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Patients at highest risk for coccidioidal meningitis are those with immunodeficiency (such as HIV/AIDS infection), diabetes mellitus, alcohol abuse, and pregnancy. Headache, vomiting, and change in mental status are the most common presenting findings. Cerebrospinal fluid (CSF) demonstrates a lymphocytic pleocytosis with elevated protein and low glucose. Eosinophils in the CSF are seen in up to 70% of patients with coccidioidal meningitis. Detection of complement-fixing antibodies in the CSF is more sensitive than is culture in diagnosing coccidioidal meningitis.

Difficile. Bibliography Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. 2014 Apr;69(4):881-91. PMID: 24324224 Question 8 A 40-year-old woman is admitted to the hospital for a 1-month history of diffuse abdominal pain, fever, sweats, fatigue, and weight loss. She reports no swallowing or other focal symptoms. Medical history is significant for AIDS, for which she began antiretroviral therapy and opportunistic infection prophylaxis 2 months ago.

The infection was likely present before therapy initiation, but her improved immune response, made possible by treating her HIV infection, resulted in development of symptoms (the so-called “unmasking” of a preexisting infection). Her lymphadenopathy, hepatosplenomegaly, anemia, leukopenia, and elevated alkaline phosphatase level are typical signs. DMAC is usually seen in patients whose CD4 cell count is, or recently was, less than 50/µL. The diagnosis can be confirmed by culture of the blood or other normally sterile site, such as bone marrow, lymph node, or liver.

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