1
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Sadiq KO, Desai S, Miller S, Abualnadi YD, Khalil ZM, Khan Z, Amjadi N, Ravindra VM, Tekle W, Georgiadis AL, Hassan AE. Epidural anesthesia causes outbreak of mycotic aneurysms: complications of Fusarium solani meningitis. J Neurointerv Surg 2024:jnis-2023-021300. [PMID: 38418228 DOI: 10.1136/jnis-2023-021300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/05/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND A health advisory was issued in response to a fungal meningitis outbreak linked to epidural anesthesia exposure in two plastic surgery clinics in Mexico, from January 1 to May 13, 2023. This descriptive analysis describes the neuroendovascular and neurosurgical observations and management of patients treated at a single stroke center located along the US-Mexico Border. METHODS We conducted a retrospective chart review of fungal meningitis patients presenting between April and July 2023. RESULTS Among the patients diagnosed with fungal meningitis (n=12), the majority (n=11) were afflicted with angio-invasive Fusarium solani. 83% received dual antifungal therapy, with 40% initiated on alternate-day intrathecal amphotericin B. Diagnostic cerebral angiography was performed on all patients, revealing aneurysms in 58% of cases, predominantly within the posterior circulation, notably the basilar artery, with a median size of 4.2 mm (IQR 3.3-4.8). Treatment strategies included flow diversion (70%) and primary coiling (14%) for aneurysms. Ventriculostomy placement was undertaken in 67% of patients, with 37.5% of these requiring conversion to ventriculoperitoneal shunts. Subarachnoid hemorrhage development was uniformly associated with 100% mortality. CONCLUSIONS In patients presenting with Fusarium solani meningitis, weekly angiographic surveillance proved instrumental for monitoring aneurysm and vasospasm development. Conventional angiography outperformed CT angiography due to its enhanced ability to detect small aneurysms. A proactive approach to aneurysm treatment is advocated, given their elevated rupture risk. While our findings suggest the potential reversibility of angiographic vasospasm with effective antifungal treatment, we acknowledge the challenge of drawing definitive conclusions based on a limited sample size.
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Affiliation(s)
- Kaiser O'Sahil Sadiq
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Sohum Desai
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
- Surgery, The University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Samantha Miller
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Yazan D Abualnadi
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Zorain Mustafa Khalil
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Zooha Khan
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Nazaneen Amjadi
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, University of Utah Health Clinical Neurosciences Center, Salt Lake City, Utah, USA
| | | | - Alexandros L Georgiadis
- Department of Neuroscience, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
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2
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De la Cerda-Vargas MF, Candelas-Rangel JA, Navarro-Dominguez P, Sandoval-Bonilla BA, Meza-Mata E, Muñoz-Hernandez MA, Segura-Lopez FK, Ramirez-Silva LH, Gonzalez-Martinez MDR, Delgado-Aguirre HA. Neurococcidiomycosis in children with hydrocephalus: assessment of functional outcome, quality of life and survival in relation to neuroimaging findings. Childs Nerv Syst 2024; 40:303-319. [PMID: 37819508 DOI: 10.1007/s00381-023-06166-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/24/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Coccidioidal meningitis (CM) is an uncommon disease frequently misdiagnosed. Neuroimaging and mortality are not considered in detail in previous pediatric CM series. Our objective is to evaluate outcome of pediatric neurococcidiomycosis in relation to neuroimaging findings. METHODS We performed a prospective, observational, cross-sectional study in children with hydrocephalus and CM treated at Specialties Hospital in Torreon, Mexico (between 2015 and 2020). The outcome was evaluated by Hydrocephalus Outcome Questionnaire (HOQ) and the modified Rankin Scale (mRS). Follow-up was established at the first shunt surgery and survival since CM diagnosis confirmation. Neuroimaging was analyzed in relation to clinical data, outcome and survival. Kaplan-Meier analysis was performed with IBM-SPSS-25. RESULTS Ten pediatric cases with CM and hydrocephalus were reported. Aged 6-228 months, 60% were female. Mean number of surgeries was 4.3 SD ± 3 (range 1-15). Asymmetric hydrocephalus was the most common neuroimaging finding (70%), followed by cerebral vasculitis (20%) and isolated fourth ventricle (IFV) (20%). The mean HOQ overall score was 0.338 SD ± 0.35. A minimum follow-up of 18 months was reported. Mean survival was 13.9 SD ± 6.15 months (range 3-24). Poor survival was correlated with asymmetric hydrocephalus (p = 0.335), cerebral vasculitis (p = 0.176), IFV (p < 0.001), bacterial superinfection (p = 0.017), lower mRS scores at hospital discharge (p = 0.017) and during follow-up (p = 0.004). The mortality rate was 20%. CONCLUSIONS We report the largest series in Latin America of pediatric CM and hydrocephalus. Asymmetric hydrocephalus, IFV and cerebral vasculitis are complications that increase mortality and must be early diagnosed for a timely surgical and medical treatment. HOQ and mRS could be alternative scales to evaluate outcome in these patients. After a long follow-up (18 months), survival remained poor after diagnosis confirmation in our series.
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Affiliation(s)
- Maria F De la Cerda-Vargas
- Department of Neurosurgery and Neurotechnologie, Universitätsklinik Tübingen, Tübingen, Germany.
