Resumo em Português:

Os autores chamam a atenção sôbre os erros de diagnóstico nos casos de neuroblastomicose, seja nas formas meningoencefálicas, seja nas tumorais. São focalizadas a paracoccidioidose e a criptococose. Depois de caracterizarem clìnicamente a paracoccidioidose, acentuam a raridade das formas nervosas (1,2% dos casos dessa micose autopsiados no Departamento de Anatomia Patológica da Faculdade de Medicina da Universidade de São Paulo). Pela revisão da literatura foi verificado haver apenas 12 casos registrados. 0 caso de Casiello e Klass é o único em que o diagnóstico foi feito em vida; os demais, ou constituem achado de necropsia, ou foram inesperadamente revelados pelo exame histopatológico realizado após intervenções cirúrgicas. Os autores registram 2 casos de paracoccidioidose do sistema nervoso. No primeiro, tratava-se de meningomielorra-diculite crônica, sendo o parasito identificado no escarro; o segundo era portador de síndrome de compressão medular, cuja patogenia é discutida pelos autores, tendo sido a etiologia paracoccidióidica comprovada pelo exame da polpa e biópsia ganglionares. Considerações clínicas sôbre a criptococose precedem o relato de um caso de meningoencefalomielite subaguda, no qual fôra feito em vida o diagnóstico de paracoccidioidose, pelo exame micológico do liqüido cefalorraqueano; êste paciente, embora medicado com doses maciças de sulfa e tiossemicarbarsona, veio a falecer, tendo o exame anátomo-patológico revelado tratar-se, na realidade, de lesões nervosas produzidas pelo Crypíococcus neo-formans. Nos três casos era incisivo o caráter neurocirúrgico da sintomatologia. Entretanto, ante o diagnóstico de paracoccidioidose, foi instituído tratamento pelas sulfas, vacina específica e tiossemicarbarsona. Os resultados foram excelentes no caso 2, em que a terapêutica pôde ser instituída mais precocemente; melhoras também foram obtidas no caso 1. No caso 3, foram verificadas melhoras transitórias com o tratamento, porém, após dois anos de moléstia, o paciente veio a falecer. Os autores concluem que a blastomicose do sistema nervoso deverá participar das cogitações neurocirúrgicas. Entretanto, na paracoccidioidose, a sulfamidoterapia em doses elevadas, associada às vacinas antiblastomicóticas, deve constituir a primeira tentativa terapêutica. Para o tratamento da torulose são indicadas a estreptotricina e a actidiona, embora a experiência com o seu uso clínico ainda seja muito pequena para que se chegue a conclusões definitivas. A cirurgia ficará reservada àqueles casos em que as condições topográficas ou evolutivas da lesão exijam solução urgente.

Resumo em Inglês:

The authors emphasize the dangers of diagnostic errors in the cases of neuroblastomycosis, whether in the meningoencephalic or the tumoral forms. Paracoccidioidosis and cryptococcosis are studied. After a clinical characterization of paracoccidioidosis, the authors stress the scarceness of its nervous forms (1,2 per cent of 84 necropsies of this mycosis performed at the Department of Pathology of the Faculty of Medicine of São Paulo). In the literature there are but 12 cases reported. Casiello and Class' is the only case where the diagnosis was made during life; the other cases were necroscopic findings or unexpected histopathologic data after the patients had been operated on por presumptive tumors. The authors report 2 cases of paracoccidioidosis of the nervous system. In the first one, showing meningo-myelo-radiculitis, the parasite was identified in the sputum; the second patient exhibited a syndrome of spinal compression, whose pathogeny is discussed by the authors (lymphatic infiltration of the epidural cervical space? lymphatic infiltration of the spinal cord? allergic diffuse serous inflammation of the spinal cord caused by the ganglionar focus?) ; the paracoccidioidal etiology was attested by bactériologie examination and biopsy of cervical lymph nodes. After clinical comments on cryptococcosis, the authors report a case of subacute meningoencephalomyelitis, which was diagnosed as paracoccidioidal by the mycologie examination of the cerebrospinal fluid; this patient, although treated with high doses of sulfonamides and thiosemicarbarsone, died after two remissions of the symptomatology; the necroscopic examination disclosed the real nature of the neurological changes, which were diagnosed as torular granuloma. In all cases the neurosurgical aspect of the symptomatology was impressive. Neverthless, the diagnosis of paracoccidioidosis imposed the treatment with sulfadiazine, sulfamerazine, specific vaccine and thiosemicarbarsone. Results were remarkable in case 2, where treatment was earlier started; case 1 also showed improvement. In case 3, transient improvement followed the treatment, but, after two years of disease, the patient died. The authors conclude that nervous blastomycosis must be taken on account in neurosurgical considerations. In paracoccidioidosis massive doses of sulfa drugs associated to specific vaccine, however, will be the first therapeutic approach. In the treatment of cryptococcosis streptothricin and actidione are worth trying according to experimental studies. Surgery is indicated only in the cases where the site or developmental conditions of the disease demand urgent resolution.

