INTRODUCTION: We described the first reported case of CSF plasmocytosis in a patient with disseminated coccidioidomycosis.
CASE PRESENTATION: Our patient is a 56 year old male smoker from Coalinga, California, with a history of hypertension and hemorrhagic stroke in 2008, without any permanent sequelae. He presented with one month of “altered mental status” which had worsened over the two days prior to admission. His daughter described him as having mild alterations of his personality which then became much more pronounced until he became unresponsive. Upon presentation a head CT was performed which showed hydrocephalus and possible gliosis along with a small (6mm) parietal-occipital density consistent with a small hemorrhage. An MRI showed enhancement in the mid-brain, pons and medulla, base of the brain and right sylvian fissure and along the superior portion of the cerebellar sulci consistent with meningitis. There was also edema involving the right middle cerebellar peduncle and the brainstem, right greater than left, particularly in the region of the right pons. This latter finding was thought to be due to cerebritis. A lumbar puncture was performed which showed a protein of 167, glucose 36, red blod cel count of 1357, a white blood cell count of 145 with the following differential: polys 6%, lymphs 50%, plasma cells 42%, and macrophages 2%. Chest x-ray and CT scan showed a right lung mass and a subsequent biopsy via bronchoscopy showed non-caseating granulomas and spherules consistent with coccidioidomycosis. The serology from the blood (IgM and IgG) and the CSF (IgG) were both positive for coccidioidomycosis with a titer of 3 at 1:16 in the serum. The patient was started on fluconazole and repeat lumbar puncture in day 3 and 5 showed significant decline in plasma cell count to 11% and then undetectable, respectively. The patient’s serum and urine protein electropheresis were normal.
DISCUSSION: Disseminated coccidioidomycosis can cause meningitis, but the CSF findings typically show a neutrophil (early in the disease) or lymphocytic pleocytosis. Plasma cells in the CSF have been described in many infectious and non-infectious cases including neuroborreliosis, neurosyphilis, neurocysticercosis, African trypanosomiasis, CNS tuberculosis, viral meningoencephalitis (including echovirus, coxsackievirus, herpes zoster virus, HIV, West Nile virus infection, and measles), multiple sclerosis, Sjogren’s syndrome, plasma cell leukemia, CNS plasmacytosis, multiple myeloma and lymphoma but has never been described previously in CSF coccidioidomycosis. To our knowledge this is the first reported case of CSF plasmacytosis in a patient with coccidioidomycosis which resolved after treatment and excluded known neoplastic and infectious causes.
CONCLUSIONS: Plasmocytosis of CSF in the setting of hydracephalus and alter mental status could be one of the manifestations of Disseminated Coccidioidomycosis. Our case expands the clinical spectrum of coccidioidal meningitis. Early diagnosis and treatment is important to optimize the outcome.
Reference #1 Carson,PJ et al. Plasma Cell Pleocytosis in Cerebrospinal Fluid in Patients with West Nile Virus Encephalitis. Clinical Infectious Diseases 2003; 37:e12-5.
DISCLOSURE: The following authors have nothing to disclose: Mostafa Tabassomi, Michael Peterson
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