Challenges in the Long-term Management of Patients With Coccidioidal Meningitis: A Retrospective Analysis of Treatment and Outcomes

Abstract

Background Coccidioidal meningitis (CM) is the most severe form of disseminated coccidioidomycosis. Despite years of clinical experience, it remains a difficult condition to treat, often requiring surgical procedures, such as placement of a ventriculoperitoneal (VP) shunt in addition to lifelong anti-fungal therapy. Methods We performed a retrospective analysis of CM patients seen in a large referral center in Central Valley, California, from 2010–2020. Data pertinent to CM were collected and analyzed. Results Among 133 patients with CM identified in the 10-year period, non-adherence to antifungal therapy was noted in 43% of patients. Out of the eighty patients who underwent VP shunt placement for management of intracranial pressure, shunt failure requiring revision surgery occurred in forty-two (52.5%). Rehospitalizations due to CM related reasons occurred in 78/133 patients (59%). Twenty-three percent of patients (n=29) died due to complications from CM, on an average 22 months after the diagnosis of CM. Encephalopathy at presentation was associated with a significantly higher risk of death. Conclusions CM patients in Central California are predominantly rural agricultural workers with elevated levels of poverty and low health literacy with many barriers to care leading to high rates of medication non-adherence and are lost to follow-up outpatient care. Management challenges are frequent such as failure of antifungal therapy, high rates of rehospitalization, and the need for repeated shunt revision surgeries. In addition to the development of curative new anti-fungal agents, understanding the barriers to patient adherence to care and anti-fungal therapy and identifying means to overcome such barriers is of paramount importance.