A 35-year-old heterosexual man had reduced dexterity in his right hand and difficulty writing; examination revealed right hand incoordination and reduced dexterity. Eight years ago he had had disseminated histoplasmosis, without central nervous system (CNS) involvement, that was successfully treated with 8 months of itraconazole. Brain magnetic resonance imaging revealed right cerebellar and frontal lobe rim-enhancing lesions with central lucency (Figure 1A). The cerebellar lesion was surgically resected. Pathologic examination revealed granulomas and yeast forms (Figures 2A and 2B) and a fungal culture was positive for Histoplasma capsulatum. The patient was also found to have liver and bone marrow involvement consistent with disseminated histoplasmosis. His Histoplasma urine antigen level was 6.15 U (normal, < 1.0 U). He had mild neutropenia; the absolute granulocyte count was 1.53 K/μL (reference range, 1.6-9.8 K/μL). He had a low CD4 cell count of 242 cells/μL (reference range, > 550 cells/μL), but his human immunodeficiency virus antibody test results were negative. The immunoglobulin M (IgM) level was elevated at 377 mg/dL (reference range, 50-200 mg/dL), with a reduced IgG level of 544 mg/dL (reference range, 750-1400 mg/dL) and an IgA level of 74 mg/dL (reference range, 75-310 mg/dL). Genetic testing for X-linked hyper-IgM syndrome was negative. He began treatment with itraconazole, but developed fever and hepatitis. Voriconazole treatment was started at 400 mg/d with clinical and radiological improvement (Figure 1B). Voriconazole trough levels in the serum and cerebrospinal fluid were within therapeutic range.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Purchase Online Access to this article for 24 hours
A and B, T1-weighted post-gadolinium images before treatment, revealing abscess in right frontal lobe and cerebellum. C and D, T1-weighted post-gadolinium images 14 months after surgical resection of cerebellar lesion and treatment with oral voriconazole.
A, Low-power view of hematoxylin-eosin stain of cerebellar tissue, demonstrating central necrosis (arrow) and surrounding granulomatous changes. B, Higher-power view of hematoxylin-eosin stain, demonstrating small intracellular yeast forms within a macrophage (arrow), with surrounding granulomatous infiltrate. C, Yeast cells of Histoplasma capsulatum (arrow) stained with methenamine silver.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Thank you for submitting a comment on this article. It will be reviewed by JAMA Neurology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 5
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
and access these and other features:
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.