A 52-year-old man came to medical attention in 1993 with fever, confusion, lethargy, and leg weakness. He had noninsulin-dependent diabetes. On examination, the patient was obtunded, with a stiff neck, leg spasticity, hyperreflexia, Babinski signs, and a skin lesion. A punch biopsy of the lesion showed multinucleated giant cells and spherules with endospores consistent with C. immitis. Cranial computed tomography showed obstructive hydrocephalus, and a ventriculo-peritoneal shunt was placed. Ventricular cerebrospinal fluid (CSF) had four leukocytes (WBC)/mm3, 40 mg/dL glucose, and 70 mg/dL protein. The ventricular CSF did not grow fungi, bacteria, or Mycobacterium tuberculosis. Both serum (1:128) and CSF (1:32) had positive microcomplement fixation antibody titers to C. immitis. Coccidioidal meningitis was diagnosed, and the patient received amphotericin B intravenously and intrathecally for 6 weeks, until elevated serum creatinine levels prevented further administration of the drug. The patient then was given 800 mg/day of fluconazole. Over the first 8 months, the patient slowly improved; his mental status returned to near normal, and he could walk and care for himself. He was discharged home on maintenance fluconazole (800 mg/day).
Four years later, the patient had recurring headaches, fevers, and declining mental status. The patient and his wife claimed that he rarely missed fluconazole doses. Neuroimaging showed no change in his previously enlarged ventricles. The ventriculo-peritoneal shunt was thought to be functioning normally. Ventricular CSF obtained from the shunt tubing contained 42 WBC/mm3 (68% lymphocytes, 14% mononuclear cells, 17% atypical lymphocytes, 15% neutrophils, and 3% eosinophils), 51 mg/dL glucose, and 11 mg/dL protein and grew C. immitis. The original shunt tubing was surgically removed and replaced. Lumbar CSF and CSF obtained directly from the ventricle at the time of shunt replacement did not grow fungi. The patient was treated with fluconazole (1,200 mg per day) for several weeks, clinically improved over several months, and was discharged on fluconazole (800 mg per day). He has been stable at home for 2 years.