Paracoccidioidomicose em hemisfério cerebral e tronco encefálico: relato de caso

Abstract

D r. Manoel Baldoino Leal Filho -Rua Thomaz Tajra 1222 / Apto. 300 -64048-380 Te resina PI -Brasil. E-mail: manoelbaldoino@uol.comRESUMO -Relata-se sobre um homem de 36 anos com passagem quatro anos antes pela selva amazônica. Admitido após seis meses do aparecimento pro g ressivo de tetraparesia, ataxia de marcha, disfagia, disart r i a , dispnéia e soluço. A ressonância magnética revelou lesão parietoccipital à direita e no bulbo, sendo esta última maior. Investigações para tuberculose e síndrome da imunodeficiência adquirida tiveram re s u l t a d o s negativos. Foi submetido a micro c i ru rgia da lesão do bulbo. O estudo anatomopatológico revelou paracoccidioidomicose. Recebeu tratamento com anfotericina B até 2100 mg, e sulfametoxazol-trimetoprim por três meses, e fisioterapia. Voltou às atividades após seis meses do término do tratamento. Comenta-se sobre a participação do sistema imunológico e das citocinas (interleucinas).PA L AV R A S -C H AVE: paracoccidioidomicose, sistema nervoso central, sistema imunológico, citocinas, interleucinas.Paracoccidioidomycosis in cerebral hemisphere and brainstem: case report ABSTRACT -We re p o rt on a 36 years-old man that had been at the Amazon forest four years before. Six months before the admission he had developed a pro g ressive quadriparesis, gait ataxia, dysphagia, dysart h r i a , d i fficulty in breathing and hiccup. The gadolinium-enhanced T1-weighted MRI showed a lesion into the right parietoccipital area and another into the medulla, that was the largest. There was any evidence of t u b e rculosis or AIDS. The patient was submitted to micro s u rgical approach to the medulla. Pathological examination revealed paracoccidioidomycosis. Treatment with anphotericin B till 2100mg was administere d followed by sulfamethoxazole-trimetoprim for three months plus physical therapy. The patient went back to his activities six months after the end of the treatment. Comments are presented about the part i c i p a t i o n of the immunological system and of the cytokines (interleukines).KEY WORDS: paracoccidioidomycosis, central nervous system, immunological system, cytokines, interleukines.A paracoccidioidomicose (PCM) é uma doença sistêmica causada pelo Paracoccidioides brasiliensis, u m fungo dimórfico, com prevalência maior na América do Sul, em regiões de florestas, principalmente no B r a s i l 1 -5 . A micose é adquirida através da inalação de conídeos e se manifesta freqüentemente por envolvimento do sistema retículo-endotelial, a lesão inicial comumente ocorrendo ao nível da mucosa oro f a r í ngea e se dissemina por via hematogênica [1][2][3] . A lesão fúngica se instala principalmente nos pulmões, nas glândulas adrenais, baço, fígado, ossos e tracto gast r i n t e s t i n a l , acometendo a medula espinhal, o tronco encefálico, o cerebelo e, mais comumente, os hemisférios cerebrais 6 . Do ponto de vista do envolvimento do sistema imunológico e da participação de citocinas na PCM, uma experiência foi descrita recentemente, em que se observou uma imunodeficiên...

Neuroparacoccidiomicosis Simulating Posterior Fossa Tumor

“…Furthermore, there is frequent association of PCM with smoking and alcoholism 5 . Neurological infection is described as secondary, and the main form of dissemination is hematologic, due to the predominance of lesions in areas with high blood flow 3,6 .…”

“…The treatment was based on antifungal therapy; the association of sulfamethoxazole-trimethoprin was used as the first option because of the facility in their administration, the high levels reached in the CNS, and the low cost 1 . However, Amphotericin B is indicated for severe cases, at least in the initial phase of treatment, in order to prevent unfavorable outcomes 5,6,8 . Duration of treatment was based on clinical improvement and regression or stabilization of the radiologic findings 5,9 . The indications for neurosurgical intervention are similar to any brain abscess case and include signs of significant mass effect, associated hydrocephalus, proximity to the ventricular system or neurological deterioration 1,4,10 .…”

Paracoccidioidomycosis in the Central Nervous System

“…The MRI may not only show parenchyma involvement and/or involvement of the meninges, but may also be useful to differentiate those lesions from other lesions. 11 The lesions were characterized by ISO (Isointense) or hyposignal in T1, hyposignal in T2, with peripheral edema and nodular or ring enhancement after contrast administration. 12 However, both imaging methods show unspecific characteristics, and histopathology is the only way to confirm the diagnosis.…”

Paracoccidioidomycosis simulating brain tumor

“…[1121] However, amphotericin B and intravenous sulfamethoxazole are indicated for severe manifestations of the disease, at least in the initial phase of treatment, in order to prevent unfavorable outcomes. [81321] Some azoles have also been used in the treatment of PCM, such as itraconazole and voriconazole. Itraconazole does not have a good penetration into the CNS, but voriconazole has been successfully used in the treatment of fungal infections of the CNS, such as blastomycosis[22] and aspergillosis,[20] and may be considered in patients who cannot tolerate the treatments of choice.…”