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CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2021; 40(02): e195-e199
DOI: 10.1055/s-0040-1719005
Case Report | Relato de Caso

Multifocal Pseudotumorous Form of Neuroparacoccidioidomycosis in an Immunocompetent Patient: A Clinicopathological Review Based on a Case Report

Neuroparacoccidioidomicose multifocal de forma pseudotumoral em paciente imunocompetente: Uma revisão clinicopatológica baseada em um relato de caso
Eduardo Cambruzzi 
1   Department of Pathology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2   Department of Pathology, Hospital Santa Rita, Complexo Hospitalar Santa Casa, Porto Alegre, RS, Brazil
3   Department of Pathology, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
4   Department of Pathology, Universidade Luterana do Brasil, Canoas, RS, Brazil
5   Department of Pathology, Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, RS, Brazil
,
Karla Lais Pêgas 
2   Department of Pathology, Hospital Santa Rita, Complexo Hospitalar Santa Casa, Porto Alegre, RS, Brazil
3   Department of Pathology, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
Gabriella Bezerra Cortês Nascimento 
6   Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
José Nathan Andrade Muller da Silva 
6   Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
Natália Brandelli Zandoná 
6   Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
William Pegoraro Kus 
6   Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
Felipe Lourezon Schiavo 
7   Department of Neurosurgery, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
,
Samir Cezimbra dos Santos 
7   Department of Neurosurgery, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
› Author Affiliations Funding No funding was received.
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Abstract

Neuroparacoccidiodimycosis (NPDM) is an uncommon granulomatous disease, which more frequently affects immunocompromised male patients over 30 years of age in the course of chronic lung disease. Paracoccidioides brasiliensis (PB) is an endemic fungus in Brazil, and grows as thick-walled yeast (with round to oval bodies) measuring 10 µm to 60 µm in diameter. Neuroparacoccidiodimycosi may develop many years after transmission and/or primary lung involvement. The authors describe a case of NPDM affecting a male patient, 52 years of age, farmer, heavy smoker, with clinical complaint of headache, asthenia, seizures, and prostration in the previous nine months. Upon physical examination, the patient presented regular general condition, without other relevant physical alterations. Computed tomography (CT) showed multiple bilateral pulmonary nodules associated to enlargement of the mediastinal lymph node. Magnetic resonance imaging (MRI) and CT scans of the central nervous system showed six heterogeneous nodular lesions compromising the frontal and parietal lobes, the largest one measuring 3.8 × 3.2 × 3.2 cm. The hypothesis of a neoplastic process compromising the lung and brain was considered. A biopsy of the mediastinal lymph node showed epithelioid granulomas, which exhibited round, thin-walled fungal structures in Grocott silver stain. The stereotactic biopsy of the frontal lesion was constituted by necrotic tissue admixed with some round to oval, thin-walled fungi measuring 10 µm to 60 µm, compatible with PB (identified on Grocott silver stain/confirmed in culture). The diagnosis of NPDM was then established. The employed therapeutic regimen was intravenous amphotericin B, itraconazole, and sulfamethoxazole-trimetropin. After ninety days of clinical follow-up, no episodes of seizures/neurological deficits were identified, and a marked decrease in the number and size of the lung and brain lesions were found.

Resumo

A neuroparacoccidiodimicose (NPDM) é uma doença granulomatosa incomum, que acomete mais freqüentemente pacientes imunocomprometidos do sexo masculino com mais de 30 anos, no curso de doença pulmonar crônica. Paracoccidioides brasiliensis (PB) é um fungo endêmico no Brasil e cresce como levedura de parede espessa (com corpos arredondados a ovais) medindo 10–60 μm de diâmetro. A NPDM pode se desenvolver muitos anos após a transmissão e / ou envolvimento pulmonar primário. Os autores descrevem um caso de NPDM em paciente masculino, 52 anos, agricultor, tabagista pesado, com queixa clínica de cefaleia, astenia, convulsões e prostração nos últimos nove meses. Ao exame físico, o paciente apresentava estado geral regular, sem outras alterações físicas relevantes. A tomografia computadorizada (TC) mostrou múltiplos nódulos pulmonares bilaterais associados a linfonodomegalia mediastinal. A TC / ressonância magnética do sistema nervoso central revelou seis lesões nodulares heterogêneas comprometendo os lobos frontal e parietal, a maior delas medindo 3,8x3,2x3,2 cm. Foi considerada a hipótese do processo neoplásico comprometendo pulmão e cérebro. A biópsia de linfonodo mediastinal mostrou granulomas epitelioides, que exibiam estruturas fúngicas arredondadas e de paredes finas na coloração pela prata de Grocott. A biópsia estereotáxica da lesão frontal era constituída por tecido necrótico entremeado por algumas estruturas fúngicas redondas a ovais e de parede fina, medindo 10–60 μm, compatível com PB (identificado na coloração de prata Grocott / confirmado em cultura). O diagnóstico de NPDM foi então estabelecido. O esquema terapêutico empregado foi anfotericina B intravenosa, itraconazol e sulfametoxazol-trimetropina. Após 90 dias de acompanhamento clínico, nenhum episódio de convulsão / déficit neurológico foi identificado, e uma diminuição acentuada no número e tamanho das lesões pulmonares e cerebrais foi encontrada.

Keywords

paracoccidiodomycosis - south american blastomycosis - paracoccidioides brasiliensis - central nervous system - mycosis - pathology

Palavras-chave

paracoccidiodomicose - blastomicose da América do Sul - paracoccidioides brasiliensis - sistema nervoso Central - Micose - patologia


Publication History

Received: 07 January 2020

Accepted: 24 August 2020

Article published online:
26 November 2020

© 2020. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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