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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2016; 74(06): 514-515
DOI: 10.1590/0004-282X20160068
IMAGES IN NEUROLOGY

Chronic meningitis, hydrocephalus and spinal paraplegia in non-systemic histoplasmosis

Meningite crçnica, hidrocefalia e paraplegia medular em histoplasmose não-sistêmica
Fabiano Reis
1   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Radiologia, Campinas SP, Brasil;
,
Marcondes Cavalcanti França Junior
2   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brasil;
,
Anamarli Nucci
2   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brasil;
,
Luciano de Souza Queiroz
3   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Anatomia Patológia, Campinas SP, Brasil.
,
Felipe Barjud Pereira do Nascimento
1   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Radiologia, Campinas SP, Brasil;
,
Alberto Rolim Muro Martinez
2   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brasil;
,
Marcelo Nunes
2   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brasil;
,
Karla de Oliveira Lucca
1   Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Radiologia, Campinas SP, Brasil;
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A 27-year-old immunocompetent agricultural worker presented chronic meningitis and hydrocephalus. Despite CSF and systemic investigation no etiology was defined. Spastic paraplegia installed 15 years later. Spinal and brain MRI are displayed in [Figures 1] and [2]. The patient developed intracranial hypertension and died days later. A diagnosis of histoplasmosis was made at autopsy ([Figure 3]).

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Figure 1 Thoracic spine MRI. A) Sagittal T2 weighted image showing a low signal central lesion in the spinal cord at T7 level, with associated edema above and below. Sagittal T1 weighted images before (B) and after contrast administration (C) and axial after contrast (D) demonstrate its nodular enhancement.
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Figure 2 Brain MRI. A and B) axial T2 weighted images demonstrate low signal lesion located at the anterior horn of the right lateral ventricle (arrow) and another isointense lesion located at the right foramen of Monroe, which suggested the possibility of a granulomatous process. Axial T1 weighted images before (C) and after contrast administration (D) demonstrate its nodular enhancement.
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Figure 3 A) Coronal section through brain showing hemorrhagic lesion distending the third ventricle. There is also dilatation of lateral ventricles by blood clots. B) Small subependymal lesion in anterior horn of right lateral ventricle with central caseous necrosis surrounded by thick fibrous capsule and lymphocytic infiltrate. This may have been the entry site for histoplasmas in the brain (primary histoplasmoma). HE, X 40. C) Macrophage in the third ventricle lesion containing abundant microorganisms with features of Histoplasma sp. HE, X 400. D) Small artery in third ventricle wall surrounded and delaminated by parasite filled macrophages. Vasculitis may have caused intraventricular hemorrhage. HE, X 100. E) Histoplasma sp. in macrophage phagosome as small regular yeast forms. Nearly all parasites were intracellular. Grocott’s methenamine silver, HE counterstain, X 400. F) Ultrastructure of Histoplasma sp. in a phagocytic cell. Numerous electron dense viable fungi often with a pale vacuole, surrounded by electron lucent capsule. Electron microscopy, X 2500.

Histoplamosis as isolated central nervous system disease is rare, being more common in immunosuppressed patients[1],[2]. As in this case, it can be a challenging diagnosis, and should be considered in any brain or spinal cord lesion with granulomatous pattern.



Publication History

Received: 02 October 2015

Accepted: 28 March 2016

Article published online:
06 September 2023

© 2023. Academia Brasileira de Neurologia. 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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  • References

  • 1 Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115-32.
  • 2 Gasparetto EL, Carvalho Neto A, Alberton J, Davaus T, Pianovski MAD, Yamauchi E et al. Histoplasmoma como lesão isolada do sistema nervoso central em paciente imunocompetente. Arq Neuropsiquiatr. 2005;63(3A):689-92. doi:10.1590/S0004-282X2005000400027