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico.
| | - Jose A Candelas-Rangel
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
- Department of Neurosrugery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Pedro Navarro-Dominguez
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Bayron A Sandoval-Bonilla
- Associated Professor, Department of Neurosurgery, Specialties Hospital, Centro Médico Nacional (CMN) Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Elizabeth Meza-Mata
- Head of Anatomical Pathology Department, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | - Melisa A Muñoz-Hernandez
- Department of Health and Research, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
| | - F K Segura-Lopez
- Department of Health and Research, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
| | - Luis H Ramirez-Silva
- Department of Neurosurgery, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
| | | | - Hector A Delgado-Aguirre
- Department of Transplants, Specialties Hospital No. 71, Instituto Mexicano del Seguro Social, Torreon, Coahuila, Mexico
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3
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Sivasubramanian G, Kadakia S, Kim JM, Pervaiz S, Yan Y, Libke R. Challenges in the Long-term Management of Patients With Coccidioidal Meningitis: A Retrospective Analysis of Treatment and Outcomes. Open Forum Infect Dis 2023; 10:ofad243. [PMID: 37333722 PMCID: PMC10270562 DOI: 10.1093/ofid/ofad243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 06/20/2023] Open
Abstract
Background Coccidioidal meningitis (CM) is the most severe form of disseminated coccidioidomycosis. Despite years of clinical experience, it remains a difficult condition to treat, often requiring surgical procedures, such as placement of a ventriculoperitoneal shunt, in addition to lifelong antifungal therapy. Methods We performed a retrospective analysis of patients with CM seen in a large referral center in Central Valley, California, from 2010 to 2020. Data pertinent to CM were collected and analyzed. Results Among 133 patients with CM identified in the 10-year period, nonadherence to antifungal therapy was noted in 43% of patients. Of the 80 patients who underwent ventriculoperitoneal shunt placement for management of intracranial pressure, shunt failure requiring revision surgery occurred in 42 (52.5%). Rehospitalizations due to CM-related reasons occurred in 78 of 133 patients (59%). Twenty-three percent of patients (n = 29) died due to complications from CM, on an average 22 months after the diagnosis of CM. Encephalopathy at presentation was associated with a significantly higher risk of death. Conclusions Patients with CM in central California are predominantly rural agricultural workers with elevated levels of poverty and low health literacy and many barriers to care, leading to high rates of medication nonadherence and loss to follow-up outpatient care. Management challenges are frequent, such as failure of antifungal therapy, high rates of rehospitalization, and the need for repeated shunt revision surgeries. In addition to the development of curative new antifungal agents, understanding the barriers to patient adherence to care and antifungal therapy and identifying means to overcome such barriers are of paramount importance.
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Affiliation(s)
- Geetha Sivasubramanian
- Correspondence: Geetha Sivasubramanian, MD, FIDSA, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 (); Robert Libke, MD, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 ()
| | - Saurin Kadakia
- Department of Internal Medicine, University of California, San Francisco, Fresno, California, USA
| | - Jani M Kim
- Division of Infectious Disease, University of California, San Francisco, Fresno, California, USA
| | - Sarah Pervaiz
- Division of Infectious Disease, University of California, San Francisco, Fresno, California, USA
| | - Yueqi Yan
- HSRI Biostatistics and Data Support Core, University of California, Merced, California, USA
| | - Robert Libke
- Correspondence: Geetha Sivasubramanian, MD, FIDSA, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 (); Robert Libke, MD, Division of Infectious Diseases, Department of Internal Medicine, University of California, San Francisco at Fresno, 155 N Fresno St, Suite 307, Fresno, CA 93701 ()
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4
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Naeem F, Laningham F, Giglio L, Sharma J, Clerkin PQ, McCarty JM. Central Nervous System Coccidioidomycosis in Children: A Retrospective Case Series. Pediatr Infect Dis J 2023; 42:286-291. [PMID: 36728889 DOI: 10.1097/inf.0000000000003813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Published literature on central nervous system (CNS) coccidioidomycosis in children is limited. Here we describe a large case series of pediatric CNS coccidioidomycosis from a tertiary care center in an endemic region. METHOD This is a retrospective case review of patients ≤21 years old with a diagnosis of CNS coccidioidomycosis from January 1, 2000, to December 31, 2018. RESULTS Thirty patients (median age 10.8 years) were identified and most (93%) were previously healthy. Fever (90%), headache (70%), vomiting (53%), and fatigue (57%) were the most common presenting clinical manifestations, with focal neurological signs/symptoms present in 14 (47%). The initial serum Coccidioides compliment fixation (CF) titer was ≤ 1:8 in 33%. Most patients had extra-axial brain involvement (83%) and seven (23%) had associated spinal cord disease. Shunt placement was required in 70% and 62% required revision. Fluconazole was the initial treatment in 22 (73%), with treatment failure occurring in 50%. Most patients (77%) stabilized and were maintained on suppressive therapy, 4 (13%) experienced relapses and/or progressive disease, and one (3%) died, while long-term neurological complications occurred in 17%. CONCLUSIONS CNS coccidioidomycosis is an uncommon and sometimes devastating complication of disseminated coccidioidomycosis. Many patients present with relatively low CF titers and hydrocephalus is common. Fluconazole treatment failures are common, and management remains difficult despite recent advances in therapy. Most patients do well once the disease is stabilized and require lifelong therapy. Newer therapeutic agents are needed.
