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Coccidioidal meningitis: clinical presentation and management in the fluconazole era

Glenn Mathisen1, Aaron Shelub, Jonathan Truong

  • 1From Cedars Sinai-UCLA Affilialted Multicampus Infectious Disease Program (GM, AS, JT, CW), Los Angeles; Cedars Sinai Medical Center, Los Angeles; Olive View-UCLA Medical Center (GM, JT, CW), Sylmar; VA West Los Angeles Medical Center, Los Angeles; Los Angeles County Department of Public Health (CW), Los Angeles; and Southern California Kaiser Permanente Medical Group (JT), Los Angeles, California.

Medicine
|September 10, 2010
PubMed

Insights

Coccidioidal meningitis (CM) remains a severe fungal infection with high mortality. While azole antifungals are used, they are not curative, necessitating new treatments for coccidioidomycosis of the brain.

Area of Science:

  • Infectious Diseases
  • Mycology
  • Neurology

Background:

  • Coccidioidal meningitis (CM) presents a significant challenge due to high morbidity and mortality.
  • Comparing CM treatment and outcomes before and after the widespread use of azole antifungals is crucial for understanding treatment evolution.

Observation:

  • The 2008 cohort showed a higher incidence of Hispanic patients and those with predisposing conditions, including HIV/AIDS, compared to the 1980 cohort.
  • Fluconazole was the primary treatment in the 2008 cohort, contrasting with the prevalent intrathecal amphotericin B use in the 1980 cohort.
  • Despite treatment differences, complication rates (stroke, hydrocephalus) and mortality remained similar between the two eras.

Findings:

  • Azole-based therapies, while advantageous, do not offer a definitive cure for coccidioidal meningitis.
  • Patients treated in the azole era (post-1980) still experienced significant long-term disability.

Implications:

  • Immunocompromised individuals, particularly those with HIV/AIDS, are at increased risk for severe CM.
  • Novel therapeutic strategies are urgently needed to achieve a definitive cure for CM and reduce reliance on long-term suppressive antifungal therapy.

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