Table 1.

Salient Points Regarding Central Nervous System (CNS) Blastomycosis.

Clinical Aspects

Two major manifestations ➢Intracranial space-occupying lesions that mimic a brain tumor or abscess and that can occur as an isolated process or with disseminated blastomycosis ➢Meningitis that is chronic and without other organ involvement causing a headache, mental status changes, and symptoms of increased intracranial pressure OR meningitis that is one manifestation of disseminated infection and that is seen more often in immunosuppressed patients

Diagnosis

➢Definite CNS blastomycosis: positive culture from cerebrospinal fluid (CSF) OR positive culture or histopathology on tissue obtained by brain biopsy ➢Presumptive CNS blastomycosis: positive culture from another involved site OR positive histopathology from another involved site in a patient with disseminated blastomycosis and symptoms, signs, and radiological findings of CNS disease OR a positive Blastomyces antigen in CSF

Treatment and Outcome

➢Amphotericin B, preferably lipid formulation, 5 mg/kg daily for 4–6 weeks ➢Step-down therapy with itraconazole, 200 mg twice daily for at least 12 months ➢Voriconazole, 200–400 mg twice daily preferred for step-down therapy by many ➢Posaconazole, 300 mg daily, might be efficacious for step-down therapy if above agents are not tolerated ➢Outcomes generally good with effective antifungal therapy; may have CNS sequelae with mass lesions