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Affiliation(s)
- Fouzia Naeem
- Division of Infectious Disease, Department of Pediatrics, Valley Children's Healthcare, Madera, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Fred Laningham
- Division of Neurosurgery, Department of Pediatrics, Valley Children's Healthcare, Madera, California
| | - Linda Giglio
- Division of Radiology, Department of Pediatrics, Valley Children's Healthcare, Madera, California
| | - Julia Sharma
- Division of Radiology, Department of Pediatrics, Valley Children's Healthcare, Madera, California
| | - Patricia Quebada Clerkin
- Department of Pediatric Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - James M McCarty
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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5
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Menghani SV, Takamatsu CL, Ibrahim R, Molina L, Jaswal N, Donovan FM. Non-shunt Management of Communicating Hydrocephalus in an Immunocompetent Host With Disseminated Central Nervous System Coccidioidomycosis. J Investig Med High Impact Case Rep 2023; 11:23247096231181060. [PMID: 37334970 DOI: 10.1177/23247096231181060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Disseminated coccidioidomycosis is associated with significant morbidity and mortality. Involvement of the meninges is often fatal if untreated, typically requiring lifelong antifungal therapy and neurosurgical intervention. We present the case of a young male without any known immunocompromising conditions who opted exclusively for medical management of newly diagnosed coccidioidomycosis meningitis with communicating hydrocephalus and discuss the controversy associated with this approach. This case highlights the importance of shared decision-making between patient and clinician, even if the plan diverges from available guidelines. Furthermore, we discuss clinical considerations in approaching the close outpatient monitoring of patients with central nervous system coccidioidomycosis with hydrocephalus.
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Affiliation(s)
- Sanjay V Menghani
- The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | | | - Ramzi Ibrahim
- The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | - Lupita Molina
- The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | - Neha Jaswal
- The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | - Fariba M Donovan
- The University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
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6
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Sivasubramanian G, Kadakia S, Kim JM, Pervaiz S, Yan Y, Libke R. Spinal Arachnoiditis in Patients with Coccidioidomycosis Meningitis-Analysis of Clinical and Imaging Features. J Fungi (Basel) 2022; 8:1180. [PMID: 36354947 PMCID: PMC9697661 DOI: 10.3390/jof8111180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 06/28/2024] Open
Abstract
Background: Coccidioidomycosis meningitis (CM) is the most aggressive form of coccidioidomycosis, requiring lifelong antifungal treatment and often cerebrospinal fluid (CSF) diversion. Long-standing CM can be associated with spinal complications such as arachnoiditis. However, studies describing the frequency, clinical, and imaging characteristics of arachnoiditis in patients with CM are limited. Methods: We identified 133 patients with CM based on CSF culture, PCR, or serology between January 2010 and December 2020. Of these, 37 patients underwent spinal imaging. Data on demographics, risk factors, symptoms, antifungal therapy, surgical management, follow-up visits, adherence, serological trends, and imaging findings were reviewed. Results: Abnormal findings were observed in 30 of the 37 patients with CM who underwent spinal imaging. The imaging abnormalities noted in our study included leptomeningeal enhancement (53%), arachnoiditis (53%), syringomyelia (23%), cord signal abnormalities (10%), and osteomyelitis (7%). Of the 30 patients, 90% had symptoms, such as weakness, numbness, or urinary retention. The incidence of arachnoiditis in the present study was 12%. Higher initial CSF protein levels and intra cranial pressure were associated with a higher risk of developing arachnoiditis/syringomyelia. Management of CM was challenging, as evidenced by shunt failure (46%), medication non-compliance (57%), and lack of adequate follow-up (60%). Persistent disabilities were noted in 62% of the patients. Conclusions: Patients with CM develop spinal complications such as arachnoiditis, or syringomyelia. Many cases may go undetected due to lack of symptoms in early stages. CM management challenges such as shunt failure, lack of follow-up care, and medication noncompliance, were frequent.
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Affiliation(s)
| | - Saurin Kadakia
- Department of Internal Medicine, University of California, Fresno, CA 93701, USA
| | - Jani M. Kim
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
| | - Sarah Pervaiz
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
| | - Yueqi Yan
- HSRI Biostatistics and Data Support Core, University of California, Merced, CA 95343, USA
| | - Robert Libke
- Department of Infectious Disease, University of California, Fresno, CA 93701, USA
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7
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Thompson GR, Ampel NM, Blair JE, Donovan F, Fierer J, Galgiani JN, Heidari A, Johnson R, Shatsky SA, Uchiyama CM, Stevens DA. Controversies in the Management of Central Nervous System Coccidioidomycosis. Clin Infect Dis 2022; 75:555-559. [PMID: 35717645 DOI: 10.1093/cid/ciac478] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 11/12/2022] Open
Abstract
Central nervous system infection with Coccidioides spp is fatal if untreated, and complications occur even when therapy is directed by experienced clinicians. We convened a panel of clinicians experienced in the management of coccidioidal meningitis to summarize current controversies and provide consensus for the management of this difficult infection.
