Neuroparacoccidioidomycosis with concomitant pulmonary and vocal cord lesions
Neuroparacococcidioidomicose com lesões concomitantes nos pulmões e na corda vocal
Authors
Adriano Basso Dias
1
Hospital Dom Vicente Scherer, Irmandade Santa Casa de Misericórdia de Porto Alegre,
Departamento de Radiologia e Diagnóstico por Imagem, Porto Alegre RS, Brasil;
Cláudia Scherber Giugno
2
Irmandade Santa Casa de Misericórdia de Porto Alegre, Departamento de Patologia, Porto
Alegre RS, Brasil;
Jessica Oliboni Scapineli
3
Irmandade Santa Casa de Misericórdia de Porto Alegre, Departamento de Medicina Interna,
Porto Alegre RS, Brasil.
Gabriel Pedro Tarso
3
Irmandade Santa Casa de Misericórdia de Porto Alegre, Departamento de Medicina Interna,
Porto Alegre RS, Brasil.
Rodrigo Miranda de Curtis
1
Hospital Dom Vicente Scherer, Irmandade Santa Casa de Misericórdia de Porto Alegre,
Departamento de Radiologia e Diagnóstico por Imagem, Porto Alegre RS, Brasil;
Rene Lenhardt
1
Hospital Dom Vicente Scherer, Irmandade Santa Casa de Misericórdia de Porto Alegre,
Departamento de Radiologia e Diagnóstico por Imagem, Porto Alegre RS, Brasil;
Paracoccidioidomycosis is a systemic granulomatous disease caused by the fungus Paracoccidioides brasiliensis
[1]. Involvement of the central nervous system is more common in the chronic form of
the disease, affecting the supratentorial region in two-thirds of cases[2]. A previously healthy 48-year-old woman presented with a two-month history of headache,
cough and hoarseness. Brain magnetic resonance imaging revealed multiple ring enhancing
cerebellar lesions ([Figure 1]), most of them with imaging features indicative of granulomas probably with liquefied
necrosis. ([Figure 2]). Chest CT showed scattered nodules and cavitations ([Figure 3]). Fiber bronchoscopy identified a vocal cord lesion, which was biopsied. The histopathological
findings were compatible with paracoccidioidomycosis ([Figure 4]).
Figure 1 Brain magnetic resonance. A) Axial postcontrast T1-weighted image shows multiple
cerebellar lesions with ring enhancement (white arrows). B) Axial FLAIR image demonstrates
that these lesions present variable signal intensities, associated with moderate surrounding
vasogenic edema (black arrows).Figure 2 A) Diffusion-weighted imaging demonstrates that most of lesions are hyperintense
(straight white arrows). B) Apparent diffusion coefficient map shows hypointensity
in these lesions, compatible with restricted diffusion (straight black arrows). C)
Magnetic resonance perfusion reveals decreased perfusion in the lesions and adjacent
white matter (arrowheads). D) Magnetic resonance spectroscopy, single voxel, echo
time = 35 ms, shows elevation of lipids and/or lactate peaks (curved arrow). The N-acetylaspartate
peak is decreased (signaling neuroaxonal loss or dysfunction). These findings are
suggestive of granulomatous lesions, probably with liquefied necrosis.Figure 3 A-D: Axial chest computed tomography reveals scattered nodules (arrowheads) and cavitations
(arrows), suggesting the possibility of a granulomatous process.Figure 4 A) Fiber bronchoscopy reveals a vocal cord lesion (arrow), which was biopsied. B)
Histological evaluation (H&E, 10x) shows focus of granulomatous inflammation (inside
the circle). C) Histological evaluation (Grocott stain, 400x) demonstrates fungal
pathogens, with characteristic yeast elements with multipolar budding of variable
size, compatible with Paracoccidioides brasiliensis.
2 Pedroso VS, Vilela Mde C, Pedroso ER, Teixeira AL. Paracoccidioidomycosis compromising
the central nervous system: a systematic review of the literature. Rev Soc Bras Med
Trop. 2009 Dec;42(6):691-7. https://doi.org/10.1590/S0037-86822009000600016
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