Treatment of Paracoccidioidomycosis with Central Nervous System Parenchymal Involvement

This protocol addresses the management of paracoccidioidomycosis in patients with confirmed parenchymal involvement of the central nervous system, as detected by CT-scan or MRI.

Clinical scenario

CNS parenchymal involvement represents a serious manifestation of paracoccidioidomycosis. Imaging-confirmed parenchymal lesions are found in 12.5% of patients evaluated by CT-scan across any phase of disease and in 38% of patients with active systemic disease evaluated by MRI. This subset requires a specific therapeutic approach distinct from non-CNS presentations.

Treatment approach

Agent selection in this setting centres on drugs with demonstrated penetration into the cerebrospinal fluid and brain parenchyma; not all standard antifungals meet this requirement and at least one commonly used agent in other paracoccidioidomycosis presentations is specifically excluded here. The complete regimen — including agent combinations, sequencing, and duration — is available in the full structured protocol.

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References

DOI: 10.1590/S0036-46652015000700007

Parenchymal involvement occurs in 12.5% of patients evaluated by CT-scan in any phase of disease and in 38% of patients with active systemic disease evaluated by MRI.
The selection of the treatment should include drugs that reach higher concentrations in cerebrospinal fluid and parenchyma, such as sulfadiazine, SMX-TMT, AmB and voriconazole.
Although itraconazole has been used in the treatment of other CNS mycosis because of its good penetration in the parenchyma, it is not recommended for neuro-PCM.
Despite its lower efficacy in this mycosis, fluconazole has been successfully used as it presents a good CNS penetration.

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