Management of Coccidioidal Meningitis Outside the Endemic Region

Leptomeningeal enhancement (LE) is an MRI neuroimaging characteristic associated with infection, malignancy, or cerebrovascular pathologies of the subarachnoid space. LE secondary to infection is most commonly a sign of meningeal tuberculosis. Fungal infections have a heightened presence in certain endemic regions in North America. We present the case of a 44-year-old male patient from Illinois with persistent headaches, hydrocephalus, and LE on MRI. He was empirically treated for tuberculosis, then blastomycosis, but later was found to have disseminated Coccidioides immitis infection via lymph node biopsy. Neurosurgical intervention with external ventricular drainage, then ventriculoperitoneal shunting, was required for hydrocephalus. The patient was treated with intravenous liposomal amphotericin B for suspected blastomycosis infection, then transitioned to oral fluconazole, resulting in resolution of symptoms and no neurological deficits at follow-up. This case is among the few reported instances of coccidioidal meningitis diagnosed outside endemic regions. Neurosurgeons and clinicians should maintain a broad differential for LE on MRI and not exclude endemic fungal infections based solely on geographic history. Prompt initiation of appropriate antifungal therapy is key to improving outcomes in coccidioidal meningitis. This case highlights the need for heightened clinical suspicion and aggressive management of meningitis with LE.