8
Î The IDSA recommends that surgical consultation be obtained
periodically during the course of medical treatment (S-L).
Newly Diagnosed Coccidioidal Infection
Î In patients with recently diagnosed coccidioidal infection, the IDSA
recommends lumbar puncture with cerebrospinal fluid analysis only in
patients with unusual, worsening, or persistent headache, with altered
mental status, unexplained nausea or vomiting, or new focal neurologic
deficit after adequate imaging of the central nervous system (CNS)
(S-M).
Î For coccidioidal meningitis (CM), the IDSA recommends fluconazole
400–1200 mg orally daily as initial therapy for most patients with
normal renal function (S-M).
• There is no role for a dose <400 mg daily in the adult patient without substantial
renal impairment. Some experts prefer to use itraconazole 200 mg 2–4 times daily,
but this requires closer monitoring to assure adequate absorption, and there are
more drug–drug interactions than with fluconazole.
Î For CM, the IDSA recommends azole treatment for life (S-M).
Î In patients with CM who clinically fail initial therapy with fluconazole,
higher doses are a first option (S-M).
• Alternative options are to change therapy to another orally administered azole, or
to initiate intrathecal AmB therapy.
Î For patients with increased intracranial pressure (ICP) at the time of
diagnosis, the IDSA recommends medical therapy and repeated lumbar
punctures as initial management (S-L).
Î Because most patients who develop ICP will not resolve this problem
without placement of a permanent shunt, the IDSA recommends early
magnetic resonance imaging (MRI) of the brain and neurosurgical
consultation (S-M).
Î The IDSA recommends that patients with ventriculoperitoneal shunt
malfunction have the revision performed in a single procedure (S-L).
When the shunt has developed a bacterial or other superinfection,
the IDSA recommends that the infected shunt be removed and a
replacement be placed at a subsequent time as a second procedure
(S-L).
Î In patients with CM who initially respond to a treatment plan and while
on therapy develop acute or chronic neurologic changes, the IDSA
recommends that repeat MRI of the brain and possibly the spinal cord,
with and without contrast, as well as spinal fluid analysis be obtained
either from a lumbar or cisternal aspiration (S-L).
Treatment