Resumo em Inglês:

The purpose of this report is to divulge peripheral neurectomy as a method for treatment of trigeminal neuralgia. This essay is based on 34 personal cases which have been operated upon, following a no scar producing method, during the period comprised between October, 1947 and December, 1950. Twenty patients of the series were submitted to neurectomy of the infra-orbital branches of one maxillary nerve; eight have undergone ipsilateral neurectomy of both infra-orbital and mentonian branches; in three cases the mentonian branches of one side were ressected the frontal branches were ressected in two cases and, in one case of bilateral neuralgia, ressection of the infra-orbital branches in both sides was performed. Five patients had to be reoperated upon after a painless period superior to one year, on account of return of pain. The follow-up period of 23 out of the 34 operated patients is superior to one year; in this group are included 10 cases with a follow-up period of over two years and 4 with more than three years. Except for six patients with whom no contact could be maintained (and whose present condition we ignore), the remaining were feeling no pain at the time of the last test. During the follow-up period all the patients experienced or are still having paresthesias. In no instance, however, such abnormal sensations were so annoying as to require any therapeutic care. The loss of sensation resulting from the nerve section has a tendency to disappear after a varying period of time, the cause of which (contrary to many authors), is the regeneration of the divided nerves themselves. The return of anesthesia following a second operation (at the time when sensibility was almost normalized) is, we think, the best proof that progressive return of sensibility on the hitherto anesthetic area has nothing to do with the surrounding nerves. Facial palsy or any other serious complication were never observed; one patient had transient paralysis of the extrinsic movements of the eye on the same side that ressection of the infra-orbital branches was performed; three had suppuration and in one instance occurred a scorch due to hot compresses. Though it is still early to conclude about the actual value of peripheral neurectomy of the fifth cranial nerve as if it can or can not be considered as a method for lasting relief of neuralgic pain, our observations lead us to a few partial conclusions which can be summarized as follows: 1 - Neurectomy of the extracranial divisions of the fifth cranial nerve brings off anesthesia on the corresponding territory of the face. This loss of sensibility has a tendency to disappear after a varying period of time. 2 - The return of sensibility in the anesthetic area is performed by regeneration of the divided nerves themselves. 3 - By regeneration of the sectioned nerves, recurrence of pain may occur. 4 - Alcohol injected in the proximal stump of a divided nerve does delay its regeneration. 5 - If pain returns, the patients can undergo a second operation either following the same method or any type of operation for trigeminal neuralgia. We feel that it is too early for a real evaluation of peripheral neurectomy as a lasting procedure for relief of trigeminal pain. Nevertheless, the simplicity of the operation, the possibility of a definite cure, and the fact that it will not interfere with re-operation or with a further greater procedure, lead us to suggest peripheral neurectomy as the first thing to be done in proper cases, i.e., those cases which bear the topographical requirements pointed out in a chapter of this paper.