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Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases and the Department of Medical Microbiology and Immunology, University of California-Davis Medical Center; Sacramento, CA USA.,University of California - Davis Center for Valley Fever, Sacramento, CA USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ, USA.,University of Arizona College of Medicine, Tucson, AZ, USA
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Fariba Donovan
- University of Arizona College of Medicine, Tucson, AZ, USA.,Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | - Joshua Fierer
- Division of Infectious Disease, Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA.,Infectious Diseases Section, VA Healthcare San Diego, San Diego, CA, USA
| | - John N Galgiani
- University of Arizona College of Medicine, Tucson, AZ, USA.,Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
| | - Arash Heidari
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Kern Medical, Bakersfield, CA, USA.,Valley Fever Institute, Kern Medical Center, Bakersfield, CA, USA
| | - Royce Johnson
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Kern Medical, Bakersfield, CA, USA.,Valley Fever Institute, Kern Medical Center, Bakersfield, CA, USA
| | | | - Christopher M Uchiyama
- Department of Neurosurgery, Scripps Clinic and Scripps Green Hospital, La Jolla, CA, USA
| | - David A Stevens
- California Institute for Medical Research, San Jose, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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8
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Shi J, Wong M, Xu Y. Coccidioidal Meningitis With Hyphal Forms Detected in Cerebrospinal Fluid in a Patient With Ventriculoperitoneal Shunt: A Case Report. J Cent Nerv Syst Dis 2021; 13:11795735211053446. [PMID: 34887691 PMCID: PMC8649429 DOI: 10.1177/11795735211053446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Coccidioidomycosis is a fungal infection caused by Coccidioides immitis and Coccidioides posadasii. The most severe disseminated coccidioidomycosis results in meningoencephalitis. Literature review reveals very rare reports of hyphal forms of coccidioides organisms detected in CSF. We present a case of a 58-year-old Hispanic male with a 10-year persistence of CM and many ventriculoperitoneal shunt reversions. The patient initially presented with a hydrocephalus of unknown source. The diagnosis of CM was made three years later based on a culture. On this presentation at the emergency department (ED), the patient reported one day of worsening left-sided weakness, altered mental status, and vomiting. We detected the hyphal forms of coccidioides in the cerebrospinal fluid (CSF) during cytopathology examination. Awareness of this reversion from spherule form to hyphal form is helpful in diagnosis and treatment. The hyphal forms of coccidioides may be associated with the increased risk of obstruction of the shunts. It is important to submit CSF for cytopathology examination for diagnosis, especially in patients with shunts.
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Affiliation(s)
- Jeremy Shi
- University of North Texas Health Science Center - Texas College of Osteopathic Medicine (UNTHSC/TCOM), Fort Worth, TX, USA
| | - Myra Wong
- Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Ya Xu
- Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
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9
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Pandora’s Box: Disseminated Coccidioidomycosis Associated with Self-Medication with an Unregulated Potent Corticosteroid Acquired in Mexico. Trop Med Infect Dis 2021; 6:tropicalmed6040207. [PMID: 34941663 PMCID: PMC8705876 DOI: 10.3390/tropicalmed6040207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/03/2021] [Accepted: 11/28/2021] [Indexed: 12/21/2022] Open
Abstract
Coccidioidomycosis (CM), caused by the dimorphic fungi Coccidioides immitis and C. posadasii, typically presents as acute or chronic pulmonary disease. However, disseminated disease occurs in about 1% of patients. Disseminated CM may affect multiple organ systems, including cutaneous, osteoarticular, and central nervous system sites. Here, we present a case of disseminated CM in a patient from a border city in Texas. The patient had a history of uncontrolled diabetes mellitus and was also taking an over-the-counter medication acquired in Mexico that contained a potent corticosteroid. The patient presented with seizures and was found to have a brain infarct, cavitary lung lesions, synovitis of the knee, multiple skin lesions, and chorioretinitis. The patient had a very high complement fixation titer for Coccidioides; fungal spherules were seen in a skin biopsy specimen, and Coccidioides grew in culture from a sample of synovial fluid and the skin biopsy specimen. This case illustrates the dissemination potential of Coccidioides, the danger of unregulated pharmaceuticals, the importance of thorough history taking, and recognizing risk factors that contribute to disseminated CM.
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10
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Mao Y, Li X, Lou H, Shang X, Mai Y, Yang L, Peng F, Fu X. Detection of Coccidioides posadasii in a patient with meningitis using metagenomic next-generation sequencing: a case report. BMC Infect Dis 2021; 21:968. [PMID: 34535093 PMCID: PMC8447723 DOI: 10.1186/s12879-021-06661-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coccidioidomycosis is a systemic infection caused by dimorphic fungi Coccidioides spp. endemic to Southwestern United States and Central and South America. A history of residence and travel in these areas is essential for the diagnostic of coccidioidomycosis, which has highly variable symptoms ranging from asymptomatic to severe, disseminated infection, and even death. Immunocompromised patients of coccidioidomycosis experience a high risk of dissemination, chronic infection, and mortality. Meningitis is one of the most deleterious coccidioidomycosis and can cause various life-threatening complications. CASE PRESENTATION Here we report a case of Coccidioides posadasii meningitis in a 49-year-old female who returned to China after one and a half years residence in Los Angeles, USA. The repeated routine cultures using CSF for bacteria or fungi were all negative. To hunt for an infectious etiology, the state-of-the-art technology metagenomic next-generation sequencing (mNGS) was then utilized, suggesting Coccidioides posadasii. Organizational pathological examination and polymerase-chain-reaction (PCR) results subsequently confirmed the mNGS detection. CONCLUSION To our knowledge, cases for coccidioidal meningitis have been rarely reported in China. While global travelling may spread this disease across continents and make the diagnosis more difficult. mNGS can detect almost all known pathogens with high sensitivity and specificity, especially for uncommon pathogen, such as Coccidioides posadasii in China.
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Affiliation(s)
- Yuqiao Mao
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Xia Li
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Haibo Lou
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Xiaoyu Shang
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Yanjun Mai
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Lan Yang
- Department of Bioinformatics, Hugobiotech Co., Ltd., Beijing, China
| | - Fuhua Peng
- Department of Neurology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Xihua Fu
- Department of Infectious Diseases, Guangzhou Panyu Central Hospital, Guangzhou, China.
