Paracoccidioidomycosis of the Central Nervous System: CT and MR Imaging Findings

M. Rosa Júnior; A.C. Amorim; I.V. Baldon; L.A. Martins; R.M. Pereira; R.P. Campos; S.S. Gonçalves; T.R.G. Velloso; P. Peçanha; A. Falqueto

doi:10.3174/ajnr.A6203

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Fig 1.
Brain CT showing different presentations of the lesions. A, Hypoattenuating lesions. B, Hypoattenuating lesions with a hyperattenuating halo. C, Hyperattenuating lesions.
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Fig 2.
Signal on the T1-weighted images: hypointense lesion (A), lesion with hypointense center and hyperintense halo (B), and hyperintense lesion (C).
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Fig 3.
T2-weighted images show a hypointense lesion (A), a heterogeneous signal (B), and a hyperintense lesion (C).
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Fig 4.
Demonstration that the lesions may not present with diffusion restriction (A) or diffusion restriction (B) with a low signal on the ADC map (C).
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Fig 5.
T1-weighted images after contrast administration demonstrating a small nodule in the cortical-subcortical transition (A), nodular lesion with annular enhancement (B), and multiple nodular lesions with annular enhancement and “daughter cysts” in a complex heterogeneous mass (C).
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Fig 6.
T2-weighted perfusion shows a lesion with low perfusion (A). T1-weighted perfusion shows the blood-brain barrier breakdown (B).
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Fig 7.
Proton spectroscopy with a TE = 144 ms showing increased lipid and choline peaks, with decreased NAA peaks.
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Fig 8.
SWI sequence showing the dual rim sign. Note the external hypointense halo with an internal hyperintense halo.
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Fig 9.
Laboratory diagnosis of paracoccidioidomycosis. Fresh examination in Parker-KOH stain shows yeast cells with multiple buds (A). Cultivation of Paracoccidioides spp. Left, yeast colonies to 37°C; and right, filamentous colonies to 25°C (B).

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Table 1:

Epidemiologic and clinical characteristics

Characteristic	Value
Age
Median (range) (yr)	54 (19–66)
Subgroup (No. of patients) (%)
0–19	1 (4.1)
20–39	6 (25.0)
40–59	11 (45.8)
≥60	6 (25.0)
Male sex (No.) (%)	24 (100)
Neurologic symptoms (No. of patients) (%)
Headache	8 (33.3)
Epilepsy	7 (29.1)
Focal neurologic signs	6 (25.0)
Paresis	5 (20.8)
Paresthesia	4 (16.6)
Plegia	2 (8.3)
Dysarthria	2 (8.3)
Mental confusion	2 (8.3)
Head lump	2 (8.3)
Diplopia	1 (4.1)
Chorea	1 (4.1)
Vertigo	1 (4.1)
Absence of neurologic symptom	2 (8.3)

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Table 2:

CT findings

Characteristic	Value
Patterns (No. of patients) (%)
Pseudotumoral	21 (87.5)
Meningeal	1 (4.1)
Pseudotumoral + meningeal (combined)	2 (8.3)
Calcifications (No. of patients) (%)	0 (0)
Perilesional edema (No. of patients) (%)^{^a}	19 (90.4)
Hydrocephalus (No. of patients) (%)	6 (25.0)
Hemorrhage (No. of patients) (%)^{^b}	3 (13.0)
No. of lesions^{^b}
Mean (range)	3.0 (1–11)
Subgroup (No. of patients) (%)
Single lesions	9 (39.1)
2–5	11 (47.8)
6–10	2 (8.6)
>10	1 (4.3)
Lesion size (No. of patients) (%)^{^b}
>2 cm	15 (65.2)
Larger axial diameter of the major lesion^{^b}
Mean (range) (cm)	2.6 (0.3–5.6)
CT attenuation (No. of patients) (%)^{^c}
Hyperattenuating lesions	11 (20.7)
Hypoattenuating lesions	30 (56.6)
Hypoattenuating center and hyperattenuating margin	12 (22.6)
CT or MR imaging contrast enhancement (No. of patients) (%)
Ring enhancement	17 (70.8)
Nodular enhancement	3 (12.5)
Ring and nodular enhancement	3 (12.5)
Leptomeningeal enhancement	1 (4.1)

↵a This category considered only in the 21 patients with pseudotumoral form.
↵b These categories excluded the patient with the meningeal form isolated.
↵c Seven patients did not have CT scans and were eliminated from the calculations.

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Table 3:

Lesion sites

Characteristic	Value
Localization (No. of patients) (%)
Basal meningitis	1 (4.1)
Pachymeningitis	1 (4.1)
Skull	2 (8.3)
Parietal lobe	7 (29.1)
Occipital lobe	6 (25.0)
Frontal lobe	9 (37.5)
Temporal lobe	5 (20.8)
Cerebellum	8 (33.3)
Cingulate gyrus	3 (12.5)
Thalamus	5 (20.8)
Basal ganglia	3 (12.5)
Striatum	1 (4.1)
Globus pallidus	1 (4.1)
Caudate nucleus	1 (4.1)
Putamen	1(4.1)
Corpus callosum	2 (8.3)
Hippocampus	1 (4.1)
Hypothalamus	1 (4.1)
Pons	2 (8.3)

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Table 4:

MR imaging findings

Characteristic	Value
MR imaging scans (No. of patients) (%)^{^a}
T1-weighted^{^b}
Hyperintense lesions	21 (34.4)
Hypointense lesions	31 (50.8)
Hypointense center and hyperintense margin
T2-weighted^{^b}
Hyperintense lesions	6 (9.8)
Hypointense lesions	36 (59.0)
Heterogeneous lesions (hyperintense + hypointense)	19 (31.1)
T1, perfusion^{^c}
Slow and progressive ascending	3 (100)
T2, perfusion^{^c}
Decreased rCBV	3 (100)
Spectroscopy^{^c}
Decrease of NAA	2 (100)
Increase of choline	2 (100)
Increase of lipids	2 (100)
Diffusion-weighted (No. of patients) (%)^{^d}
Restricted diffusion	9 (47.3)
Target sign	1 (5.2)

Note:—rCBV indicates relative CBV.
↵a Five patients did not have MR imaging scans and were eliminated from the calculations.
↵b The patient with the meningeal form was eliminated from the calculations.
↵c Only 3 patients underwent perfusion, and only 2 underwent spectroscopy.
↵d Five patients did not have diffusion and were eliminated from the calculations.