RESUMO

A twenty four year-old male patient with a history of morbid obesity and acute lymphocytic leukemia diagnosed in 2003, underwent an autologous bone marrow transplantation the same year. He had two relapses of leukemia on 2003 and 2007. On January 2009, he underwent a double cord bone marrow transplantation with myeloablative conditioning and craneospinal radiotherapy. The patient received prophylaxis with aciclovir, cotrimoxazole and fluconazole. The latter was changed afterwards to posaconazole. On day 16 post-transplantation, fever and menin-geal signs appeared. The cerebrospinal fluid exam revealed pleocytosis with polymorphonuclear predominance. Empirical therapy was started with meropenem. Due to neurological impairment, at day 33, a brain magnetic resonance imaging (MRI) was performed, showing multiple hypodense supra and infratentorial nodules with peripheral edema. Biopsy, universal PCR for fungi and a new cerebrospinal fluid analysis were performed and amphotericin B was added showing a favorable response. He was discharged with itraconazole, as the universal PCR of brain tissue revealed Penicillium spp. This is the third report presented in this journal that stresses the importance of early neuroimaging, especially MRI to certify the involvement of the central nervous system in immunocompromised patients.

Paciente de 24 años, sexo masculino, con antecedente de obesidad mórbida que debutó con una leucemia linfática aguda (LLA) en el año 2003. Se le efectuó trasplante (Tx) de precursores hematopoyéticos, autólogo, recayendo el mismo año. En el año 2007 presentó una segunda recaída por lo que se le sometió a Tx doble de cordón como rescate en enero de 2009, con acondicionamiento mieloablativo y radioterapia cráneo-espinal recibiendo profilaxis con aciclovir, cotrimoxazol y fluconazol, el que fuera cambiado posteriormente a posaconazol. El día 16 post trasplante presentó fiebre y signos meníngeos, con LCR que revelaba una pleocitosis de predominio polimorfonuclear. Se inició terapia empírica con meropenem. Debido al deterioro neurológico, en el día 33, se le efectuó una resonancia magnética cerebral (RM) donde se evidenciaron múltiples nódulos hipodensos supra e infratentoriales con edema periférico. Se le realizó biopsia cerebral, cultivos, reacción de polimerasa en cadena (RPC) para hongos, nuevo estudio de LCR completo y se agregó anfotericina B deoxicolato presentando una respuesta favorable. Finalizada la terapia con anfotericina B se dio de alta con itraconazol ya que la RPC de tejido cerebral reveló Penicillium sp. Este es el tercer caso presentado en esta revista en los que enfatizamos la importancia de las neuroimágenes, en especial la RM, realizadas en forma precoz para certificar el compromiso del SNC en pacientes inmunocomprometidos.

Assuntos

RESUMO

A twenty four year-old male patient with a history of morbid obesity and acute lymphocytic leukemia diagnosed in 2003, underwent an autologous bone marrow transplantation the same year. He had two relapses of leukemia on 2003 and 2007. On January 2009, he underwent a double cord bone marrow transplantation with myeloablative conditioning and craneospinal radiotherapy. The patient received prophylaxis with aciclovir, cotrimoxazole and fluconazole. The latter was changed afterwards to posaconazole. On day 16 post-transplantation, fever and meningeal signs appeared. The cerebrospinal fluid exam revealed pleocytosis with polymorphonuclear predominance. Empirical therapy was started with meropenem. Due to neurological impairment, at day 33, a brain magnetic resonance imaging (MRI) was performed, showing multiple hypodense supra and infratentorial nodules with peripheral edema. Biopsy, universal PCR for fungi and a new cerebrospinal fluid analysis were performed and amphotericin B was added showing a favorable response. He was discharged with itraconazole, as the universal PCR of brain tissue revealed Penicillium spp. This is the third report presented in this journal that stresses the importance of early neuroimaging, especially MRI to certify the involvement of the central nervous system in immunocompromised patients.

Assuntos

RESUMO

BACKGROUND: Central nervous system fungal infections (FI) are important complications and a cause of mortality in patients who receive hematopoietic stem cell transplantation (HSCT). AIMS: To study the clinical aspects of fungal encephalitis (FE). SETTINGS AND DESIGN: The study was carried out at the HSCT Center of the Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil. MATERIALS AND METHODS: Clinical records and autopsy reports from patients submitted to HSCT with a diagnosis of FE. RESULTS: Twelve patients were diagnosed with FE presenting with lowered level of consciousness, hemiparesis and seizures. We were able to identify two subgroups regarding susceptibility to FE: (1) patients with early onset FI and severe leucopenia, and (2) patients with later onset FI with graft-versus-host disease using immunosuppressive drugs. Eleven of the patients died directly due to the neurological complication, all had post-mortem confirmation of the diagnosis of FI. CONCLUSIONS: These clinical, paraclinical and temporal patterns may provide the opportunity for earlier diagnosis and interventions.

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RESUMO

The cerebral lesions are uncommon in patients with histoplasmosis, occurring more frequently in the disseminated form of the disease. Rarely, the disease may present as a histoplasmoma, simulating a neoplastic lesion. The histoplasmoma as the only manifestation of this infection in immunocompetent patients is even rarer. This case report describes a 13 year-old male patient with headache, vomit, low visual acuity and auditive deficit on the left, and paresis on the right. The magnetic resonance image showed an expansible lesion in the thalamic, hypothalamic, and chiasmatic regions, which showed ring enhancement. The stereotactic biopsy was performed and the histological diagnosis of histoplasmosis was defined. The treatment was initiated with fluconazole. The patient showed important clinical improvement after 6 months.

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RESUMO

O acometimento cerebral pela histoplasmose é raro, ocorrendo mais comumente sob a forma de doença disseminada. Raramente, a doença pode ocorrer sob a forma de histoplasmomas, que simulam tumores do sistema nervoso central. Mais raro ainda é a ocorrência de histoplasmomas em pacientes imunocompetentes como única manifestação desta infecção. Neste relato é apresentado um paciente masculino de 13 anos com cefaléia, vômitos, redução da acuidade visual e auditiva à esquerda e hemiparesia à direita. A ressonância magnética mostrou lesão expansiva com impregnação anelar de contraste, localizada na região talâmica, hipotalâmica e quiasmática à esquerda. Foi realizada biópsia estereotáxica e a avaliação histológica do material definiu o diagnóstico de histoplamose. Iniciou-se tratamento com fluconazol, com melhora clínica importante após 6 meses do início do tratamento.

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RESUMO

Paracoccidioidomycosis (PCM) is a chronic granulomatous infectious disease, whose etiologic agent is the fungus Paracoccidioides brasiliensis. The central nervous system (CNS) involvement with paracoccidioidomycosis (NPCM) occurs more frequently than has been admitted in the past. There are some major histocompatibility complex antigen association studies with systemic paracoccidioidomycosis. Some indicate a positive association with HLA antigens, but there is no study with the involvement of the CNS. To investigate why not all cases of systemic PCM show the involvement of the CNS and whether genetic factors are involved, we studied 6 patients with NPCM, from the neuroinfection outpatient clinic. The patients were typed for class I and class II antigens by a microlymphocytoxity standard test. The HLA antigen frequencies found in this study in patients with NPCM were not different from the alleles frequencies observed in the Paraná population.

Assuntos