Aseptic Meningitis Unmasking Coccidioidomycosis of the Central Nervous System Outside an Endemic Region.

A 20-year-old male presented with persistent aseptic meningitis. Cerebrospinal fluid (CSF) showed neutrophil-dominant pleocytosis, high protein, low glucose, and an opening pressure >55 cmH2O. Fluid metagenomic next-generation sequencing detected Coccidioides immitis/posadasii and subsequent culture confirmed the diagnosis. The retrospective history revealed residence in Arizona approximately six months prior to hospitalization. Antifungal therapy was escalated, and the patient was transferred to a tertiary neurocritical care center for advanced neurocritical care. This case demonstrates that geographic bias can delay the recognition of coccidioidal meningitis outside endemic regions. Clinicians should therefore obtain a patient's travel history even if the patients have only a remote travel history.