• coccidioidomycosis
• brain
• meningioma

A 38 year old woman, originally from the Pacific Islands with a history of residence in south western United States, presented with new onset severe headaches. Past medical history included disseminated coccidioidomycosis involving cervical lymph nodes two years earlier, which was incompletely treated with oral fluconazole because of non-compliance. Serum complement fixation coccidioides titres had risen from 1:8 to 1:32. MRI demonstrated multiple isointense, dural based lesions that uniformly enhanced upon contrast administration. These were located over the right parieto-occipital convexity (fig 1a) as well as on the tentorium at the left occipital pole (fig 1b). These lesions were consistent in appearance with en plaque meningiomas. Given the patient’s history, however, the possibility of chronic dural inflammation from coccidioidomycosis of the CNS was also considered. The patient was started on high dose fluconazole (800 mg) therapy and

followed with serial MRIs. Despite improvement in the patient’s headaches, follow up MRI showed minimal change in lesion size. The patient underwent a left occipital craniotomy and biopsy for definitive diagnosis three months after reinitiating fluconazole. Intraoperatively, numerous bosselated, firm, dural based lesions were noted pushing into the surface of the brain. Pathological evaluation of the biopsy revealed granulomatous inflammation consistent with smoldering coccidioidomycosis (fig 1c).

Coccidioidomycosis is an endemic fungus of south western United States.¹ Infection results from inhalation of windborne arthrospores and characteristically manifests with pulmonary symptoms. An infrequent complication of coccidioidomycosis is dissemination beyond the lung and hilar lymph nodes to bone, skin, subcutaneous tissue, and joints.² In addition, infection may spread to the CNS, typically causing chronic

meningitis.³ Our case illustrates an exceedingly rare example of CNS coccidioidomycosis resulting in dural based mass lesions resembling meningiomas. The treatment for this condition remains controversial. Patients who fail oral fluconazole therapy may be candidates for intravenous amphotericin B and surgical debulking. The roles of experimental therapies such as caspofungin or variconcyole remain undefined in the treatment of coccidioidomycosis CNS mass lesions.

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Figure 1

(A) Gadolinium enhanced MRI demonstrating an enhancing dural lesion over the right parieto-occipital convexity. (B) Gadolinium enhanced MRI demonstrating an enhancing dural lesion along the left tentorium near the transverse sinus. (C) Microscopic appearance of the dural biopsy. The specimen shows confluent granulomata of various sizes, some of which demonstrate centrally necrotic foci, and multinucleated giant cells. The larger granulomata display hyalinisation (haematoxylin and eosin stain; original magnification ×50).