Controversies in the Management of Central Nervous System Coccidioidomycosis.

Central nervous system infection with Coccidioides spp. is fatal if untreated and complications occur even when therapy is directed by experienced clinicians. We convened a panel of clinicians experienced in the management of coccidioidal meningitis to summarize current controversies and provide consensus for the management of this difficult infection.

Intrathecal amphotericin in the management of coccidioidal meningitis.

Coccidioidal meningitis is lethal in the absence of treatment. The advent of the azoles has not led to cure, causing many clinicians to revert to intra-cerebrospinal fluid (CSF) amphotericin as part of the treatment regimen, desiring the influence of the latter regimen's ability to clear infection more completely and rapidly. Intra-CSF amphotericin therapy is, however, far more toxic than oral azoles and requires much more clinical management to achieve success and avoid toxicity.

Cryptococcal meningitis in the immunocompromised host: intracranial hypertension and other complications.

Cryptococcosis as a complication of the immunocompromised host has dramatically increased in frequency since the start of the AIDS epidemic. This trend has heightened awareness of the complications of cryptococcal meningitis; of these, intracranial hypertension is common, severe, and life-threatening, as exemplified by three cases in our institutions presented here in detail. An aggressive approach to management of this complication has not been the standard of care, but neurosurgical interventional studies combined with physiologic observations suggest early intervention may reduce the devastating morbidity and mortality.

Hyphal forms in the central nervous system of patients with coccidioidomycosis.

Coccidioides immitis is a dimorphic fungus that grows as a filamentous mold in soil and as a spherule at human body temperature. The hyphal or soil form is found rarely in human tissue. We report 5 cases of coccidioidomycosis in which hyphae were found in brain tissue or spinal fluid.

An improved stereotactic technique for cyst cannulation.

Stereotactic techniques for cannulation of cystic structures, within the brain, are well known. Superimposed structures (vessels, ventricles, etc.) may make this problematic as does the need to approach the cystic structure perpendicular to its tangent plane (rather than "glancing") as with a craniopharyngioma cyst.