title: Neuroendoscopic diagnosis of central nervous system histoplasmosis with basilar arachnoiditis.
abstract: OBJECTIVE
  Histoplasmosis of the central nervous system (CNS) is seen in 10% to 20% of patients with disseminated histoplasmosis and/or in association with immunocompromised patients. Meningitis, arachnoiditis, and hydrocephalus are the most common clinical manifestations of CNS histoplasmosis. Patients with CNS histoplasmosis present similarly to other infectious etiologies, and confirmatory diagnosis is important in the management of these patients. However, diagnosis of CNS histoplasmosis can be difficult, and sometimes performing a parenchymal biopsy is necessary to confirm the diagnosis.
  
  
  RESULTS
  We describe the case of a 41-year-old man with HIV/AIDS who presented with the signs, symptoms, and radiologic evidence of basal meningitis and hydrocephalus. Cerebrospinal fluid (CSF) analysis from multiple lumbar punctures was negative. The patient underwent a neuroendoscopic procedure with diagnostic and therapeutic goals. Internal CSF diversion (endoscopic third ventriculostomy) and biopsy of the floor of the third ventricle and subarachnoid space were performed; surgical biopsies identified noncaseating granulomas, and ventricular CSF was positive for Histoplasmosis antibodies. The patient was treated with liposomal amphotericin B and itraconazole. The patient had resolution of his symptoms immediately after surgery, and 1-month follow-up computed tomography of the head demonstrated resolution of the hydrocephalus. At the last follow-up 12 months postoperatively, the patient has not required insertion of a ventriculoperitoneal shunt.
  
  
  CONCLUSIONS
  Clinicians should maintain a high index of suspicion for fungal basal meningitis in patients with AIDS and hydrocephalus. With nondiagnostic lumbar CSF sampling, neuroendoscopy can be considered as an alternative for diagnosis and treatment of basal meningitis and hydrocephalus.
authors: Department of Neurosurgery, The Methodist Neurological Institute, Houston, Texas, USA. LRCastilla@tmhs.org
authors: Leonardo
authors: L
authors: Rangel-Castilla
authors: Steven W
authors: SW
authors: Hwang
authors: A Clinton
authors: AC
authors: White
authors: Yi Jonathan
authors: YJ
authors: Zhang
mesh_terms: D000328:Adult; D000666:Amphotericin B / Q000627:therapeutic use; D000908:Antibodies, Fungal / Q000134:cerebrospinal fluid; D000935:Antifungal Agents / Q000627:therapeutic use; D001100:Arachnoiditis / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D001706:Biopsy; D020314:Central Nervous System Fungal Infections / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D002552:Cerebral Ventricles / Q000382:microbiology / Q000473:pathology; D015658:HIV Infections / Q000150:complications; D006660:Histoplasmosis / Q000134:cerebrospinal fluid / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D006849:Hydrocephalus / Q000150:complications; D017964:Itraconazole / Q000627:therapeutic use; D008297:Male; D044583:Neuroendoscopy / Q000379:methods*; D009460:Neurologic Examination; D019635:Neurosurgical Procedures; D010291:Paresis / Q000209:etiology; D013129:Spinal Puncture; D013346:Subarachnoid Space / Q000473:pathology; D014057:Tomography, X-Ray Computed; D014696:Ventriculostomy
chemical_list: D000908:Antibodies, Fungal; D000935:Antifungal Agents; D017964:Itraconazole; D000666:Amphotericin B