Vertebrobasilar Insufficiency Caused by Disseminated Coccidioidomycosis with Central Nervous System Involvement - A Case Report (2628)

Objective: To demonstrate a case report of vertebrobasilar insufficiency caused by disseminated Coccidioidomycosis with central nervous system (CNS) involvement Background: Extrapulmonary disseminated CNS Coccidioidomycosis is a rare condition. However, CNS Coccidioidomycosis has a high mortality and relapse rate if untreated. The most common manifestations include nonspecific symptoms of headache, altered mental status and unexplained nausea/vomiting. Neuroimaging typically detects leptomeningeal enhancement of basilar cistern, sylvian fissure and pericallosal regions. Without adequate treatment, clinical course can be complicated by hydrocephalus, cranial neuropathy or arachnoiditis. We illustrate a rare example of CNS coccidioidomycosis resulting in vertebrobasilar insufficiency. Design/Methods: A case report Results: A case of 70 years old Hispanic male with diabetes mellitus presented with a 2-day history of recurrent episodes of loss of consciousness with transient binocular visual disturbance. Family denied seizure like activity, incontinence, or confusion. Neurological exam showed no focal neurological deficits or meningeal irritation signs. Magnetic resonance imaging with gadolinium of brain showed an enhancement along the basal cistern, prechiasmatic optic nerve, optic chiasm, hypothalamus and encasement of vertebrobasilar arteries from the extra-axial pathology along the basal cistern which was confirmed by computed tomography angiography. Continuous electroencephalography could capture a typical event. There was generalized slow activities without epileptiform discharge which was suggestive of cerebral hypoperfusion. Serum 1,3 beta-d-Glucan level was elevated (389 pg/mL). Cerebrospinal fluid (CSF) manifested lymphocytic pleocytosis with elevated protein (WBC 171cell/mm3 Lymphocyte 40% glucose 76mg/dL and protein 409mg/dL). Brain biopsy revealed acute inflammation. Elevation of CSF complement fixation for IgG of Coccidioides titer of 1:4 confirmed the diagnosis of Coccidioidal meningitis. Amphotericin B was initiated for 2 weeks and oral Fluconazole was continued for infinite. After treatment, patient had no further episodes of loss of consciousness or visual disturbances. Conclusions: CNS Coccidioidomycosis can present as vertebrobasilar insufficiency. Early recognition, prompt diagnosis and effective treatment reduces mortality and prevent complications. Disclosure: Dr. Karukote has nothing to disclose. Dr. Thakolwiboon has nothing to disclose. Dr. Pan has nothing to disclose. Dr. Wilms has nothing to disclose.