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Print version ISSN 0004-282X
Arq. Neuro-Psiquiatr. vol.53 no.1 São Paulo Mar. 1995
Neuroparacoccidioidomycosis: critical analysis of 33 cases (Abstract)*. Thesis. São Paulo, 1994
Antonio Morato Leite Neto**
Thirty-three cases of paracoccidioidomycosis of the central nervous system (neuro-paracoccidioidomycosis) ara critically analysed. All them were hospitalized in Hospital das Clinicas da Faculdade de Medicina da Universidade (HC/FMUSP) for diagnosis and treatment. Their subsequent follow-up took place at the Ambulatório de Neurologia of HC/FMUSP. Follow-up spanned from January 1961 through February 1991. Demographics: 93.94% of the cases were male; 90.91% were white; mean age was 46.46 years (SD=9.011). Time span from emergence of symptoms to diagnosis ranged from 1 to 36 months with a mean of 11.88 months (SD=9.011). Relevant clinical data for an early diagnosis are as follows.
The majority of patients (84.85%) displayed involvement of other organs and systems. Pulmonary involvement was by far the most frequent (72.73%), followed by cutaneomucous involvement (33.33%). Neurological data: increased intracranial pressure (IIP) was recorded in 81.82%; seizures in 48.48%; and the association of IIP and seizures in 45.45%. Neurological examination yielded: pyramidal syndrome in 81.82%; cerebellar syndrome in 30.30%.
The granulomatous form of presentation was recorded in 69.70%, and the leptomeningeal in only 30.30%. Occurrence of abscess was registered in 36.36% of the whole sample, whereas 52.17% of the granulomatous presentation displayed abscess formation. The leptomeningeal presentation was accompanied in 70% by signs and symptoms of CNS parenchyma and/or of spinal root involvement.
Anatomic diagnosis was reached in 45.45% of the sample on neurosurgery in 42.42% and on post-mortem examination in only 3.03%. A clinico-laboratorial diagnosis has been reached in 54.55% of the entire sample. The most common cerebrospinal fluid (CSF) changes were: pleocytosis (56.67%); increased protein content (83.33%); increased gamma globulin content (100%); severe decrease of glucose content (18.18%). Isolation of Paracoccidioides brasiliensis from CSF occurred in 10%. CAT scan revealed masses or nodules. They were frequent in the the granulomatous presentation. Ring-like contrast enhancement of the lesion has been detected. Communicating hydrocephalus was recorded in the leptomeningeal form. Magnetic resonance imaging (MRI) offered the most relevant diagnostic information.
Results of treatment yielded no statiscally signficant difference (p=0.3386) between isolated drug therapy and drug therapy associated with neurosurgical procedures. No statistically significant difference (p=1.000) was found between drug therapy with Amphotericin-B or with Sulfadiazine.
Follow-up data showed total remission in 21 cases (63.64%), unchanged clinical condition with sequelae in one case (3.03%), and death in 11 cases (33.33%). Relapse was recorded in 8 cases (24.24%).
The author suggests that in order to prevent clinical complications an early diagnosis of neuroparacoccidiodomycosis should be obtained by means of physician's awareness on the disease. This is an important task to be reminded. Modern diagnostic tools such as CAT scan and MRI are also recommended for that purpose. More clinical and laboratorial research on imidazolines, particularly on Ketoconazole and Itraconazole (that showed promising results), should be conducted in order to have conclusive data on the effectiveness of these drugs. Sulfas, preferentially Cotrimoxazole (an association of Trimethoprin and Sulfamethoxazole), are the drugs of choice in the treatment of neuroparacoccidiomycosis. Amphotericin B is recommended only in those cases in which there is resistance or intolerance to sulfonamides.
Key words: paracoccidioidomycosis, central nervous system, diagnostics, treatment
* Neuroparacoccidioidomicose: análise crítica de 33 casos (Resumo). Tese de Doutorado, Faculdade de Medicina da Universidade de São Paulo (Departamento de Neurologia). Orientador: José Paulo Smith Nóbrega.
** Address: Rua Itapeva 366 conj 132 - 01332-000 São Paulo SP - Brasil.