My 70-year-old mother has been diagnosed with valley fever and meningitis. She has been in the hospital for the last two weeks and is being treated with amphotericin B through her IV and also through her spinal cord at the base of her neck. Her blood count is very low and her fever never seems to get below 100. She has become very weak and has no appetite. Is this normal for this illness? Can you please give me some insight about this and more information? My mother also has multiple sclerosis.

Irene

Coccidioidomycosis is an infection caused by the fungus Coccidioides immitis. This infection is almost exclusively seen in the Western Hemisphere, primarily in the arid regions of the southwestern United States. The most common manifestation of coccidioidomycosis is valley fever. This is an acute infection with symptoms beginning from one to three weeks after exposure. The typical patient has cough, fever, chest pain and shortness of breath. In the vast majority of patients, the infection resolves without treatment after an average of a month or so. Rarely, the lung infection progresses rapidly, causing respiratory failure and death. A small number of patients are left with a lung nodule, which causes no harm to the patient but can later be confused with lung cancer. Cavities can also form in the lung, resulting in bleeding.

The most dreaded complication of coccidioidomycosis is dissemination outside the lung. This occurs in less than 1 percent of patients and is more common in pregnant women, Filipinos and those with dark skin, such as African-Americans. It is also more common in those with a weakened immune system, such as those with AIDS. The most common sites for dissemination are the skin, the bones and the joints. Coccidial meningitis is the most severe of the disseminated infections and is fatal without treatment. ("Meningitis" is infection or inflammation of the meninges, membranes that surround the brain and spinal cord.)

While there are several drugs that can be used to treat coccidioidomycosis, treating the meningitis form has always been difficult. One main reason is that amphotericin B (trade name Amphotec), the medication used to treat most cases of coccidioidomycosis, does not penetrate into the meninges very well at all. For this reason, physicians may instill amphotericin B directly into the meninges, usually through a special device inserted into the brain. As you might expect, this form of treatment can be quite toxic. There can be many side effects, including damage to the brain and spinal cord.

Based on your description, there is no way to know if your mother's current symptoms are due to the infection, the amphotericin B or even her multiple sclerosis. Currently, most physicians treat coccidial meningitis with fluconazole (Diflucan) rather than amphotericin B. Usually, fluconazole is prescribed at a dose of 400mg per day. This drug does penetrate the meninges, and since it is well absorbed it can be given orally. One medical-research study performed in Bakersfield, Calif., suggests that 800mg may be even more effective. Fluconazole can affect the liver and have some side effects, but it is substantially better tolerated than amphotericin B. Since coccidial meningitis is extremely difficult to cure, most patients remain on fluconazole forever.

What I suggest you do is the following. Ask you mother's physician (with your mother's permission, of course) why she is not receiving fluconazole. I assume that there is a reason. Perhaps it did not work or your mother did not tolerate it. There are probably enough cases of coccidioidomycosis in your area that I am sure any infectious-diseases specialist has treated quite a few cases.