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11
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Gastélum-Cano JM, Dautt-Castro M, García-Galaz A, Felix-Murray K, Rascón-Careaga A, Cano-Rangel MA, Islas-Osuna MA. The clinical laboratory evolution in coccidioidomycosis detection: Future perspectives. J Mycol Med 2021; 31:101159. [PMID: 34157512 DOI: 10.1016/j.mycmed.2021.101159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022]
Abstract
Coccidioidomycosis is a systemic disease caused by the fungi Coccidioides immitis and C. posadasii. It is a prevalent disease in arid regions with high temperatures and low precipitations in America. Coccidioidomycosis is a highly endemic disease of US-Mexico border states but commonly underdiagnosed. The diagnosis of coccidiomycosis is not easy due to the lack of specific symptoms; it is usually an integral approach, including clinical laboratory tests as an essential part of the diagnosis. Nevertheless, despite various laboratory tests available, affordability can be a limitation, mainly in developing countries. This review's objectives are 1) to learn the different laboratory approaches that arose and their application for clinical diagnosis; 2) to discuss their advantages and weaknesses, and finally, 3) propose what is on the horizon for future advances in clinical laboratory diagnosis of coccidioidomycosis. It has been a long way in laboratory tests evolution to detect coccidioidomycosis from tissue microscopy to Real-Time PCR. However, there is a delay in technology adoption for Coccidioides spp. detection in the clinical laboratory. The molecular Point of Care Testing (POCT) technology has reached us in our trench while research in PCR variants stills on-going. None of the currently existing scientific literature in coccidioidomycosis research has mentioned it. However, this trend in infectious and non-infectious disease diagnosis will continue in that way in order to offer better options for an easy and fast diagnosis. Undoubtedly, the implementation of molecular POCT for Coccidioides spp. would save resources in health care attention and improve access to diagnostic tools.
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Affiliation(s)
- José María Gastélum-Cano
- Lab. de Genética y Biología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico
| | - Mitzuko Dautt-Castro
- Instituto Potosino de Investigación Científica y Tecnológica A.C. (IPICYT). Camino a la Presa de San José No. 2055. Lomas 4ta Sección, San Luis Potosí, S.L.P. 78216, Mexico
| | - Alfonso García-Galaz
- Lab. de Microbiología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico
| | - Katya Felix-Murray
- Universidad de Sonora. Blvd. Luis Encinas y Rosales S/N. Col. Centro, Hermosillo, Sonora 83000, Mexico
| | - Antonio Rascón-Careaga
- Universidad de Sonora. Blvd. Luis Encinas y Rosales S/N. Col. Centro, Hermosillo, Sonora 83000, Mexico
| | - Manuel A Cano-Rangel
- Hospital Infantil del Estado de Sonora (HIES), Reforma 355. Ley 57, Hermosillo, Sonora 83100, Mexico
| | - María A Islas-Osuna
- Lab. de Genética y Biología Molecular, Centro de Investigación en Alimentación y Desarrollo A.C. (CIAD, A.C.) Gustavo Enrique Astiazarán Rosas No. 46. La Victoria, Hermosillo, Sonora 83304, Mexico.
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12
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De la Cerda-Vargas MF, Sandoval-Bonilla BA, McCarty JM, De León FCP, Candelas-Rangel JA, Rodríguez-Rodríguez JD, Navarro-Domínguez P, Muñoz-Hernández MA, Meza-Mata E, Fernández-González EM, Sámano-Aviña MG. Hydrocephalus in Mexican children with Coccidioidal Meningitis: Clinical, serological, and neuroimaging findings. Surg Neurol Int 2021; 12:119. [PMID: 33880224 PMCID: PMC8053472 DOI: 10.25259/sni_895_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/08/2021] [Indexed: 01/03/2023] Open
Abstract
Background Coccidioidal meningitis (CM) is a fungal infectious disease that rarely affects children. Even in endemic areas, coccidiomycosis rarely affects the pediatric population. However, 40% of affected children develop hydrocephalus. Here, we describe the clinical, serological, and neuroimaging findings in a series of Mexican children admitted to our neurosurgical service with hydrocephalus and subsequently diagnosed with CM. Methods We report a prospective series of pediatric patients with hydrocephalus secondary to CM in an endemic area at the north of Mexico. Our report includes children with CM who were hospitalized from 2015 to 2019 in a regional hospital in Torreón, Coahuila. Clinical evolution was monitored for 1 year after hospital discharge. Results Our series include five children with CM (2-17-years-old, three female), who were hospitalized for hydrocephalus and developed intracranial hypertension. The most frequent neuroimaging findings were leptomeningeal enhancement (5/5) and basal arachnoiditis (4/5), followed by asymmetric hydrocephalus (3/5), abnormalities in fourth ventricle morphology (3/5), and cerebral vasculitis (2/5). CM was diagnosed by positive serology or pathology studies. All children were initially managed with fluconazole and a shunt was placed for management of hydrocephalus. Four patients recovered without permanent neurological deficits and one subject developed persistent vegetative state. One year after hospital discharge, none of the subjects died. Conclusion This series contributes to the limited number of pediatric CM cases reported in the literature, and describes neuroimaging findings in the pediatric population. The cases here presented show that the identification of Coccidioides as causal agent in pediatric meningitis is crucial for targeted treatment and can affect dramatically neurological prognosis. Furthermore, our report stresses that even in endemic areas pediatric coccidiomycosis represents a diagnostic challenge, which is further exacerbated by the limited availability of resources in these regions. Therefore, a positive immunoglobulin G by enzyme immunoassay is enough for diagnosis of CM in endemic areas without access to CF.
