Concomitant pulmonary and central nervous system paracoccidioidomycosis with cerebellar abscess

A 59-year-old man with no previous diagnosis was admitted to hospital with a history of headache, ataxia, and cough.

Computed tomography (CT) of the chest showed ground-glass attenuation, consolidation, nodules, cavitations, and fibrotic lesions in both lungs, strongly suggesting the possibility of a granulomatous process (Figure A). These radiological findings are commonly seen in fungal disease, supporting a diagnosis of a chronic form of pulmonary paracoccidioidomycosis¹.

The contrast-enhanced coronal T1-weighted magnetic resonance image (MRI) of the brain showed a ring-enhancing mass in the left cerebellar hemisphere, suggesting a necrotic lesion (Figure B). A hypersignal in the cavity on the axial diffusion-weighted image (Figure C) was interpreted as reduced water molecule movement (restricted diffusion) and reflected a high viscosity of the proteinaceous fluid with a high concentration of inflammatory cells. Although these features are not pathognomonic, they are extremely characteristic of an abscess².

The patient underwent surgical drainage of the cerebellar lesion. The histopathological findings were leveduriform structures of Paracoccidioides brasiliensis .

Paracoccidioidomycosis (PCM) is one of the most common fungal diseases and can compromise one or multiple organs³. Diagnosis can be confirmed by biopsy, immunological assay, culture, or direct microscopy. Recommended pharmacological treatment includes itraconazole, sulfamethoxazole + trimethoprim, and amphotericin B.

Thus, the combination of chest CT findings, suggesting a granulomatous infectious process, and MRI, showing a probable encephalic abscess, should lead to a diagnosis of PCM with concomitant involvement of the central nervous system and lungs, allowing early initiation of specific treatment and reduction of the associated morbimortality.

• ¹
  Barreto MM, Marchiori E, Amorim VB, Zanetti G, Takayassu TC, Escuissato DL et al. Thoracic paracoccidioidomycosis: radiographic and CT findings. Radiographics 2012; 32:71-84.
• ²
  Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007; 28:1332-1338.
• ³
  Pedroso VS, Lyon AC, Araújo SA, Veloso JM, Pedroso ER, Teixeira AL. Paracoccidioidomycosis case series with and without central nervous system involvement. Rev Soc Bras Med Trop 2012; 45:586-590.

Publication Dates

• Publication in this collection
  Dec 2015

History

• Received
  10 Aug 2015
• Accepted
  03 Sept 2015