713. Coccidioidal Meningitis Among Children: A Case Series and Single Center Experience In Central California

Abstract Background Coccidioidal meningitis is a severe form of coccidioidomycosis associated with significant morbidity and mortality. Published literature in the pediatric population is limited, particularly on coccidioidal meningitis. Here we describe a large case series of pediatric coccidioidal meningitis followed at a tertiary care center in an endemic region. Methods We performed a retrospective case review of patients ≤21 years old followed at our facility with a diagnosis of coccidioidal meningitis from January 1, 2000, to December 31, 2018. Results Overall, 30 patients were identified during the study period. The median age was 10.8 years (IQR: 4.6-15). The majority of patients were previously healthy (93%) and all required hospitalization. Fever (90%), headache (70%), vomiting (53%), and fatigue (57%) were the most common clinical manifestations. More than one-third (40%) had concurrent pulmonary disease. Only 20 patients (67%) had initial Coccidioides complement fixation (CF) titers >=1:16. The majority had extra-axial brain involvement (60%) and seven (23%) had associated spinal canal disease. Over two-third required shunt placement (70%) and almost half of them (43%) underwent revision. Neurological complications including paresis/paralysis, stroke, neuropathy, seizures, and cognitive delay were observed in 20% of patients. Two-thirds (73%) of patients received fluconazole as the initial drug. However, 37% of those had fluconazole failure, requiring alternative treatment. Due to refractory disease, two patients required a novel triazole, isavuconazole, while adjunctive therapy with steroids and interferon-gamma (IFNγ) was used in 20% of patients. Most cases (83%) stabilized, 13% experienced relapses and/or progressive disease, and 3% were fatal. Conclusion Pediatric coccidioidal meningitis is an uncommon and sometimes devastating complication of disseminated coccidioidomycosis. Many patients present with relatively low CF titers, and communicating hydrocephalus and long term neurologic complications are common. Fluconazole treatment failures are common, and management remains difficult despite recent advances in therapy. Most patients do well once the disease is stabilized and require lifelong therapy. Newer therapeutic agents are needed. Disclosures All Authors: No reported disclosures


Background.
Coccidioidal meningitis is a severe form of coccidioidomycosis associated with significant morbidity and mortality. Published literature in the pediatric population is limited, particularly on coccidioidal meningitis. Here we describe a large case series of pediatric coccidioidal meningitis followed at a tertiary care center in an endemic region.
Methods. We performed a retrospective case review of patients ≤21 years old followed at our facility with a diagnosis of coccidioidal meningitis from January 1, 2000, to December 31, 2018.

Conclusion.
Pediatric coccidioidal meningitis is an uncommon and sometimes devastating complication of disseminated coccidioidomycosis. Many patients present with relatively low CF titers, and communicating hydrocephalus and long term neurologic complications are common. Fluconazole treatment failures are common, and management remains difficult despite recent advances in therapy. Most patients do well once the disease is stabilized and require lifelong therapy. Newer therapeutic agents are needed. Background. Invasive fungal infections (IFIs) are uncommon infections that account for approximately 27.2/100,000 cases per year in the United States. One form of IFI is chronic invasive fungal sinusitis (CIFS). If untreated, invasion into neighboring structures may cause altered mental status, seizures, strokes, proptosis, and intracranial complications.

Invasive Fungal Infection Caused by Curvularia Species in a Patient with
Case Report. An afebrile 43-year-old female with a history of polysubstance abuse presented to the ED due to altered mental status, left sided facial droop, right sided hemiparesis, and slurred speech. The patient was somnolent but arousable to stimuli and appeared acutely ill. The patient's mother reported a history of cocaine abuse, which was confirmed on urine toxicology. A CT head and neck with contrast revealed subacute basal ganglia lacunar infarcts and a left sphenoid opacity with scattered hyperintensities and erosive changes [ Figure 2]. One month prior, she had been diagnosed with a left superior pole kidney mass and a left-sided enlarged periaortic lymph node containing multiple noncaseating granulomas and GMS stains positive for fungal hyphae [ Figure 1].
The patient underwent nasal endoscopy with tissue biopsy. Tissue showed necrotizing invasive fungal sinusitis with granuloma formation and foreign-body giant cell reaction. Fungal speciation of the tissue culture showed Curvularia species was placed on IV voriconazole. While the infection stabilized, her neurologic deficits did not significantly improve. She was discharged to inpatient rehabilitation.