INFECTION (J HALPERIN, SECTION EDITOR)
Coccidioidal Meningitis: A Review on Diagnosis, Treatment,
and Management of Complications
Published online: 13 March 2018
Springer Science+Business Media, LLC, part of Springer Nature 2018
Purpose of review This article summarizes the diagnosis and treatment of coccidioidal meningitis (CM) and its complications.
An overview of current and prospective pharmacologic treatment options and monitoring parameters is provided. A consensus
has not been reached regarding universally accepted therapeutic serum levels for azoles because of insufficient evidence. We
describe the preferred therapeutic drug level ranges that our institution uses to monitor azole therapy.
Recent findings Ho et al. described the preparation and administration of intrathecally delivered amphotericin B deoxycholate.
Thompson et al. described possible benefits of controversial adjuvant corticosteroid therapy for secondary prevention of vascu-
litic infarction secondary to CM.
Summary CM was universally fatal until the advent of intrathecal amphotericin B deoxycholate therapy, the introduction of
which changed the natural history of the disease in much the same way as penicillin changed the natural history of bacterial
meningitis. Although there was still significant morbidity, survival rates drastically increased to approximately 70%. The
introduction of azole therapy has decreased the side effects and burden of treatment but without a significant change in CM-
related mortality and morbidity compared with the use of intrathecal amphotericin B deoxycholate therapy.
Keywords Coccidioidal meningitis
Intrathecal amphotericin B therapy
Adjunctive corticosteroid therapy
Coccidioidomycosis, often referred to as “valley fever,” is a
fungal infection endemic to the southwestern USA, north-
western Mexico, and regions of Central and South America.
It is caused by the dimorphic fungus Coccidioides, with
C. immitis and C. posadasii as the causative pathogens. In
the USA, Coccidioides can be found primarily in the states
of Arizona, California, Nevada, New Mexico, Texas, and
Utah, although it has recently been isolated in soil as far north
as southeastern Washington State .
In 1892, coccidioidomycosis was described for the first
time by Posadas  and Wernicke  as a cutaneous disease.
C. immitis was identified and described by Rixford and
Gilchrist  in 1896, although it was originally
miscategorized as a protozoan because of its microscopic ap-
pearance. Ophuls and Moffitt  verified that C. immitis was
indeed a fungus that existed in two forms during its life cycle.
In 1905, Ophuls  described coccidioidal meningitis
(CM). The first living patient with hydrocephalus attributed
to CM was described by Ryfkogel  in 1910. In the
pretherapy era, Vincent et al.  provided the definitive de-
scription of CM and described its natural history in Veterans
Affairs Armed Forces studies from 1955 to 1958.
This article reviews the diagnosis, treatment, and manage-
ment of complications secondary to CM. Current and prospec-
tive pharmacologic treatment options and monitoring
This article is part of the Topical Collection on Infection
* Jackie Ho
David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Division of Infectious Disease, Valley Fever Institute, Kern Medical,
Bakersfield, CA, USA
Department of Pharmacy, San Leandro Hospital, 13855 E 14th St,
San Leandro, CA 94578, USA
Department of Pharmacy, Kaiser Permanente, Oakland, CA, USA
Current Neurology and Neuroscience Reports (2018) 18: 19