What is the role of lumbar puncture in the workup of coccidioidomycosis?

Updated: Aug 27, 2019
  • Author: Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH; Chief Editor: Michael Stuart Bronze, MD  more...
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Perform lumbar puncture in patients with fever, headache, nuchal rigidity, meningismus, mental status changes, or ataxia. [9, 59] Many physicians perform lumbar puncture in all patients with extrapulmonary disease or significantly elevated CF IgG titers.

CSF analysis typically reveals a lymphocytic pleocytosis with elevated protein levels and hypoglycorrhachia. In as many as 70% of patients, coccidioidal meningitis is associated with eosinophils in the CSF. Coccidioidomycosis is the most common cause of eosinophilic pleocytosis in the United States.

The diagnosis is aided by the detection of complement-fixating antibodies in the CSF. Coccidioidal meningitis preferentially involves the basilar meninges.

Demonstration of elevated CF titers in CSF establishes the diagnosis of coccidioidal meningitis. CF IgG is present in 90% of patients with coccidioidal meningitis. Elevated CSF CF titers can also be seen with isolated epidural coccidioidal involvement, but only the CSF total protein value is elevated in that situation.

False-positive CSF CF titers are rare but can occur in patients with very high serum CF titers and no meningeal involvement. Rarely, patients with meningitis as their only site of coccidioidal infection have positive CSF CF titers with negative serum CF titers.

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