Novo tratamento para extenso granuloma paracoccidioidomicótico cerebral

Abstract

Surgical treament and/or amphotericin B have been the treatment of choice for cerebral infections caused by the fungus Paracoccidioides brasiliensis 1,3,6,7,8,9,11,12,13,15,17 . We are reporting a new drug treatment for the encephalic form of paracoccidioidomycosis. P. brasiliensis, the agent of a deep fungal infection highly endemic in Central and South America, has been associated with two types of CNS lesions: granuloma reaction in the meninges, frequently causing a ba silar leptomeningitis similar to tuberculous meningitis; solitary and multiple gra nulomas, most commonly localized in cerebral hemispheres 11 .We report a patient with a large granuloma of South American blasto mycosis in the right fronto-parietal region, successfuly treated with sulfame thoxazole-trimethoprim alone, with follow-up documented by repeated CT scans. CASE REPORTA.M.S., a 59-year-old Brazilian male, truck drive, was admitted to the University of Campinas Hospital because of partial motor seizures starting in the left extremities and progressing to generalized tonic-clonic movements, beginning four months before, associated with a two months history of left progressive hemiparesis. He had been smoking a pack of cigarettes per day since age nine and had abused alcohol up to eight months before admission. Physical examination disclosed discretely pale mucous membranes, distant breath sounds and mild hepatomegaly. The neurologic examination showed a severe left hemiparesis predominating in the upper extremity, suggesting a supratentorial lesion; funduscopic examination and mental status were normal. CBC showed mild normocytic anemia and increased sedimentation rate.Skull X-ray, EEG and CSF were normal. A cranial CT (Fig 1 A) revealed a large hypodense area in the right fronto-parietal region extending up to the cortex; contrast iniection enhanced the central area and ring-like pattern. A chest X-ray showed bilateral diffuse pulmonary infiltrates, more proeminent in the parahilar regions, consistent with pulmonary paracoccidioidomycosis (Fig. 2). Sputum smears revealed the presence of Paracoccidioides brasiliensis. Treatment was started 1200 mg of sulfamethoxazole, plus 240 mg of trimethoprim twice a day. The seizures were controled with phenobarbital 100 mg per day. One week after initiation of treatment with sulfamethoxazole-trimethoprim a definite improvement of the left hemiparesis was noted. After the first month, clinical improvement was remarkable but the contrasted CT scan (Fig 1 B) still showed the lesion, although there was evidence