[Paracoccidioidomycosis of the central nervous system]

Pseudotumoral neuroparacoccidioidomycosis of the posterior fossa: A case report and review of the literature

Background:

Paracoccidioidomycosis is a systemic mycosis of significant importance in some Latin American countries. The widespread use of neuroimaging methods has shown that involvement of the central nervous system was more frequent than previously reported. The most common form of occurrence of neuroparacoccidioidomycosis is the pseudotumoral one. The authors report a case of pseudotumoral neuroparacoccidioidomycosis localized in the posterior fossa.

Case Description:

A 49-year-old single man, rural worker, born and raised in Laranjal Paulista-SP, was admitted to the hospital with 3 months history of bilateral occipital headache every day. Along with a history of active smoking and previous use of alcohol, the patient reported personal history of mild occipitotemporal injury 3 months ago. The patient was submitted to computed tomography in a 16-row multidetector scanner, which revealed a nodular hypodense lesion with a ring-enhancement and associated perilesional edema in the left cerebellar hemisphere. Radiological workup was initiated to investigate the eventual primary neoplastic site.

Conclusion:

The analysis of the lipid peak by spectroscopy of proton magnetic resonance may indicate the neurological involvement by paracoccidioidomycosis, notably in patients with concomitant risk and pulmonary involvement signals.

Central nervous system paracoccidioidomycosis in an AIDS patient: case report

Up to now, over 200 patients with paracoccidioidomycosis (PCM) associated to HIV infection have already been reported; however, the central nervous system involvement in this coinfection was rarely reported. This paper presents a 35-year-old Brazilian male AIDS patient who developed pulmonary PCM successfully treated with itraconazole. At the antiretroviral therapy starting, he had 32 CD4(+) T cells baseline count and high viral load levels. After 9 months, he presented severe fungal meningoencephalitis diagnosed by sublenticular enhanced nodular lesion at computerized tomography and magnetic resonance brain imaging and a positive Paracoccidiodes brasiliensis smear and culture from cerebrospinal fluid. At the time, a sixfold increase in CD4(+) T cell count and undetectable viral load level were evidenced. The patient received amphotericin B during 1 year presenting slow but progressive clinical improvement, and he is currently asymptomatic and without neurological disabilities. To our knowledge, this is the second case report of a patient with neuroparacoccidioidomycosis associated to HIV infection.

Disseminated paracoccidioidomycosis with a single brainstem lesion. A case report and literature review

Paracoccidioidomycosis is a systemic disease endemic to subtropical areas in Central and South America caused by a dimorphic fungus known as Paracoccidioides brasiliensis. Central nervous system involvement is a severe complication of the systemic disease, and has been found in approximately 13% of patients. This paper describes the case of a patient whose computed tomography scan and magnetic resonance imaging showed a single tumor-like lesion in the brainstem. Histopathological and mycological examinations of stereotactic biopsy smears showed the characteristic yeast cells that confirmed the diagnosis of neuroparacoccidioidomycosis.

Paracoccidioidomicose com comprometimento do sistema nervoso central: revisão sistemática da literatura

Este trabalho é o primeiro a realizar uma revisão sistemática dos casos de neuroparacoccidioidomicose disponíveis na literatura. Foram encontrados 257 casos em 81 trabalhos pesquisados pelo MEDLINE e LILACS, com maior número de publicações após as décadas de 1970-1980. Aproximadamente, 93% dos pacientes eram homens, principalmente lavradores, com idade média de 43 anos. O quadro caracterizou-se por sintomatologia motora ou de hipertensão intracraniana. A forma crônica pseudotumoral predominou. O período médio de evolução foi de 4,9 meses. As lesões foram principalmente supratentoriais (66,8%), localizando-se nos lobos frontais e parietais. A biópsia determinou o diagnóstico em 57,2% dos casos e utilizaram-se métodos de neuroimagem em 64,6% deles. Houve grande associação com a forma pulmonar da doença (59,1%). A mortalidade foi de 44,1% e 50,1% dos sobreviventes evoluíram com sequelas, principalmente motoras. Assim, deve-se considerar a neuroparacoccidioidomicose no diagnóstico diferencial dos processos expansivos e meningoencefalíticos do sistema nervoso central para se estabelecer tratamento precoce e evitar seqüelas incapacitantes.

Central nervous system paracoccidioidomycosis: diagnosis and treatment

BACKGROUND

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by Paracoccidioides brasiliensis. The involvement of the central nervous system (CNS) in paracoccidioidomycosis is higher than previously thought and 2 clinical presentations have been reported, meningitis and pseudotumoral.

METHODS

Twenty medical records of patients with CNS paracoccidioidomycosis treated from 1986 to 2003 were analyzed. The follow-up ranged from 1 to 18 years (mean = 8.9 +/- 4.2).

RESULTS

Besides CNS paracoccidioidomycosis, all patients but one had the chronic systemic form and the pseudotumoral clinical presentation was the most frequent. Based on computed tomography scan findings, 4 image patterns were identified: low-density lesion with ring enhancement, lesion with calcification and ring enhancement, multiloculated low-density lesion with ring enhancement, and diffuse subarachnoid enhancement. The magnetic resonance imaging was performed in 3 patients and showed subarachnoid enhancement in 1 patient and heterogeneous lesion with ring enhancement in 2 patients. Eleven patients were submitted to medical treatment and 9 needed neurosurgical treatment; ventriculoperitoneal shunts in 4 patients, brain lesions resection in 3 patients, and partial resection of spinal cord lesions in 2 patients. Eleven patients had excellent outcome, 4 patients died, 3 are in good clinical condition with residual pulmonary dysfunction, and 1 patient was lost to follow-up.

CONCLUSIONS

The diagnosis of paracoccidioidomycosis with involvement of the CNS is difficult and clinical suspicion is a key point to achieve the correct diagnosis. Patients with early diagnosis have a favorable outcome with clinical or surgical treatment.