Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review

Abstract

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.

A Case of Histoplasmosis with Central Nervous System Relapse after Itraconazole Therapy Needs Further Research

“…However, a combination of high index of suspicion, clinical features, imaging studies and testing spinal fluid or urine for Histoplasma antigen might be useful. Identifying the histoplasma in the brain either by stereotactic or open biopsy remains gold standard for diagnosis of CNS histoplasma [1]. Patients with CNS histoplasmosis can present with chronic meningitis, encephalitis, hydrocephalus, parenchymal lesions involving the brain and spinal cord resulting in stroke, seizures, confusion, memory impairment [1,2].…”

“…Histoplasmosis is a fungal infection caused by Histoplasma capsulatum which is one of the common fungal respiratory infections, endemic in Africa, Latin America, Asia, central and southeastern states of the United States [1]. Most of the documented histoplasmosis infections are asymptomatic in immunocompetent individuals, and are self-resolving.…”

“…Most of the documented histoplasmosis infections are asymptomatic in immunocompetent individuals, and are self-resolving. Symptomatic cases of infections are seen in patients who are immunocompromised like acquired immunodeficiency syndrome (AIDS), transplant patients on immunosuppressants, patients with ventriculoperitoneal shunts, and patients on steroids [1]. Here we present a patient with history of adrenal histoplasmosis status post bilateral adrenalectomy presenting with central nervous system (CNS) histoplasmosis despite being on itraconazole (ICZ) therapy.…”

Diagnóstico da Neurohistoplasmose por Biopsia Estereotáxica Guiada por Fusão Computacional de Imagens

“…O envolvimento cerebral ocorre entre 5% e 10% dos casos de histoplasmose, e apenas 25% dos pacientes apresentam sintomas neurológicos 1,6 . A doença é de difícil diagnóstico devido à alta inespecificidade dos sintomas e dos testes sorológicos e imaginológicos 2,5 . Em pacientes com AIDS é de suma importância o diagnóstico etiológico, visto que as possibilidades infecciosas e neoplásicas são diversas pela imunossupressão 3,5 .…”

“…As apresentações neurológicas ocorrem desde meningite crônica, que evolui com hidrocefalia, forma mais comum de apresentação, até formação de lesões expansivas encefálicas e/ou medulares 1 . Na maioria das vezes, essa doença cursa com comprometimento neurológico severo, independentemente de se desenvolver de forma isolada no SNC de um imunocompetente ou não [2][3][4] . A prevalência aumenta em casos de imunossupressão, principalmente celular, podendo ser confundida nos métodos de diagnóstico por imagem e por sorologia, com lesões oportunistas de diferentes etiologias ou mesmo neoplásicas [5][6][7][8][9] .…”