Abstract
Coccidioidal meningoencephalitis often carries a poor prognosis.1 Brain imaging can reveal focal enhancement at the basal cisterns, infarction, and communicating hydrocephalus.2 A 38-year-old HIV-negative Korean man with a history of CSF- and serum-confirmed coccidioidal meningitis, receiving chronic antifungal therapy, presented with a first generalized tonic-clonic seizure. CSF demonstrated pleomorphic leukocytosis, normal protein and glucose, negative acid-fast bacillus and fungal cultures, negative Mycobacterium tuberculosis PCR, and negative Coccidioides antibodies. The diagnosis is presumed coccidioidomycosis based on imaging (figure) and clinical history. This case is an uncommon presentation with an enhancing lesion in the sylvian fissure, progressing to parenchymal invasion and extensive edema.
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