Computed tomography of disseminated coccidiodomycosis

2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Coccidioidomycosis with cerebral and cerebellar granulomas

We discuss the diagnosis, treatment and prognosis of a Danish male with disseminated coccidioidomycosis. He presented with headaches and slight fever. Examination showed pulmonary, cutaneous and cerebral and cerebellar granulomas, a rare complication. He was treated with intravenously and subsequently orally administered fluconazole. Symptoms and clinical findings regressed during treatment.

Vascularites secondaires aux infections fongiques

THE FUNGI INCRIMINATED: Cerebral vascular lesions are frequently observed in the rhino-cerebral localisations of aspergillosis and mucormycosis, and during cerebral coccidioidomycosis, but far more rarely in neuro-meningeal cryptococcosis and histoplasmosis. Other fungi are occasionally at the origin of vasculitis. THE CONTEXT: Diagnosis is difficult to establish. It should be evoked in immunodepressed patients presenting with clinical and radiological manifestations of cerebral vasculitis. AS FAR AS TREATMENT IS CONCERNED: Treatment relies on antifungal therapy. Steroids and/or anticoagulants can be envisaged in some patients.

Oculomotor motion disorders: current imaging of cranial nerves 3, 4, and 6

The eye movements are controlled by the cranial nerves 3, 4, and 6 working in close cooperation under the supervision of the voluntary cortex. Clinically, the most common presentation of abnormal ocular motor motion is double vision. A thorough clinical examination can usually separate a local orbital cause which can produce a restriction of the muscles moving the eye from a neurogenic cause due to an abnormality of one of the three nerves or their association pathways. Recent articles in the scientific literature have described major advances in our understanding of the anatomy and vascular relationships of the three ocular motor nerves (cranial nerves 3, 4, and 6) and of the diagnosis and treatment of a variety of pathological processes that damage these nerves, including ischemia, inflammation, and compression.

Intracranial tuberculosis in children: CT appearance and clinical outcome

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.

Multiple intracranial aneurysms due to Coccidioides immitis infection. Case report

True mycotic (fungal) aneurysms are distinctly uncommon. The case of a young woman with multiple intracranial aneurysms of Coccidioides immitis origin is presented. Coccidioides immitis organisms are not uncommon central nervous system pathogens and usually cause basilar meningitis and hydrocephalus. There are no previous reports of a coccidioidal mycotic aneurysm. The management of intracranial coccidioidomycosis and fungal aneurysms is reviewed.

Central nervous system coccidioidomycosis: a clinicopathologic study of treatment with and without amphotericin B

The clinical and pathologic findings in 32 patients with central nervous system (CNS) coccidioidomycosis were studied. Seventeen patients had received more than 1.5 g of amphotericin B (AMB), chiefly intravenously, during treatment periods of up to eight years. Eight patients had received 246 mg to 1.3 g of AMB, and three patients had received only brief treatment (one to three days; total dose, no more than 100 mg). Fifteen patients had not received AMB. Significant clinical differences between the patients treated with and without AMB were longer survival time following diagnosis of illness (P less than 0.05) and more frequent cranial nerve signs in the treated patients (P = 0.089). The wide spectrum of macroscopic and microscopic lesions in the CNS included meningitis, ventriculitis, hydrocephalus, and cerebritis. Long-standing infections were associated with disseminated discrete foci of gliosis and infarcts in the brain, particularly in the basal ganglia and deep white matter, related to endarteritis obliterans in basilar meninges. In contrast to patients with CNS and systemic mycoses treated with amphotericin B methyl ester (J Infect Dis 146:125, 1982), no diffuse lesions of white matter were found in patients treated with or without AMB. Histopathologic patterns observed in this study included leptomeningitis alone, leptomeningitis with cerebritis, leptomeningitis with cerebritis and infarcts, and the unusual pattern of disseminated miliary granulomas. The frequency and extent of CNS lesions in the groups treated with and without AMB were not significantly different. It is concluded that AMB therapy, while prolonging survival, does not alter the spectrum of pathologic findings in CNS coccidioidomycosis infection.