Disseminated neurosporotrichosis and neurotuberculosis in advanced AIDS: infectious overlap and therapeutic challenge

Abstract

Case Presentation: A 38-year-old man working at a beach kiosk, with a history of illicit drug abuse, presented with a 3-month history of holocranial headache, vomiting, fever, confusion, and weight loss. Examination revealed disseminated umbilicated, crusted erythematous papules on the face and chest. He progressed to a decreased level of consciousness, requiring intubation and mechanical ventilation. Initially treated for meningoencephalitis with ceftriaxone and acyclovir, a cranial CT showed no acute abnormalities. Workup revealed HIV (CD4: 24 cells/mm³; viral load: 109,000 copies/mL) and serum VDRL 1:8. Cerebrospinal fluid (CSF) showed lymphomonocytic pleocytosis, elevated protein, and marked hypoglycorrhachia. Mycobacterium tuberculosis was detected via TRM-TB in CSF and bone marrow aspirate. Management included the RHZE regimen, antiretrovirals, and empiric treatment for neurosyphilis and neurotoxoplasmosis. Later, Sporothrix sp. was isolated from CSF, skin, and bone marrow cultures, confirming disseminated neurosporotrichosis. Liposomal amphotericin B (5 mg/kg/day) was initiated. Despite treatment, he developed refractory seizures and worsening CSF parameters, prompting the addition of voriconazole. His course was aggravated by upper gastrointestinal bleeding (Forrest IIA), hemodynamic instability, and pancytopenia. Given his profound immunosuppression and poor prognosis, palliative care was adopted alongside ongoing antimicrobials. The patient ultimately died. Discussion: Neurosporotrichosis is a rare opportunistic fungal infection with increasing incidence in AIDS patients with profound immunosuppression (CD4 < 50 cells/mm³), frequently mimicking other granulomatous meningitides. Diffusion restriction in the bilateral thalami suggested small perforating vessel vasculitis, a complication where fungal angioinvasion or adjacent inflammation causes acute vascular occlusion. The exceptional coexistence of neurosporotrichosis and neurotuberculosis imposes major diagnostic and therapeutic challenges, including drug interactions and hematological toxicity. Furthermore, positive CSF culture for Sporothrix spp. is uncommon, making this finding clinically and microbiologically relevant. Literature demonstrates that even with liposomal amphotericin B, outcomes are frequently lethal or involve severe neurological sequelae, reinforcing the critical need for early clinical suspicion and timely intervention. Final Comments: This report highlights the severity and diagnostic challenges of disseminated neurosporotrichosis in immunosuppressed patients, alongside the complexities of managing coinfections. The fatal outcome underscores the importance of including sporotrichosis in the differential diagnosis of neuroinfections in immunocompromised individuals, emphasizing the need for early diagnosis and adequate antifungal intervention.