Diagnostic dilemma in primary Blastomyces dermatitidis meningitis

Role of neurosurgical biopsy

Desmond A. Brown, Mark A. Whealy, Jamie Van Gompel, Lindsy N. Williams, James P. Klaas

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)63-70
Number of pages8
JournalCase Reports in Neurology
Volume7
Issue number1
DOIs
StatePublished - May 22 2015

Fingerprint

Blastomyces
Meningitis
Biopsy
Fungal Meningitis
Hyperacusis
Blastomycosis
Polymyalgia Rheumatica
Diplopia
Aphasia
Prednisone
Gait
Skull
Nausea
Headache
Inflammation

Keywords

  • Central nervous system blastomycosis
  • Fungal meningitis
  • Leptomeningeal enhancement
  • Neurosurgical biopsy

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Diagnostic dilemma in primary Blastomyces dermatitidis meningitis : Role of neurosurgical biopsy. / Brown, Desmond A.; Whealy, Mark A.; Van Gompel, Jamie; Williams, Lindsy N.; Klaas, James P.

In: Case Reports in Neurology, Vol. 7, No. 1, 22.05.2015, p. 63-70.

Research output: Contribution to journalArticle

Brown, Desmond A. ; Whealy, Mark A. ; Van Gompel, Jamie ; Williams, Lindsy N. ; Klaas, James P. / Diagnostic dilemma in primary Blastomyces dermatitidis meningitis : Role of neurosurgical biopsy. In: Case Reports in Neurology. 2015 ; Vol. 7, No. 1. pp. 63-70.
@article{dcf85174894242c7bd589c5e183a6b6f,
title = "Diagnostic dilemma in primary Blastomyces dermatitidis meningitis: Role of neurosurgical biopsy",
abstract = "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.",
keywords = "Central nervous system blastomycosis, Fungal meningitis, Leptomeningeal enhancement, Neurosurgical biopsy",
author = "Brown, {Desmond A.} and Whealy, {Mark A.} and {Van Gompel}, Jamie and Williams, {Lindsy N.} and Klaas, {James P.}",
year = "2015",
month = "5",
day = "22",
doi = "10.1159/000381469",
language = "English (US)",
volume = "7",
pages = "63--70",
journal = "Case Reports in Neurology",
issn = "1662-680X",
publisher = "S. Karger AG",
number = "1",

}

TY - JOUR

T1 - Diagnostic dilemma in primary Blastomyces dermatitidis meningitis

T2 - Role of neurosurgical biopsy

AU - Brown, Desmond A.

AU - Whealy, Mark A.

AU - Van Gompel, Jamie

AU - Williams, Lindsy N.

AU - Klaas, James P.

PY - 2015/5/22

Y1 - 2015/5/22

N2 - 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.

AB - 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.

KW - Central nervous system blastomycosis

KW - Fungal meningitis

KW - Leptomeningeal enhancement

KW - Neurosurgical biopsy

UR - http://www.scopus.com/inward/record.url?scp=84929578417&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84929578417&partnerID=8YFLogxK

U2 - 10.1159/000381469

DO - 10.1159/000381469

M3 - Article

VL - 7

SP - 63

EP - 70

JO - Case Reports in Neurology

JF - Case Reports in Neurology

SN - 1662-680X

IS - 1

ER -