10/21/2008 Case 2: Coccidioides immitis meningitis

Presented by: Dr. Ehud Lavi - New York Presbyterian Hospital

Clinical History:

A 35-year-old man was seen in another state. He was found by his car, confused. He was brought to an emergency room where he was found to be hyponatremic (Na 118), and the conclusion was that this was due to water intoxication. He was given hypertonic saline and discharged. However, a CT scan had been done and the report had some sketchy detail but concluded that there was no major head lesion. A subsequent CT showed minimal periventricular small vessel disease, and a lumbar puncture revealed decreased glucose, elevated protein and lymphocytic pleocytosis. He was started on anti-tuberculosis drugs. He had visited Southern California a few months before the episode of confusion. He was HN -negative. He died soon after, and at autopsy the brain showed no parenchymal lesions but the subarachnoid space contained lymphocytes and multinucleated giant cells. There were spherules containing endospores in the subarachnoid space, including within the giant cells.

Diagnostic Notes:

Coccidioides immitis meningitis. The fungus had been confirmed serologically. There was a general discussion of the odd histories and the usual and unusual (brain)
presentations of this organism, including its geographic restriction in the Southwest and South America and a danger of infection from newly turned soil, as well as potential danger to laboratory personnel if cultured (tape the culture plate lids tightly closed).

Slide Image:

view high resolution slide image