Table 2.

Salient Points Regarding Central Nervous System (CNS) Paracoccidioidomycosis.

Clinical Aspects

Two major manifestations ➢Intracranial space-occupying lesions that mimic a brain tumor or abscess that usually occur as one manifestation of disseminated infection in patients with the chronic form of paracoccidioidomycosis ➢Meningitis is less common; usually occurs as one manifestation of disseminated infection in either an acute or chronic form of paracoccidioidomycosis

Diagnosis

➢Definite CNS paracoccidioidomycosis: positive culture from cerebrospinal fluid (CSF) (uncommon) OR positive culture or histopathology on tissue obtained by brain biopsy ➢Presumptive CNS paracoccidioidomycosis: positive culture from another involved site OR positive histopathology from another involved site in a patient with disseminated paracoccidioidomycosis and symptoms, signs, and radiological findings of CNS disease ➢Serology on CSF may be useful for patients with meningitis; not standardized; may be available in reference laboratories in endemic areas

Treatment and Outcomes

➢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, might be efficacious for step-down therapy, but little experience ➢Trimethoprim/sulfamethoxazole (TMP/SMX), 240 mg TMP/1200 mg SMX (or higher) daily for step-down therapy for at least 12 months ➢Life-long maintenance azole or TMP/SMX therapy may be required ➢Outcomes depend on CNS damage from mass lesions; sequelae are common