Introduction: Coccidioidomycosis is a common fungal infection in the southwestern United States. Hydrocephalus is a serious complication of cranial coccidioidomycosis, and the surgical management of coccidioidomycosis-related hydrocephalus has unique challenges. We reviewed our institutional experience with hydrocephalus in the setting of coccidioidomycosis.
Methods: We retrospectively identified 44 patients who were diagnosed with coccidioidomycosis-related hydrocephalus at our institution since 1990, who underwent 99 shunting procedures. We examined patient demographics, type of shunt and valve used, pressure settings, failure rates, medical treatment, ventricular response to shunting, and other variables.
Results: The majority of patients were young (average age, 37 years) men (male:female ratio 28:16) with mean follow-up of 63 months. Patients of Asian and African descent were over-represented in the cohort when compared to regional demographic data. The overall shunt failure rate during follow-up was 50%; the average number of revisions required if a patient ever failed was 2.5 (range 1-8). Lower draining pressure settings were the norm (mean 88mm of water). Fourteen patients received intrathecal antifungals; a trend of initiating intrathecal therapy after need for a shunt revision was observed (P = 0.051). The majority of shunt failures (81%) were due to mechanical blockages in the drainage system. Most patients (59%) had at least partial persistent postoperative ventriculomegaly despite successful cerebrospinal fluid (CSF) diversion. Four patients (9%) died due to coccidioidomycosis during the follow-up period.
Conclusions: Coccidioidomycosis-related hydrocephalus is most likely to affect young men, especially those of African and Asian descent. There is a high rate of shunt failure due to clogged catheters or valves due to the underlying disease process, despite best medical therapy. Many patients continue to have ventriculomegaly even with adequate CSF diversion. The morbidity and mortality of this chronic disease process must be recognized by the treatment team and patients appropriately counseled.
Patient Care: By improving physician awareness of the unique characteristics and management pitfalls of hydrocephalus from coccidioidomycosis infection
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of coccidioidomycosis-relayed hydrocephalus and its unique management concerns, 2) Discuss, in small groups the best management for these patients 3) Identify an effective treatment paradigm for a patient with coccidioidomycosis, a shunt, and ventriculomegaly .