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Opportunistic Fungal Infections

CNS mycosis is sometimes found in otherwise healthy persons but mainly occurs as a component of an opportunistic systemic mycosis in persons with immune compromise due to AIDS, organ transplantation, severe burns, malignant diseases, diabetes mellitus, connective tissue diseases, chemotherapy, or chronic corti-costeroid therapy. Certain types of mycosis (blastomycosis, coccidioidmycosis, histoplasmosis) are endemic to certain regions of the world (North America, South America, Africa).

■ Cryptococcus neoformans (Cryptococcosis)

Cryptococcus, a yeastlike fungus with a polysaccharide capsule, is a common cause of CNS mycosis. It is mainly transmitted by inhalation of dust contaminated with the feces of pet birds and pigeons. Local pulmonary infection is followed by hematogenous spread to the CNS. In the presence of a competent immune system (particularly cell-mediated immunity), the pulmonary infection usually remains asymptomatic and self-limited. Immune-compromised persons, however, may develop meningoen-cephalitis with or without prior signs of pulmonary cryptococcosis. Its manifestations are heterogeneous and usually progressive. Signs of subacute or chronic meningitis are accompanied by cranial nerve deficits (III, IV, VI), en-cephalitic syndrome, and/or signs of intracranial hypertension. Diagnosis: MRI reveals granulomatous cystic lesions with surrounding edema. Lung infiltrates may be seen. The nonspecific CSF changes include a variable (usually mild) lymphomonocytic pleocytosis as well as elevated protein, low glucose, and elevated lactate concentrations. An india ink histological preparation reveals the pathogen with a surrounding halo (carbon particles cannot penetrate its polysaccharide capsule). Identification of pathogen: demonstration of antigen in CSF and serum; tests for anticryptococcal antibody yield variable results. Treatment: initially, amphotericin B + flucytosine; subsequently, fluconazole or (if fluconazole is not tolerated) itraconazole.

■ Candida (Candidiasis)

Candida albicans is a constituent of the normal body flora. In persons with impaired cell-medi ated immunity, Candida can infect the oropharynx (thrush) and then spread to the upper respiratory tract, esophagus, and intestine. CNS infection comes about by hemato-genous spread (candida sepsis), resulting in meningitis or meningoencephalitis. Ocular changes: Candida endophthalmitis. Diagnosis: Candida abscesses can be seen on CT or MRI. The CSF changes included pleocytosis (several hundred cells/ill) and elevated concentrations of protein and lactate. Pathogen identification: Microscopy, culture, or detection of specific antigens or antibodies. Local treatment: Amphoter-icin B or fluconazole. Systemic tratment: Amphotericin B + flucytosine.

■ Aspergillus (Aspergillosis)

The mold Aspergillus fumigatus is commonly found in cellulose-containing materials such as silage grain, wood, paper, potting soil, and foliage. Inhaled spores produce local inflammation in the airways, sinuses, and lungs. Organisms reach the CNS by hematogenous spread or by direct extension (e. g., from osteomyelitis of the skull base, otitis, or mastoiditis), causing encephalitis, dural granulomas, or multiple abscesses. Diagnosis: CT and MRI reveal multiple, sometimes hemorrhagic lesions. The CSF findings include granulocytic pleocytosis and markedly elevated protein, decreased glucose, and elevated lactate concentration. Pathogen identification: Culture; if negative, then lung or brain biopsy. Treatment: Amphotericin B + flucy-tosine or itraconazole.

■ Mucor, Absidia, Rhizopus (Mucormycosis)

Inhaled spores of these molds enter the nasopharynx, bronchi, and lungs, where they mainly infect blood vessels. Rhinocerebral mu-cormycosis is a rare complication of diabetic ke-toacidosis, lymphoproliferative disorders, and drug abuse; infection spreads from the paranasal sinuses via blood vessels to the retro-orbital tissues (causing retro-orbital edema, exoph-thalmos, and ophthalmoplegia) and to the brain (causing infarction with secondary hemorrhage). Diagnosis: CT, MRI; associated findings on ENT examination. Pathogen identification: Biopsy, smears. Treatment: Surgical excision of infected tissue if possible; amphotericin B.

Absidia Tongue

Pigeon feces

Candidiasis of tongue (thrush) Candida

Pigeon feces

Candidiasis of tongue (thrush) Candida

Ink-stained CSF specimen

Bright polysaccharide capsule, sprouting of daughter cells

Bright polysaccharide capsule, sprouting of daughter cells

Cryptococcosis

Cerebral aspergillosis (multiple hemorrhagic, necrotic foci)

Erythema, periorbital edema, exophthalmos, ptosis

Facial nerve palsy

Ink-stained CSF specimen

Cryptococcosis

Cerebral aspergillosis (multiple hemorrhagic, necrotic foci)

Erythema, periorbital edema, exophthalmos, ptosis

Facial nerve palsy

Aspergillosis

Cryptococcosis

Rhinocerebral mucormycosis

Aspergillosis

Rhinocerebral mucormycosis

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