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Affiliation(s)
- María F De la Cerda-Vargas
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - B A Sandoval-Bonilla
- Department of Neurosurgery, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, México
| | - James M McCarty
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, United States
| | | | - José A Candelas-Rangel
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Jorge D Rodríguez-Rodríguez
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Pedro Navarro-Domínguez
- Department of Neurosurgery, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Melisa A Muñoz-Hernández
- Department of Health Education and Research, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Elizabeth Meza-Mata
- Department of Anatomycal Pathology, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Elena M Fernández-González
- Department of Health Education, Hospital de Especialidades N° 71, Instituto Mexicano del Seguro Social, Torreón Coahuila
| | - Mariana G Sámano-Aviña
- Department of Pediatric Infectious Disease, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
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13
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Chee D, Moritz AW, Profit AP, Agarwal AN, Anstead GM. Fatal coccidioidomycosis involving the lungs, brain, tongue, and adrenals in a cirrhotic patient. An autopsy case. IDCases 2021; 23:e01049. [PMID: 33532240 PMCID: PMC7822947 DOI: 10.1016/j.idcr.2021.e01049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/12/2021] [Indexed: 12/17/2022] Open
Abstract
In this paper, we describe a case of fatal disseminated coccidioidomycosis (CM). The patient was a 44-year old male with a history of cirrhosis who presented with altered mental status, cough, and an enlarged, ulcerated tongue. On evaluation, the patient was found to have coccidioidal infection of the tongue, lungs, and brain. Despite over two months of antifungal treatment, the patient died from aspiration pneumonia and at autopsy was found to have persistent infection of the tongue and lungs, extensive mycosis of the brain, and involvement of both adrenal glands. The fulminant course of coccidioidomycosis in this patient is ascribed to his baseline cirrhosis and lymphocytopenia. There are few autopsy cases of CM that have been described in the post-antifungal era and few published cases of CM with either tongue or adrenal involvement.
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Affiliation(s)
- David Chee
- San Antonio Infectious Diseases Consultants, 8042 Wurzbach Road, San Antonio, TX, 78229, United States
| | - August W Moritz
- Methodist Hospital, 7700 Floyd Curl, San Antonio, TX, 78229, United States
| | - Amanda P Profit
- Medical City Dallas Hospital, 7777 Forest Ln, Suite A-200, Dallas, TX, 75230, United States
| | - Apeksha N Agarwal
- Department of Pathology, University of Texas Health, 7703 Floyd Curl Drive, San Antonio, TX, 78229, United States
| | - Gregory M Anstead
- Medical Service, Division of Infectious Diseases, South Texas Veterans Healthcare System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, United States.,Department of Medicine, Division of Infectious Diseases, University of Texas Health, 7703 Floyd Curl Dr, San Antonio, TX, 78229, United States
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14
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Phelps RRL, Lu AY, Lee AT, Yue JK, Winkler EA, Raygor KP, Oh T, Barkovich MJ, Hollander H. Cerebrovascular complications of coccidioidomycosis meningitis: Case report and systematic review. J Clin Neurosci 2020; 80:282-289. [PMID: 33099362 DOI: 10.1016/j.jocn.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/03/2020] [Indexed: 11/25/2022]
Abstract
Coccidioidomycosis exposure is common in the southwest United States and northern Mexico. Dissemination to the meninges is the most severe form of progression. Although ischemic strokes are well-reported in these patients, other cerebrovascular complications of coccidioidomycosis meningitis (CM), as well as their treatment options and outcomes, have not been systematically studied. We present a uniquely severe case of CM with several cerebrovascular complications. We also systematically queried PubMed and EMBASE databases, including articles published before April 2020 reporting human patients with CM-induced cerebrovascular pathology other than ischemic infarcts. Sixteen articles met inclusion criteria, which describe 6 patients with aneurysmal hemorrhage, 10 with non-aneurysmal hemorrhage, one with vasospasm, and one with transient ischemic attacks. CM-associated aneurysms invariably presented with hemorrhage. These were universally fatal until the past decade, when advances in surgical clipping and/or combined surgical and endovascular treatment have improved outcomes. We found that non-aneurysmal intracranial hemorrhages were limited to male patients, involved a diverse set of intracranial vasculature, and had a mortality rate surpassing 80%. Vasospasm was reported once, and was treated with percutaneous transluminal angioplasty. Transient ischemic attacks were reported once, and were successfully treated with fluconazole and dexamethasone. This review suggests that CM can present with a wide array of cerebrovascular complications, including ischemic infarcts, aneurysmogenesis, non-aneurysmal intracranial hemorrhage, vasospasm, and transient ischemic attacks. Mortality has improved over time due to advances in surgical and endovascular treatment modalities. The exception is non-aneurysmal intracranial hemorrhage, which remains associated with high mortality rates and few targeted therapeutic options.
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Affiliation(s)
- Ryan R L Phelps
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA.
| | - Alex Y Lu
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - Anthony T Lee
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - John K Yue
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - Kunal P Raygor
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, Box 0112, San Francisco, CA 94143, USA
| | - Matthew J Barkovich
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Room M391, San Francisco, CA 94143, USA
| | - Harry Hollander
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, Room M1498, Box 0119, San Francisco, CA 94117, USA
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15
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Coccidioidal meningitis in non-AIDS patients. A case series at a Mexican neurological referral center. Clin Neurol Neurosurg 2020; 196:106011. [PMID: 32593044 DOI: 10.1016/j.clineuro.2020.106011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Coccidioidal meningitis is a life-threatening condition and a diagnostic challenge in cases of chronic meningitis. It is associated to severe complications, like basal arachnoiditis, hydrocephalus, and secondary vasculitis. OBJECTIVE To present a 20-year retrospective clinical series of coccidioidal meningitis cases at a Mexican neurological referral center. RESULTS The clinical records of 11 patients, predominantly males, were retrieved. Weight loss and night sweats were observed in 64 % of cases. Neurological signs included intracranial hypertension in 91 % of cases, altered alertness and meningeal syndrome in 72 %, and neuropsychiatric symptoms in 64 %. Mean CSF glucose levels were 30 ± 25 mg/dL, and pleocytosis ranged from 0 to 2218 cells/mm3. The diagnosis was confirmed by coccidioidal antigen latex agglutination in 91 % of cases. Radiological findings were hepatomegaly in 55 % of cases and pneumonia in 45 %. Neuroimaging findings included leptomeningitis in 73 % of cases, pachymeningitis in 45 %, and vascular involvement in 91 %. Less common findings included spinal cord lesion and mycotic aneurism, found in 18 % of cases. A molecular coccidioidal DNA test confirmed the predominance of Coccidioides immitis, detected in 64 % of cases. With respect to the clinical outcome, 46 % of patients died. The survivors suffered from sequels like chronic headache, cognitive alterations, and depression. CONCLUSIONS Coccidioidal meningitis is an entity with high mortality rates. More than one half of patients suffered disseminated disease. Although meningeal signs are not frequent in chronic meningitis, more than two-thirds of our patients showed mild nuchal rigidity. In addition, cerebral and cerebellar volume loss, associated with cognitive impairment and depression, was often observed in surviving patients during the clinical-radiological follow-up.
