Solitary thalamic abscess without meningitis from Coccidioides immitis: illustrative case

Area of Science:

• Mycology
• Neurology
• Infectious Diseases

Background:

• Brain abscess prognosis depends on location and organism, with deep-seated abscesses posing high mortality risks.
• Coccidioidomycosis, caused by Coccidioides immitis, is increasing but rarely forms deep brain abscesses, leaving management strategies unclear.
• This report details a unique case of a solitary thalamic Coccidioides abscess without meningitis.

Purpose of the Study:

• To report the diagnosis and management of a rare solitary thalamic abscess caused by Coccidioides immitis.
• To highlight diagnostic challenges, including negative fungal cultures and serology.
• To outline an effective treatment strategy for deep-seated fungal brain abscesses.

Main Methods:

• A 59-year-old female presented with neurological deficits suggestive of a brain lesion.
• Stereotactic brain biopsy was performed, revealing Coccidioides spherules despite negative fungal cultures and serum antibodies.
• Diagnosis was confirmed via polymerase chain reaction (PCR) testing on biopsy tissue.

Main Results:

• The patient's symptoms resolved within 3 weeks of surgery and dexamethasone treatment.
• Lifelong fluconazole therapy was prescribed to prevent relapse.
• The patient remained disease-free at 1-year follow-up, despite discontinuing fluconazole at 11 months.

Conclusions:

• Coccidioides immitis can manifest as a solitary brain abscess, even with negative fungal cultures.
• Surgical intervention combined with dexamethasone and prolonged fluconazole therapy is effective in clearing the infection and preventing recurrence.
• This case provides valuable insights into managing uncommon deep-seated fungal brain abscesses.