Arquivos de Neuro-Psiquiatria (Jun 2006)
Paracoccidioidomicose do sistema nervoso central: análise de 13 casos Central nervous system paracoccidioidomycosis: analysis os 13 cases
Abstract
A paracoccidioidomicose (PCM) é infecção granulomatosa sistêmica, causada pelo fungo Paracoccidioides brasiliensis, prevalente na América Latina, particularmente no Brasil. Acomete o sistema nervoso central (SNC) em 10% dos casos. Foram estudados 13 pacientes com paracoccidioidomicose no SNC, entre 1991 e 2001, com ênfase para os aspectos clínicos, neuroradiológicos e terapêuticos. Onze pacientes eram do sexo masculino (84,6%) e dois do feminino (15,4%), com idade entre 30 e 71 anos (M= 47,1 ± 11,6 Me= 46). Os sintomas mais freqüentes foram déficits motores (53,8%), alterações cognitivas (53,8%), emagrecimento (46,1%), cefaléia (46,1%) e crises convulsivas (46,1%). O diagnóstico foi confirmado pela detecção do P. brasiliensis no SNC. Todos os pacientes apresentavam a forma granulomatosa e quatro (30,8%) tinham a forma meningoencefalítica associada. Todos foram estudados com tomografia computadorizada (TC) de crânio e um caso com ressonância magnética (RM) encefálica. Dez pacientes (76,9%) realizaram sorologia para o HIV, todos com resultados negativos. A anfotericina B foi utilizada em 12 casos (92,3%), em um deles por via intratecal. Em oito casos (61,5%) o sulfametoxazol-trimetropim foi utilizado; em dois (15,4%) a sulfadiazina e pirimetamina, e o fluconazol, cetoconazol e itraconazol, cada um deles em um paciente. Seis pacientes (46,1%) morreram e sete evoluíram satisfatoriamente. O tempo de seguimento variou de 2 a 74 meses (M=30,9). Conclui-se que as manifestações clínicas assim como os exames de imagem na PCM do SNC são inespecíficos.Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis, prevalent in Latin America, particularly in Brazil. Central nervous system (CNS) involvement occur in about 10% of cases. Thirteen patients with PCM involving CNS were studied considering clinical manifestation, neuroradiology and treatment modalities. Age ranged from 30 to 71 years-old (M= 47.1 ± 11.6 Me= 46). There were eleven men and two women. The most frequent symptoms were motor deficits (53.8%), cognitive disturbance (53.8%), weight loss (46.1%), headaches (46.1%) and seizures (46.1%). The diagnosis was confirmed by the demonstration of P. brasiliensis. Granulomatous forms were present in all patients. Four (30.8%) of them had also meningeal involvement (mixed form). Computerized tomography (CT) scans were obtained in all cases and magnetic resonance imaging (MRI) was used in one case. Serology for HIV was done in ten patients (76.9%), and all the tests were negatives. Amphotericin B was used in twelve patients (92.3%), one of them by intraventricular infusion. In eight patients (61.5%), trimethopim and sulfamethoxazole were used, and, in two (15.4%), sulfadiazine and pirimetamine. Fluconazole, ketoconazole and itraconazole were each one used in a different patient as well. Six patients died (46.1%) and seven (53.9%) had satisfatory outcome. The follow-up period ranged from 2 to 74 (M=30.9) months. In conclusion, the CNS involvement in paracoccidioidomycosis is more frequent and more serious than thought before. The clinical manifestations, CT scans and MRI findings are not specific of paracoccidioidomycosis.
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