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Recurrence of Coccidioidal Meningitis After Discontinuation of Fluconazole

Sarah Nelson, MD1; Michal Vytopil, MD2
[+] Author Affiliations
1Tufts Medical Center, Boston, Massachusetts
2Lahey Clinic Medical Center, Burlington, Massachusetts
JAMA Neurol. 2013;70(12):1586. doi:10.1001/jamaneurol.2013.1139.
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A 53-year-old woman with a history of coccidioidal meningitis discontinued her long-term suppressive fluconazole following normal head computed tomography (Figure 1A) and cerebrospinal fluid evaluation. Four months later, she presented with gait instability, confusion, and headache. Computed tomography of the head demonstrated hydrocephalus (Figure 1B) and magnetic resonance imaging of the brain showed extensive vasogenic edema and meningeal enhancement (Figure 2). Results of cerebrospinal fluid evaluation were consistent with fungal infection and positive for the coccidioidal antibody.

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Figure 1.
Noncontrast Computed Tomography of the Head

Computed tomography of the head performed before discontinuation of fluconazole (A) and 4 months later, demonstrating evolving hydrocephalus (B).

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Figure 2.
Axial Magnetic Resonance Imaging of the Brain

A, Fluid-attenuated inversion recovery sequence demonstrating vasogenic edema. B, T1+ gadolinium images showing extensive meningeal enhancement consistent with severe meningitis.

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