High Stakes, High Dose? Retrospective Treatment Outcomes of Coccidioidal Meningitis Treated With Steroids.

Background and Objectives Coccidioidal vasculitis is a serious complication of coccidioidal infection. Prior studies suggest that steroids may reduce the risk of secondary vasculitis in coccidioidal meningitis (CM), but data on optimal dosing are limited. This study compared the characteristics and outcomes of CM patients with vasculitis who received different steroid doses.

Methods The Stanford Research Data Repository was used to identify adult patients diagnosed with coccidioidal meningitis from 1992 to 2024. Patients were divided into those who received no steroids, low or medium dose steroids, and high dose steroids. Characteristics at admission were compared by steroid use category, and their association with clinical outcomes were assessed.

Results A total of 65 patients with CM were identified, with mean (standard deviation) age 45 (17) and 35% female. A higher percentage of patients not treated with steroids had a better modified Rankin score (mRS) of 2 or lower on admission compared to patients who were treated with steroids (standardized mean difference [SMD] = 0.67). Compared to patients who received a low/medium dose, those who received a high dose were 32% (95% CI 0.12, 3.61; P = 0.65) less likely to experience death or vasculitis.

Discussion There is a complex relationship between the use of steroids and outcomes among patients with CM. Among steroid recipients, those who received high dose steroids may achieve better long-term outcomes. A larger study is needed to validate these findings.