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Affiliation(s)
| | | | - Tiziana Ascione
- Department of Infectious Diseases, D. Cotugno Hospital, AORN Dei Colli, Naples, Italy
| | - Anna M Spera
- Department of Infectious Diseases, University of Salerno, Italy
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17
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Abstract
Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.
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Affiliation(s)
- Victoria Poplin
- Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66160, USA
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18
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Krogstad P, Johnson R, Garcia-Lloret MI, Heidari A, Butte MJ. Host-Pathogen Interactions in Coccidioidomycosis: Prognostic Clues and Opportunities for Novel Therapies. Clin Ther 2019; 41:1939-1954.e1. [PMID: 31648806 PMCID: PMC10482146 DOI: 10.1016/j.clinthera.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Coccidioidomycosis (CM) is a systemic fungal disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. In its endemic areas of the United States, CM is growing as a public health challenge with a marked increase in incidence in the last 15 years. Although Coccidioides infection is asymptomatic in most cases, symptomatic pulmonary disease occurs in ~40% and disseminated coccidioidomycosis (DCM) occurs in ~1% of previously healthy children and adults. DCM is markedly more common in immunocompromised people, who often experience life-threatening disease despite use of antifungal medications. Although options for antifungal therapy have improved, lifelong therapy is needed for those who develop coccidioidal meningitis. The purpose of this article was to review the state of antifungal therapy and recent studies of host-pathogen interactions in CM in light of advances in immunomodulatory therapy. METHODS The study included a review of PubMed and abstracts of the Coccidioidomycosis Study Group (years 2000-2019). FINDINGS Current therapy for CM relies upon azole and polyene antifungal agents. Murine models and studies of DCM in patients with monogenic primary immunodeficiency states and acquired immunodeficiency have revealed the importance of both innate and adaptive immune responses in the control of infections with Coccidioides species. In particular, defects in sensing of fungi and induction of cellular immune responses have been frequently reported. More recently, polymorphisms in key signaling pathways and in the generation of Th17 and Th1 immune responses have been linked with DCM. IMPLICATIONS Antifungal therapy is sufficient to control disease in most cases of CM, but treatment failure occurs in cases of severe pulmonary disease and nonmeningeal disseminated disease. Lifelong therapy is recommended for meningitis in view of the very high risk of recurrence. Corticosteroid therapy is advised by some experts for severe pulmonary disease and for some neurologic complications of DCM. DCM is only rarely the result of a severe monogenic immunodeficiency. Case studies suggest that reorienting cellular immune responses or augmenting effector immune responses may help resolve DCM. Systematic investigation of immunotherapy for coccidioidomycosis is advisable and may help to address the recent marked increase in reports of the disease in endemic areas.
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Affiliation(s)
- Paul Krogstad
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA.
| | - Royce Johnson
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria I Garcia-Lloret
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Arash Heidari
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Manish J Butte
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
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19
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Lang R, Stokes W, Lemaire J, Johnson A, Conly J. A case report of Coccidioides posadasii meningoencephalitis in an immunocompetent host. BMC Infect Dis 2019; 19:722. [PMID: 31420023 PMCID: PMC6697908 DOI: 10.1186/s12879-019-4329-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 07/29/2019] [Indexed: 11/26/2022] Open
Abstract
Background Coccidioides spp. are dimorphic fungi endemic to Central America, regions of South America and southwestern USA. Two species cause most human disease: Coccidioides immitis (primarily California isolates) and Coccidioides posadasii. Coccidioidomycosis is typically acquired through inhalation of soil or dust containing spores. Coccidioidal meningitis (CM), most common in the immunocompromised host, can also affect immunocompetent hosts. Case presentation We report a case of C. posadasii meningoencephalitis in a previously healthy 42-year-old Caucasian male who returned to Canada after spending time working in New Mexico. He presented with a 3-week history of headache, malaise and low-grade fevers. He developed progressive confusion and decreasing level of consciousness following hospitalization. Evidence of hydrocephalus and leptomeningeal enhancement was demonstrated on magnetic resonance imaging (MRI) of his brain. Serologic and PCR testing of the patient's CSF confirmed Coccidioides posadasii. Despite appropriate antifungal therapy he continues to have significant short-term memory deficits and has not returned to his full baseline functional status. Conclusions Travel to endemic regions can result in disease secondary to Coccidioides spp. and requires physicians in non-endemic areas to have a high index of suspicion. Effective therapeutic options have reduced the mortality rate of CM, however, it is still associated with significant morbidity and requires life-long therapy.
