We describe a case of a young patient with a recurrent pleomorphic xanthoastrocytoma (PXA) showing unusual cell-in-cell (CiC) phenomena. We observed mostly viable but also necrotic neutrophils engulfed within tumor cells. The recurrent tumor was immunopositive for BRAFV600E mutant protein and showed CDKN2 homozygous deletions typical of PXA. Both genetic alterations were also reported in the original primary tumor. Unlike the original tumor that was GFAP and Olig-2 immunopositive, the recurrent neoplasm was largely negative for GFAP and Olig-2 suggesting dedifferentiation. The large malignant cells that contained the neutrophils were negative for histiocytic and lymphohematopoietic markers. Whereas CDKN2 homozygous deletion is common in PXA, its presence is rare in histiocytic neoplasms. Both reactive astrocytes and glial neoplasms very rarely may engulf neutrophils in a process resembling emperipolesis or cellular cannibalism. Future work may clarify which type of CiC pathway is involved.

Recently, the California Department of Public Health issued an advisory related to the substantial rise in Coccidioidomycosis in California, which has been attributed in part to climate change and rapid housing development. Most cases are self-limiting, but some may spread to the meninges, resulting in coccidioidal meningitis (CM). Many providers mistakenly presume that CM is limited to patients who are immunocompromised. In this case series and literature review, we present 12 cases of CM in immunocompetent individuals seen at a single tertiary academic center between 1 January 2019 and 31 December 2023. All 12 cases developed complications, with 10 requiring ventriculoperitoneal shunting, 6 having spinal cord involvement (5 with cervical spine involvement), 4 having strokes, and 3 dying from complications related to CM. It is important to recognize CM as it may be life-threatening if not promptly diagnosed.