Indications for the surgical management of central nervous system blastomycosis

Blastomycotic infections of the central nervous system (CNS) occur infrequently. The medical literature concerning blastomycosis of the CNS contains little information regarding indications for surgery.

We report five cases of CNS blastomycosis that required surgery: four intracranial and one intraspinal. One patient had a prior diagnosis of sarcoidosis, whereas none of the others had been diagnosed with any other systemic illness. The patients were evaluated with plain x rays as well as with computed tomography or magnetic resonance imaging.

Four of these patients had extradural abscesses that required surgical drainage as well as debridement of granulomatous tissue and infected bone. The remaining patient had an intracerebellar abscess. Postoperatively, three patients were treated with amphotericin B, one with amphotericin B and ketoconazole, and one with an experimental protocol of fluconazole alone. All of the patients recovered without sequelae of seizures, recurrence of disease, or reaction to pharmacotherapy, although one patient had transient renal insufficiency due to amphotericin B.

Our experience with CNS blastomycosis managed surgically is reported. We propose three general surgical indications for these patients: mass lesions, diagnostic biopsy, and osteomyelitis refractory to pharmacotherapy.