In contrast to patients with cryptococcal meningitis whose cerebrospinal fluid is often surprisingly unremarkable, patients with coccidioidal meningitis typically have a lymphocytic pleocytosis with more than 50 lymphocytes per milliliter of cerebrospinal fluid. The characteristic finding on chest radiographs is a diffuse reticulonodular infiltrate, but focal pulmonary lesions, cavities, mediastinal adenopathy, and pleural effusions have all been reported. 5 Diagnosis is made by culture of the organism from clinical specimens or by demonstration of the typical spherule on histopathologic examination. The spherule can be identified using stains such as Gomori's silver methenamine or Papanicolaou's stain. Coccidioides immitis is a highly contagious organism that can infect laboratory workers handling specimens, and the clinical laboratory should be warned of the danger of positive cultures.
Blood cultures are positive in a minority of patients.
In contrast, some patients may present with fever in association with positive coccidioidal serology without focal lesions 9 and are presumed to have coccidioidal infection. Estimates of the risk of infection in such individuals approach 70 percent and suggest that treatment is warranted. In general, the response to antifungal therapy is suboptimal. The outcome of diffuse pulmonary disease appears to be worse than that of other forms of coccidioidomycosis, with a response rate of only 50 percent and a median survival of only one month in one large series. Both itraconazole and fluconazole have been reported to be successful in approximately 80 percent of patients with C immitis meningitis 13,14 and thus should be regarded as an alternative to intracisternal amphotericin B. which has been the therapy of choice for this complication.