2. Case Presentation
● A young woman w Hx of back pain treated
with steroid injections p/w decreased level of
consciousness after two weeks of
progressively worsening of headache.
● After a careful history and physical exam
your working diagnosis is meningitis
● You decide to perform a lumbar puncture
and treat the patient for possible fungal
meningitis
3. Things to Consider
● What are the CSF characteristics in fungal meningitis?
● What's the medical therapy for Cryptococcal
meningitis?
● What's the medical therapy for Coccidioides
meningitis?
● What's the management of increased intracranial
pressure?
4. ●
Fungal meningitis CSF:
– Normal/elevated opening pressure
– Lymphocytic pleocytosis
– Elevated protein concentration
– Decreased glucose concentration
– Send CSF for fungal culture, india ink, ag detection, C.
immitis ab fixation test
● Cryptococcal meningitis therapy: Primary: -Induction:
amphotericin B + flucytosine -Consolidation: fluconazole
Maintenance (suppressive): fluconazole
● Coccidioides immitis: High dose fluconazole or amphotericin B
(IV or intrathecal)
●
Increased ICP: If initial pressure is elevated lower by 50% →
daily lumbar puncture → if not possible → ventriculostomy
5. Reference
Infectious Disease and Impaired Consciousness
Michael R. Wilson, MD, Karen L. Roos, MD
Neurology Clinics; 2011 Nov;29(4):927-42.
