Brown Desmond A, Whealy Mark A, Van Gompel Jamie J, Williams Lindsy N, Klaas James P
Department of Neurosurgery, Mayo Clinic, Rochester, Minn., USA.
Department of Neurology, Mayo Clinic, Rochester, Minn., USA.
Case Rep Neurol. 2015 Mar 27;7(1):63-70. doi: 10.1159/000381469. eCollection 2015 Jan-Apr.
A 52-year-old male on chronic prednisone for polymyalgia rheumatica presented with a subacute history of headaches, nausea, phonophobia, intermittent diplopia and gait instability. He was hospitalized 2 weeks prior to presentation with extensive evaluations only notable for leptomeningeal inflammation on MRI. His symptoms progressively worsened and he developed aphasia. He was transferred to our facility where extensive spinal fluid examinations were repeated and were again nondiagnostic. Ultimately, a diagnostic skull-based biopsy was performed which demonstrated Blastomyces dermatitidis fungal meningitis. Despite extensive sampling and cultures, only 1 of the intraoperative samples yielded diagnostic results. This underscores the low sensitivity of current methods to diagnose CNS blastomycosis. This case suggests that a neurosurgical biopsy may be necessary and should be considered early in the diagnostic process, especially if a definitive diagnosis is elusive. If a biopsy is performed, sampling should be ample and from multiple areas. Following the diagnosis, our patient was treated with liposomal amphotericin B and then voriconazole with a good clinical response.
一名52岁男性因风湿性多肌痛长期服用泼尼松，出现头痛、恶心、畏声、间歇性复视和步态不稳的亚急性病史。他在就诊前2周住院，进行了全面评估，MRI仅显示软脑膜炎性改变。其症状逐渐加重，出现失语。他被转至我院，再次进行了全面的脑脊液检查，但仍未确诊。最终，进行了基于颅骨的诊断性活检，结果显示为皮炎芽生菌性真菌性脑膜炎。尽管进行了广泛的取样和培养，但术中样本只有1份得出诊断结果。这凸显了当前诊断中枢神经系统芽生菌病方法的低敏感性。该病例提示，神经外科活检可能是必要的，应在诊断过程早期予以考虑，尤其是在难以明确诊断时。如果进行活检，取样应充分且来自多个部位。确诊后，我们的患者接受了脂质体两性霉素B治疗，随后使用伏立康唑，临床反应良好。
