Coccidioidal meningitis: update on epidemiology, clinical features, diagnosis, and management

Coccidioidomycosis is a fungal infection endemic to geographically restricted areas of the southwestern United States, and its incidence is increasing within endemic areas. Coccidioidal meningitis, an infrequent but very severe form of coccidioidomycosis, is associated with significant mortality and morbidity. The diagnosis depends on the demonstration of coccidioidal antibody or positive culture, histopathology, or cytology in the presence of typical abnormalities of the cerebrospinal fluid. Central nervous system complications of this infection may include hydrocephalus, vasculitis, infarctions, or parenchymal abscesses. Many patients with coccidioidal meningitis can achieve remission of infection following treatment with triazole antifungal agents. However, first-line therapy with high-dose oral fluconazole is associated with a high incidence of relapse after drug discontinuation. This article summarizes the pathogenesis, epidemiology, clinical manifestations, diagnostic studies, and treatment of coccidioidal meningitis, and highlights new information regarding this devastating infection.