Case Report A 28-year-old Guatemalan male presented with headache, neck stiffness, and fevers without chills. Lumbar puncture was performed and was consistent with viral meningitis. A tuberculin skin test placed was reactive at 48 hours to 16 mm. Multiple sputums for AFB were negative on smear and culture; chest radiography was normal. The patient's symptoms improved, and he was discharged on isoniazid for latent tuberculosis (TB). The patient returned with worsening headaches, nausea, fevers, confusion, agitation, and gate instability. Repeat lumbar puncture revealed no additional diagnostic information. The patient was again admitted and started empirically on broad-spectrum antibiotics, antiviral agents, and antiTB agents. He continued to deteriorate, with worsening mental status and neurological examination. Magnetic resonance imaging (MRI) confirmed increased intracranial pressure with extensive enhancement in the subarachnoid spaces at the base of the brain and extensive nonenhancing T2 prolongation within the adjacent basal ganglia and capsular region and inferoposterior frontal region consistent with basilar meningoencephalitis. He eventually required intubation with mechanical ventilation. Deterioration continued to the point of clinically evident brainstem herniation and brain death. Autopsy revealed a 1 cm granuloma in the patient's left lung and thick gelatinous exudates surrounding the brainstem. Microscopic examination revealed multiple nonbudding thick walled spherules of variable diameter containing numerous small nonbudding endospores consistent with coccidiomycosis.
Discussion This case appears to be one of the few cases reported in Mississippi. Coccidioidal involvement of the central nervous system frequently causes chronic meningitis. This may be confused with other causes of granulomatous chronic meningitis, such as TB. Symptoms of coccidioidal meningitis differ little from other causes of meningitis. Physical examination does not help differentiate between coccidioidal meningitis and other forms of chronic meningitis. Contrasted MRI early in the course of disease frequently shows the typical basilar cysternal findings associated with coccidiococcal meningitis. These areas of inhancement represent areas of increased localized organisms. Untreated, coccidioidal meningitis is uniformly fatal. Treatment includes antifungal agents such as fluconazole; however, treatment failures do occur. Hydrocephalus may occur regardless of therapy and may require a ventriculoperitoneal shunt procedure; however, this does not necessarily represent treatment failure or a need to change antifungal therapy. The most common cause of death in these patients is vasculitis, leading to cerebral infarction and hemorrhage. Lack of exposure to this disease in the state of Mississippi likely contributed to the difficulty in diagnosing this case.
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