Bies Jared J, Hassan Mariam, Prakash Swathi, Aguilar Mateo-Porres, Peralta Diego P
Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA.
Infectious Diseases, Texas Tech University Health Sciences Center El Paso, El Paso, USA.
Cureus. 2023 Jul 31;15(7):e42758. doi: 10.7759/cureus.42758. eCollection 2023 Jul.
The clinical presentation, diagnosis, treatment, and complications of coccidioidal meningitis caused by the dimorphic pathogenic fungus ( and ) have been well documented in the literature. Despite the abundance of literature concerning this disease manifestation, it is not very commonly seen in clinical practice, delaying its diagnosis and treatment and leading to devastating neurological sequelae. Therefore, considering this disease process as a potential diagnosis in endemic areas is important for appropriate and timely treatment. We present the case of a 26-year-old male who was found to have chronic coccidioidal meningitis on further investigation. The patient presented as a transfer for an abnormal head MRI with a three-month history of progressive occipital headaches and shortness of breath. Associated symptoms included transit vision loss, upper extremity numbness, night sweats, decreased appetite, and weight loss. Relevant risk factors were being a hiker and living in the southwest of Texas. The patient was started on empiric ceftriaxone and vancomycin. A repeat MRI showed leptomeningeal enhancement and acute infarcts in the left temporal lobe and lentiform nucleus. Cerebrospinal fluid (CSF) analysis showed pleocytosis with lymphocytic predominance, the presence of eosinophils, elevated protein level, and an extremely low glucose level. Further workup ruled out syphilis and tuberculosis. Therefore, considering his clinical presentation, risk factors, and workup results, ceftriaxone and vancomycin were discontinued, and high-dose oral fluconazole was started, which produced a marked clinical response within the next 48 hours. A CT thorax showed findings suggestive of pulmonary coccidioidomycosis, and serology in both serum and CSF specimens returned positive.
由双相致病真菌（球孢子菌）引起的球孢子菌性脑膜炎的临床表现、诊断、治疗及并发症在文献中已有充分记载。尽管关于这种疾病表现的文献丰富，但在临床实践中并不常见，这导致其诊断和治疗延迟，并引发严重的神经后遗症。因此，在流行地区将此疾病过程视为潜在诊断对于恰当及时的治疗很重要。我们报告一例26岁男性病例，经进一步检查发现患有慢性球孢子菌性脑膜炎。该患者因头部MRI异常而转诊，有三个月进行性枕部头痛和呼吸急促病史。相关症状包括一过性视力丧失、上肢麻木、盗汗、食欲减退和体重减轻。相关危险因素为是一名徒步旅行者且居住在得克萨斯州西南部。患者开始经验性使用头孢曲松和万古霉素治疗。复查MRI显示软脑膜强化以及左颞叶和豆状核急性梗死。脑脊液（CSF）分析显示细胞增多以淋巴细胞为主，有嗜酸性粒细胞，蛋白水平升高，葡萄糖水平极低。进一步检查排除了梅毒和结核。因此，考虑到他的临床表现、危险因素及检查结果，停用了头孢曲松和万古霉素，开始使用高剂量口服氟康唑，在接下来的48小时内产生了显著的临床反应。胸部CT显示提示肺球孢子菌病的表现，血清和脑脊液标本的血清学检查均呈阳性。
