Chronic Cerebral Coccidioidomycosis: An unusual case beyond geographic boundaries

Abstract

Coccidioidomycosis (CM) is an emerging fungal infection caused by Coccidioides immitis and C. posadasii, primarily affecting semi-arid regions of the Americas. While pulmonary disease is most common, central nervous system (CNS) involvement—particularly chronic cerebral CM—is rare and presents significant diagnostic and therapeutic challenges. We describe a 64-year-old male from Mexico City with a history of type 2 diabetes and hypertension, who had previously lived and worked for four decades in Salinas, California, an endemic region for CM. Twelve years earlier, he was diagnosed with cerebral CM, treated with intravenous amphotericin followed by oral fluconazole, but prematurely discontinued therapy. He subsequently required placement of a ventriculoperitoneal shunt. He presented with acute neurological decline, including somnolence, gait instability, urinary incontinence, and confusion. Neuroimaging revealed hydrocephalus, prompting shunt revision. CSF cultures confirmed C. posadasii reactivation. CNS involvement in CM, though uncommon, can lead to severe complications such as hydrocephalus and arachnoiditis. Reactivation of CM is a concern, especially in immunocompromised individuals. This case underscores the importance of long-term management and monitoring in patients with CNS CM, particularly those with underlying comorbidities. Chronic CNS coccidioidomycosis requires sustained antifungal treatment and vigilant follow-up to prevent reactivation and associated complications. Increased clinical awareness and early intervention are essential, particularly in endemic areas.