Central nervous system infection: imaging findings suggestive of a fungus as the cause / Infecção do sistema nervoso central: os achados de imagem sugestivos de fungo como causa

Abstract Fungal infections of the central nervous system (CNS) are rare. However, because of the increase in the number of immunocompromised individuals, they have been gaining prominence in the differential diagnosis of CNS infections. Imaging techniques are sensitive for detecting and localizing an abnormality, in many cases allowing the origin of a lesion to be categorized as infectious, inflammatory, neoplastic, or vascular. This essay illustrates the magnetic resonance imaging and computed tomography findings of the most common fungal infections of the CNS, based on the experience of the Radiology Department of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, RS, Brazil.

Resumo As infecções fúngicas do sistema nervoso central (SNC) são raras, entretanto, com o aumento no número de indivíduos imunocomprometidos elas têm ganhado destaque no diagnóstico diferencial de infecções no SNC. As atuais técnicas de imagem são sensíveis para detectar uma anormalidade, localizá-la, e em muitos casos categorizar a lesão como de origem infecciosa e/ou inflamatória, neoplásica ou vascular. Este ensaio ilustra os achados de ressonância magnética e tomografia computadorizada mais comuns nas infecções fúngicas do SNC baseadas na experiência do Serviço de Radiologia do Hospital de Clínicas de Porto Alegre.

Multisystemic fusariosis with fulminant evolution

Abstract This report presents the case of a 13-year-old female patient with history of acute myeloid leukemia, who, after a bone marrow transplant, began to vomit and experienced rapidly progressive deterioration of consciousness, in addition to disseminated erythematous-violaceous macules, and some blisters with hemorrhagic content inside. Skin biopsy evidenced intravascular filamentous structures. A blood culture confirmed the presence of Fusarium oxysporum. Intravenous treatment with voriconazole was initiated. The patient evolved unfavorably with multiple necrotic skin lesions, ischemic brain lesions, and death.

Diagnosis and treatment of 3 patients of intracranial fungai granulomas / 中华神经科杂志

Objective To examine clinical features, neuroimaging presentation and treatment of intracranial fungal granulomas (ICFG) in order to improve the accuracy rates of diagnosis and cure. Methods Three pathologically proven cases with ICFG were retrospectively analyzed. Cases of ICFG reported in literature were also summarized. Results Among the 3 patients with ICFG, 1 patient had a history of head trauma and craniotomy and 1 had a history of type 2 diabetes mellitus and a long history of exposure to doves. In all 3 patients, the symptoms started with headache and vomiting, accompanied by low-grade fever, convulsion, and cranial nerve deficits. Intracranial mass lesion was revealed on brain computed tomography (CT) scan and (or) magnetic resonance imaging (MRI) with or without intravenous contrast. CT scan showed low-density lesions and granulations with ring and homogenous enhancement, indicating fungal abscesses. MRI in all 3 cases showed one or multiple circumscribed intracranial space-occupying lesion, with ring, heterogeneous contrast enhancement and perilesional edema. The treatments were initiated with craniotomy and surgical resection of granulations followed by intravenous injection of amphotericin B (AMB) combined with fluconazole. The daily administration of AMB was increased gradually from 0.25-1.50 mg/kg and the total dosage of 2-4 g should be achieved within 3 months. The combination therapy with fluconazole (400 mg/d ) was also given by intravenous injection. To increase penetration into cerebrospinal fluid, intrathecal injection of AMB had also been given at the maximum dosage of 1 mg every time, twice a week. Two patients were administered fluconazole (200 mg/d ) orally for 3, 6 months consecutively after completing the combination therapy of AMB with fluconazole, while the other patient refused continuous antifungal treatment 1 month postoperatively. All 3 patients were followed up for a period between 3, 24, 48 months. The 2 patients that completed full antifungal treatment were cured without recurrence. The other patient had improved transiently after operation but died after 3 months. Conclusions Because no distinct chnical and neuroimaging features are presented in ICFG, it is difficult to diagnose preoperatively. Indications for surgery include diagnosis, relief mass effect and increase efficiency of drug treatment. Use of appropriate and completed antifungal treatment decreases mortality. The treatment requires continued and long-term administration of antifungal medication to prevent relapses, whether granulomas are totally removed or not.

Paracoccidioidomicose com comprometimento do sistema nervoso central: revisão de literatura / Paracoccidioidomycose with central nervous systeminvolvement: review of the literature

A Paracoccidioidomicose (PCM), considerada a micose profunda mais importante da América Latina, é causada pelo fungo Paracoccidioides brasiliensis. O Brasil concentra o maior número de casos, especialmente na região Sudeste. A doença pode acometer inúmeros órgãos como os pulmões, a pele, as mucosas. O envolvimento do sistema nervoso central (SNC) ocorre em aproximadamente 10% dos casos e sua incidência pode ser subestimada devido à ocorrência de apresentações assintomáticas, avaliação neurológica inadequada, falta de testes específicos de neuroimagem e baixa freqüência de estudo do SNC em necrópsias. As formas de apresentação são a meníngea/meningoencefálica, raras, e a pseudotumoral, mais freqüente. A sintomatologia é diversa, variando conforme a localização das lesões, e não específica. Os métodos de neuroimagem são considerados essenciais no auxílio diagnóstico, o exame do líquor é pouco específico e métodos sorológicos ainda têm valor limitado, sendo usados principalmente para seguimento da resposta ao tratamento, cuja primeira escolha, para qualquer forma de apresentação, é a associação sulfametoxazoltrimetoprim. Reserva-se a anfotericina B para os casos de resistência ou intolerância às sulfonamidas. Uma alternativa são o azólicos, como o itraconazol ou o fluconazol. Ainda não se estabeleceram parâmetros confiáveis para indicar o momento seguro de interrupção do tratamento ou para sua reintrodução precoce em caso de recidivas. A PCM deve ter ser considerada no diagnóstico diferencial dos processos meningoencefalíticos e expansivos do SNC, dependendo de um alto grau de suspeição do médico a fim de se estabelecer o tratamento precoce e evitar o surgimento de seqüelas incapacitantes.

Paracoccidioidomycosis (PCM), considered the most important systemic mycosis in Latin America, is caused by the fungus Paracoccidioides brasiliensis. Brazil has the greatest amount of reported cases, especially in the Southeastern region. The disease can affect several sites as the lungs, the skin and the mucous membranes. Central nervous system (CNS) involvement occurs approximately in 10% of the cases, and its incidence can be underestimated due to the occurrence of asymptomatic cases, inadequate neurological evaluation, no specific neuroimagingexams, and low frequency of SNC investigation in autopsies. Neuroparacoccidioidomycosis (NPCM) comprises meningeal form, which is rare, and the most frequent pseudotumoral one. The symptoms are varied, depending on the location of the lesions, and not specific. Neuroimaging methods are considered essential for the diagnosis. Examination of the cerebral spinal fluid is not specific and serological methods still have limited value, being used mainly in the evaluation of treatment response. The first choice for PCM treatment is the association sulfamethoxazoletrimethoprim. Amphotericin B is reserved for the cases of resistance or intolerance to sulfonamides. Alternatively there are itraconazole or fluconazole. No trustworthy parameters were yet established to indicate the ideal moment for interrupting drug treatment or for its early reintroduction. NPCM must be considered in the differential diagnosis of the meningeal and the tumoral/expansive processes of the CNS, depending on a high suspicion level of the physician in order to establish the early treatment and to avoid the development of disabling sequelae.