Paracoccidioidomycosis simulating brain tumor

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Abstract

Background:

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis. Involvement of the central nervous system (CNS) occurs in about 10% of cases.

Case Description:

A 57-year-old white man presented with the complaint of headache and an episode of focal seizure 1 month earlier. Magnetic resonance imaging (MRI) revealed a ring-enhancing lesion in the right parietal lobe with peri-lesional vasogenic edema suggestive of a primary neoplasm. The patient underwent craniotomy and the intraoperative finding was a yellowish, hard lesion with thick content and yellow inside. Anatomo-pathological findings were pathognomonic of PCM: large, thick-walled, spherical yeast cells with multiple peripheral buds. The patient tested negative for human immunodeficiency virus (HIV). Encephalitis and meningitis were ruled out by cerebrospinal fluid analysis. Culture confirmed the diagnosis of PCM and the patient was treated with amphotericin B. The patient responded well to treatment with resolution of the headache and clinical improvement, despite a bitemporal hemianopia. He was clinically stable and then discharged in good general condition.

Conclusions:

Radiographic findings of PCM with CNS involvement may suggest neoplasia, making diagnosis difficult. In endemic areas, the diagnosis of PCM should be promptly considered when a ring-enhancing mass associated with peri-lesional edema is observed on MRI.

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Most cited references 29

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Paracoccidioidomycosis: an update.

E. Brummer, E Castañeda, A. Restrepo (1993)

This review summarizes knowledge on various aspects of paracoccidioidomycosis. Mycelial propagules, chlamydospores, and arthroconidia exhibit thermal dimorphism; arthroconidia are infectious in animals and, by electron microscopy, appear well provided for survival. The mycelial-to-yeast-phase transformation requires a strict control of glucan synthesis probably mediated by membrane enzymes. Hormonal influences on the transformation of the fungus (mycelium or conidium to yeast phase) have been demonstrated. Estrogen-binding proteins have been detected in the fungal cytosol, and during the transformation novel proteins are produced as a result of estradiol incorporation. Clinical forms have been better defined on the basis of better experimental models. Emphasis has been placed on the lungs as the portal of entry and on the existence of silent pulmonary infections. A specific Paracoccidioides brasiliensis antigen, the 43-kDa glycoprotein (Gp43), has been identified, characterized, and cloned. This has led to improved reproducibility and specificity of serologic tests. The depression of cell-mediated immune responses has been associated with severe disease in humans and in the experimental host. T-cell subsets in patients' tissues were characterized by means of monoclonal antibodies, and a reduced CD4/CD8 ratio was demonstrated. This has been related to alterations in lymphokine and tumor necrosis factor production, production of antigen-antibody complexes, etc. Amphotericin B has provided effective therapy. Azole derivatives have also improved prognosis and facilitated therapy. Itraconazole is presently the drug of choice, yet incapacitating sequelae (mainly pulmonary fibrosis) still constitute major problems.

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[Guidelines in paracoccidioidomycosis].

Maria Aparecida Shikanai-Yasuda, Flavio de Queiroz Telles Filho, Rinaldo Poncio Mendes … (2015)

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Improved outcome in central nervous system aspergillosis, using voriconazole treatment.

Stefan Schwartz, Markus Ruhnke, Patricia Ribaud … (2005)

The mortality of central nervous system (CNS) aspergillosis approaches 100%, requiring improved therapies. Voriconazole gives superior efficacy and survival in invasive aspergillosis, compared with amphotericin B. Also, in contrast to other antifungal drugs, voriconazole penetrates well into the CNS. We evaluated, retrospectively, the outcome and survival of 81 patients who were treated with voriconazole for definite (n = 48) or probable (n = 33) CNS aspergillosis. Complete and partial responses were recorded in 35% of patients and varied by the underlying disease group: hematologic malignancies (54%), other underlying conditions (50%), chronic immunosuppression (45%), solid organ transplantation (36%), and hematopoietic stem cell transplantation (16%). Thirty-one percent of patients survived CNS aspergillosis for a median observation time of 390 days. There were 31 patients who underwent neurosurgical procedures, including craniotomy/abscess resection (n = 14), abscess drainage (n = 12), ventricular shunt (n = 4), and Ommaya-reservoir (n = 1). Multifactorial analysis revealed that neurosurgery was associated with improved survival (P = .02). Patients who underwent hematopoietic stem cell transplantation had a poorer survival (P = .02), but 7 (22%) of 32 survived for a median of 203 days. We conclude from this large cohort of patients that voriconazole treatment together with neurosurgical management, whenever feasible, is currently the best approach to treat patients with CNS aspergillosis.

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Author and article information

Contributors

Gustavo R. Isolan

Daniel M. Vieira

Francine Hehn

Ápio C. M. Antunes

Journal

Journal ID (nlm-ta): Surg Neurol Int

Journal ID (iso-abbrev): Surg Neurol Int

Journal ID (publisher-id): SNI

Title: Surgical Neurology International

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 2229-5097

ISSN (Electronic): 2152-7806

Publication date Collection: 2014

Publication date (Electronic): 12 September 2014

Volume: 5

Electronic Location Identifier: 134

Affiliations

[1 ]Department of Neurology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, 90035-903, Porto Alegre, RS, Brazil

[2 ]Graduate Program in Medicine: Surgical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400, 90035-003, Porto Alegre, RS, Brazil

[3 ]Department of Pathology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, 90035-903, Porto Alegre, RS, Brazil

Author notes

[* ]Corresponding author

Article

Publisher ID: SNI-5-134

DOI: 10.4103/2152-7806.140656

PMC ID: 4174673

PubMed ID: 25298916

SO-VID: 003f9f23-4367-4ec2-96ec-f283e7e32d02

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Paracoccidioidomycosis simulating brain tumor

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Abstract

Background:

Case Description:

Conclusions:

Related collections

Karger: Neurology and Neuroscience

Most cited references 29

Paracoccidioidomycosis: an update.

[Guidelines in paracoccidioidomycosis].

Improved outcome in central nervous system aspergillosis, using voriconazole treatment.

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