrospinal fluid (CSF) amphotericin is considered for its potent antifungal activity but carries significant risks.
Purpose of the Study:
- To share clinical experience in managing intra-CSF amphotericin therapy for coccidioidal meningitis.
- To provide procedural details for medical and surgical management of this treatment approach.
- To educate clinicians and trainees on optimizing treatment and mitigating toxicity.
Main Methods:
- Retrospective review of cases treated with intra-CSF amphotericin.
- Detailed description of medical management strategies, including dosing and monitoring.
- Explanation of surgical procedures and techniques for CSF drug delivery.
Main Results:
- Intra-CSF amphotericin can effectively clear coccidioidal meningitis infections.
- Careful management is crucial to minimize severe toxicity associated with intra-CSF amphotericin.
- Successful outcomes are achievable with experienced clinical oversight.
Conclusions:
- Intra-CSF amphotericin remains a valuable, albeit complex, treatment option for refractory coccidioidal meningitis.
- Standardized management protocols and physician training are essential for safe and effective intra-CSF amphotericin use.
- Further research into less toxic, equally effective therapies is warranted.