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.
Srinivasan J, Ooi WW. Successful Treatment of Histoplasmosis Brain Abscess With Voriconazole. Arch Neurol. 2008;65(5):666-667. doi:10.1001/archneur.65.5.666