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Affiliation(s)
- Raynell Lang
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
| | - William Stokes
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Jane Lemaire
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Andrew Johnson
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - John Conly
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,Departments of Medicine, Microbiology, immunology & Infectious Diseases, Pathology & Laboratory Medicine. Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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20
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Jackson NR, Blair JE, Ampel NM. Central Nervous System Infections Due to Coccidioidomycosis. J Fungi (Basel) 2019; 5:jof5030054. [PMID: 31261704 PMCID: PMC6787616 DOI: 10.3390/jof5030054] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Coccidioidomycosis is a common infection in the western and southwestern United States as well as parts of Mexico and Central and South America and is due to the soil-dwelling fungi Coccidioides. Central nervous system (CNS) infection is an uncommon manifestation that is nearly always fatal if untreated. The presentation is subtle, commonly with headache and decreased mentation. The diagnosis should be considered in patients with these symptoms in association with a positive serum coccidioidal antibody test. The diagnosis can only be established by analysis of cerebrospinal fluid (CSF), which typically demonstrates a lymphocytic pleocytosis, hypoglycorrhachia, elevated protein, and positive CSF coccidioidal antibody. Cultures are infrequently positive but a proprietary coccidioidal antigen test has reasonable sensitivity. Current therapy usually begins with fluconazole at 800 mg daily but other triazole antifungals also have efficacy and are often used if fluconazole fails. Triazole therapy should be lifelong. Intrathecal amphotericin B, the original treatment, is now reserved for those in whom triazoles have failed. There are several distinct complications of CNS coccidioidal infection, the most common of which is hydrocephalus. This is nearly always communicating and requires mechanical shunting in addition to antifungal therapy. Other complications include cerebral vasculitis, brain abscess, and arachnoiditis. Management of these is difficult and not well established.
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Affiliation(s)
- Niki R Jackson
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Janis E Blair
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA.
- University of Arizona College of Medicine, Tucson, AZ 85724, USA.
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21
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Hernandez H, Erives VH, Martinez LR. Coccidioidomycosis: Epidemiology, Fungal Pathogenesis, and Therapeutic Development. CURRENT TROPICAL MEDICINE REPORTS 2019; 6:132-144. [PMID: 34367879 DOI: 10.1007/s40475-019-00184-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose of Review Coccidioidomycosis can result from the inhalation of infectious spores of Coccidioides species (spp.) immitis or posadasii. Clinical manifestations range from mild flu-like disease to severe disseminated infection that can require life-long therapy. Burden of this mycosis is high in the southwest region of the USA where it is well characterized, and in many areas of Mexico and Latin America where it is inadequately characterized. Here, we provide historical data and current knowledge on Coccidioides spp. pathogenesis as well as recent progress in therapeutic and vaccine development against coccidioidomycosis. Recent Findings The virulence mechanisms of Coccidioides spp. are largely unknown; however, production and regulation of a spherule glycoprotein, ammonium production, and melanization have all been proposed as integral factors in Coccidioides spp.' pathogenesis. Therapeutic options are limited and not 100% effective, but individualized treatment with triazoles or amphotericin B over the course of pulmonary or disseminated infection can be effective in resolution of coccidioidomycosis. Human immunization has not been achieved but efforts are ongoing. Summary Advances in therapeutic and vaccine development are imperative for the prevention and treatment of coccidioidomycosis, especially for those individuals at risk either living or traveling to or from endemic areas.
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Affiliation(s)
- Hazael Hernandez
- Department of Biological Sciences, The Border Biomedical Research Center, The University of Texas at El Paso, 500 W. University Ave., Bioscience Research Building, Room 2.170, El Paso, TX 79968-9991, USA
| | - Victor H Erives
- Department of Biological Sciences, The Border Biomedical Research Center, The University of Texas at El Paso, 500 W. University Ave., Bioscience Research Building, Room 2.170, El Paso, TX 79968-9991, USA
| | - Luis R Martinez
- Department of Biological Sciences, The Border Biomedical Research Center, The University of Texas at El Paso, 500 W. University Ave., Bioscience Research Building, Room 2.170, El Paso, TX 79968-9991, USA
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22
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D'Assumpcao C, Heidari A, Johnson RH. Patient With a 42-Year History of Coccidioidal Meningitis. J Investig Med High Impact Case Rep 2018; 6:2324709618820047. [PMID: 30622991 PMCID: PMC6302271 DOI: 10.1177/2324709618820047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/13/2018] [Indexed: 11/28/2022] Open
Abstract
This is a case of a 56-year-old man diagnosed with coccidioidal meningitis 42 years ago at the age of 14. He was treated with intrathecal amphotericin B deoxycholate by cisternal puncture for 15 years before switching to fluconazole once it became available in 1991. Over 42 years of treatment, he developed hearing loss due to auditory nerve neurotoxicity, hydrocephalus requiring ventriculoperitoneal shunting with associated malfunctions, lumbar arachnoiditis, and hypokalemic paralysis. Regular cerebrospinal fluid studies to this day do not show disease clearance. Many of the lessons from his clinical history are enshrined in the current iteration of the Infectious Diseases Society of America Coccidioidomycosis Treatment Guidelines. To our knowledge, he is the longest surviving coccidioidal meningitis patient.
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Affiliation(s)
- Carlos D'Assumpcao
- Kern Medical-UCLA, Bakersfield, CA, USA.,Ross University, Miramar, FL, USA
| | - Arash Heidari
- Kern Medical-UCLA, Bakersfield, CA, USA.,Valley Fever Institute, Bakersfield, CA, USA
| | - Royce H Johnson
- Kern Medical-UCLA, Bakersfield, CA, USA.,Valley Fever Institute, Bakersfield, CA, USA
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