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February 19, 2013; 80 (8) Resident and Fellow Section

Teaching Neuroimages: Fungus in the brain

Coccidioidomycosis meningoencephalitis

Daniel M. Goldenholz, Neal Mehra, Brian Dahlin, Stuart H. Cohen, Vicki L. Wheelock
First published February 18, 2013, DOI: https://doi.org/10.1212/WNL.0b013e3182825041
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  • Figure
    Figure Evolving coccidioidomycosis infection in the brain

    (A) Initial MRI after the seizure showed meningeal enhancement in the left sylvian fissure, a nonspecific pattern. (B) Two-month follow-up MRI revealed multiple rim-enhancing nodules extending into the adjacent frontal and temporal lobe parenchyma with extensive surrounding edema. These nodules, along with the clinical history, confirm the diagnosis of coccidioidomycosis.

Coccidioidomycosis meningoencephalitis

  1. Daniel M. Goldenholz, MD, PhD,
  2. Neal Mehra, MD,
  3. Brian Dahlin, MD,
  4. Stuart H. Cohen, MD and
  5. Vicki L. Wheelock, MD
  1. From the University of California Davis Medical Center, Sacramento.
  1. Correspondence to Dr. Goldenholz:daniel.goldenholz{at}ucdmc.ucdavis.edu
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  1. serves on the editorial team for the Neurology(r) Resident and Fellow Section.

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  1. NONE

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  1. NONE

Consultancies:

  1. NONE

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  1. NONE

Other Activities:

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Clinical Procedures or Imaging Studies:

  1. NONE

Research Support, Commercial Entities:

  1. NONE

Research Support, Government Entities:

  1. NONE

Research Support, Academic Entities:

  1. NONE

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  1. NONE

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Funding for Travel or Speaker Honoraria:

  1. Commercial,Covidien Neurovascular, Travel Expense for Advanced Stroke Treatment Summit July 2012

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  1. NONE

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  1. NONE

Employment, Commercial Entity:

  1. NONE

Consultancies:

  1. NONE

Speakers' Bureaus:

  1. NONE

Other Activities:

  1. NONE

Clinical Procedures or Imaging Studies:

  1. NONE

Research Support, Commercial Entities:

  1. NONE

Research Support, Government Entities:

  1. NONE

Research Support, Academic Entities:

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Research Support, Foundations and Societies:

  1. NONE

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  1. NONE

Other Activities:

  1. NONE

Clinical Procedures or Imaging Studies:

  1. NONE

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  1. NONE

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Patents:

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Consultancies:

  1. (1) Commercial entity: Consultant Fee from Lundbeck, 2012

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Other Activities:

  1. 1) Non-profit entity: Honorarium from the Huntington's Disease Society of America for co-authorship of A Physician's Guide to the Management of Huntington's Disease, 3rd edition, 2011(2) Commercial entity Lundbeck: Grant for Huntington's Disease Educational Symposium, 2011

Clinical Procedures or Imaging Studies:

  1. NONE

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  1. NONE

Research Support, Government Entities:

  1. (1)California Institute of Regenerative Medicine Disease Team Planning Award DR2-05415, Principle Investigator, 2010-11(2)California Institute of Regenerative Medicine Disease Team Award DR2-05415, Principle Investigator, 2012-2016

Research Support, Academic Entities:

  1. NONE

Research Support, Foundations and Societies:

  1. (1) Huntington's Disease Society of America Center of Excellence Grants(2) Joseph P. Roberson Foundation Grant for UC Davis Huntington's disease program(3) Charles and Margaret Pue Foundation Grants for UC Davis Huntington's disease program

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Coccidioidal meningoencephalitis often carries a poor prognosis.1 Brain imaging can reveal focal enhancement at the basal cisterns, infarction, and communicating hydrocephalus.2 A 38-year-old HIV-negative Korean man with a history of CSF- and serum-confirmed coccidioidal meningitis, receiving chronic antifungal therapy, presented with a first generalized tonic-clonic seizure. CSF demonstrated pleomorphic leukocytosis, normal protein and glucose, negative acid-fast bacillus and fungal cultures, negative Mycobacterium tuberculosis PCR, and negative Coccidioides antibodies. The diagnosis is presumed coccidioidomycosis based on imaging (figure) and clinical history. This case is an uncommon presentation with an enhancing lesion in the sylvian fissure, progressing to parenchymal invasion and extensive edema.

Figure
Figure Evolving coccidioidomycosis infection in the brain

(A) Initial MRI after the seizure showed meningeal enhancement in the left sylvian fissure, a nonspecific pattern. (B) Two-month follow-up MRI revealed multiple rim-enhancing nodules extending into the adjacent frontal and temporal lobe parenchyma with extensive surrounding edema. These nodules, along with the clinical history, confirm the diagnosis of coccidioidomycosis.

AUTHOR CONTRIBUTIONS

D. Goldenholz wrote the text and did a chart review. N. Mehra edited the text. B. Dahlin edited the text, reviewed the radiology studies, and selected appropriate images. S. Cohen and V. Wheelock edited the text.

STUDY FUNDING

No targeted funding reported.

DISCLOSURE

D. Goldenholz is on the Resident and Fellow Section of Neurology® editorial board. N. Mehra, B. Dahlin, and S. Cohen report no disclosures. V. Wheelock reports an unrestricted educational grant for medical education symposium from Lundbeck Pharmaceuticals, grant support from the California Institute of Regenerative Medicine (TR1-01257-1 and DR2-05415), grant support from HDSA for the HDSA Center of Excellence at UC Davis, grant support from the Joseph. P. Roberson Foundation for Huntington's disease program, and a gift from Charles and Margaret Pue Charitable Foundation for Huntington's disease program. Go to Neurology.org for full disclosures.

REFERENCES

  1. 1.↵
    1. Mathisen G,
    2. Shelub A,
    3. Truong J,
    4. Wigen C
    . Coccidioidal meningitis: clinical presentation and management in the fluconazole era. Medicine (Baltimore) 2010;89:251–284.
    OpenUrlCrossRefPubMedWeb of Science
  2. 2.↵
    1. Erly WK,
    2. Bellon RJ,
    3. Seeger JF,
    4. Carmody RF
    . MR imaging of acute coccidioidal meningitis. AJNR Am J Neuroradiol 1999;20:509–514.
    OpenUrlAbstract/FREE Full Text

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