What is the treatment for coccidioidal meningitis?

Updated: Aug 27, 2019
  • Author: Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH; Chief Editor: Michael Stuart Bronze, MD  more...
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While patients with suspected coccidioidal meningitis can be treated adequately in an outpatient setting, hospitalization helps facilitate confirmation of diagnosis and initiation of therapy.

Fluconazole can be used in the treatment of mild to moderate meningitis and, occasionally, life-threatening meningitis in patients who opt against amphotericin B or who have contraindications to its use. Because of its excellent penetration into the cerebrospinal fluid (CSF), fluconazole has become the drug of choice for long-term therapy of meningeal infection. The 2016 guidelines of the Infectious Diseases Society of America recommend fluconazole as initial therapy. [65]

The usual dosage of fluconazole is 400 mg/day, but many physicians start with 800 or 1000 mg/day. Itraconazole 400-600 mg/day offers comparable efficacy. If the azole therapy elicits a response, treatment is continued indefinitely, because treatment is suppressive rather than curative and relapse rates are high. [45]

Some physicians initiate intrathecal amphotericin B along with the azole, whereas others reserve amphotericin B for cases in which azoles fail. [45, 85] The optimal dose and duration of intrathecal amphotericin is unknown. The IV dose ranges from 0.5-1.5 mg/kg/day, given in 5% glucose over 2-6 hours; the intrathecal dose, administered via cisternal injection, is 0.01-1.5 mg/dose administered at intervals that range from daily to every 48 hours to once per week. Headache, nausea, and fever begin about 30 minutes following the injection and may last for hours.

These injections continue until signs of intolerance appear, including vomiting, prostration, and dose-related mental-status changes. Corticosteroids (eg, 25 mg cortisone succinate) are added to the amphotericin injection to reduce these drug-related inflammation symptoms.

An alternative is continuous infusion of amphotericin B given via a programmable pump implanted into the abdominal wall and connected to the cisternal subarachnoid space. Liposomal amphotericin is lipid-based and has less nephrotoxicity than the deoxycholate formulation

Ventricular peritoneal shunts may be required to treat complications of meningitis (eg, hydrocephalus). In the absence of a CSF block, lumbar peritoneal shunting may be required.

CNS vasculitis is a life-threatening complication of coccidioidal meningitis. Short-term treatment with high-dose IV corticosteroids has been reported with varying results in regards to benefit; however, this information is anecdotal.

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