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April 1988

Coccidioidal Meningitis Narcotic—Amphotericin B Intracisternal Therapy

Arch Intern Med. 1988;148(4):985. doi:10.1001/archinte.1988.00380040225038

To the Editor.  —We agree with Labadie and Hamilton1 that successful treatment of coccidioidal meningitis requires doses of amphotericin that exceed doses previously recommended. Since doses given less frequently than daily may not be fungistatic,2 we have attempted to treat patients every day with 1 mg of amphotericin B. In our experience, required dosages often exceed 80 mg. However, a significant obstacle to adequate therapy has been poor patient compliance because of the severe headaches and vomiting caused by intracisternal administration of amphotericin B.The use of a subcutaneous reservoir with access to the cisterna magna has facilitated therapy, in spite of the need for frequent reservoir revisions and complicating infections.2 This route of administration is more comfortable and results in fewer significant neurologic complications than does direct cisternal puncture. We abandoned lumbar intrathecal injections because of the almost universal appearance of permanent neurologic injury to the

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