Correct!
5. Lymphocyte predominance

Coccidioidal meningitis should be considered when the patient is noted to have worsening or persistent headache, altered mentation, unexplained nausea and vomiting, or neurological deficit (7). An opening pressure should be obtained and CSF sent for cell count with differential, glucose, protein, fungal culture, cocci complement fixation as well as coccidioidal antigen. Pleocytosis is usually remarkable with lymphocyte predominance however a neutrophil predominance may be present early in the course. Protein is typically elevated >150 mg/dL and glucose is typically found to be normal or slightly lower. The sensitivity of CSF culture is typically ~25%, however, imaging may demonstrate hydrocephalus or basilar inflammation up to 50% of the time. Coccidioides spherules are rarely seen on microscopy, this would indicate a very high fungal burden.

Historically, intrathecal amphotericin B deoxycholate was used until being largely replaced by azole therapy in the 1990s. Oral fluconazole is the drug of choice with a recommended dosing of 400–1200mg daily (8). Itraconazole may be used alternatively, however, levels need to be monitored at least weekly. Liposomal amphotericin B is still recommended for refractory cases and may be given intrathecally. Therapy with fluconazole is recommended to be continued lifelong as it has been found that many patients who stop therapy may suffer from relapse (9). Many patients who present with hydrocephalus will likely require neurosurgical intervention with some CSF diversion procedure such as a VP shunt (10). These devices may need to be frequently re-evaluated due to mechanical blockage however they are essential in management of hydrocephalus due to this disease.

Our patient eventually made an uneventful recovery.

References

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  8. Galgiani JN, Catanzaro A, Cloud GA, Higgs J, Friedman BA, Larsen RA, Graybill JR. Fluconazole therapy for coccidioidal meningitis. The NIAID-Mycoses Study Group. Ann Intern Med. 1993 Jul 1;119(1):28-35. [CrossRef] [PubMed]
  9. Dewsnup DH, Galgiani JN, Graybill JR, Diaz M, Rendon A, Cloud GA, Stevens DA. Is it ever safe to stop azole therapy for Coccidioides immitis meningitis? Ann Intern Med. 1996 Feb 1;124(3):305-10. [CrossRef] [PubMed]
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