1. Leandro Tavares Lucato 1,2 ltlucato@uol.com.br Infectious diseases The importance of local singularities in an increasingly interconnected world Latin America experience 1 Clinics Hospital, Faculty of Medical Sciences, University of Sao Paulo 2 Fleury Centro de Medicina Diagnóstica SAO PAULO, BRAZIL

2. Background Interconnected worldInterconnected world –2.1 billion airline passengers (2006) ScenarioScenario –Dissemination of endemic diseases –Away from their common locations World Health Organization. The world health report 2007

3. Paracoccidioidomycosis Paracoccidioides brasiliensis 1 st systemic fungal infection in Brazil1 st systemic fungal infection in Brazil 15♂ : 1♀15♂ : 1♀ Chronic pneumopathy ±Chronic pneumopathy ± –Mucosal and skin lesions –Disseminated lesions CNS involvement: 8-10%CNS involvement: 8-10% Martinez R. Rev Soc Bras Med Tropical. 2010; 43:480

4. Paracoccidioidomycosis Paracoccidioides brasiliensis PresentationPresentation –Granulomatous (pseudotumoral) 90% cases90% cases –Meningeal disease (leptomeningeal) Tobón A. Rev Inst Med Tropical S Paulo. 2004;42:231-234

5. Paracoccidioidomycosis Male, 69 y, LOC Noncontrast CT Axial T2 Axial T1-Gd

6. Paracoccidioidomycosis Male, 69 y, LOC Stereotactic Bx – H&E Stereotactic Bx – Grocott

7. Paracoccidioidomycosis Male, 66 y, right hemiparesis Axial FLAIR Coronal T2 Axial T1-Gd

8. Paracoccidioidomycosis Male, 66 y, right hemiparesis Multivoxel MRS Lip map – MRS

9. Paracoccidioidomycosis Male, 66 y, right hemiparesis Axial DWI rCBV map

10. Hotez PJ et al. PLoS Negl Trop Dis. 2008;2:e300

11. Cysticercosis - Taenia solium (pork tapeworm) http://www.dpd.cdc.gov/dpdx

12. Cysticercosis Taenia solium (pork tapeworm) Clinical manifestations nonspecificClinical manifestations nonspecific Serologic tests: variable sensitivity/specificitySerologic tests: variable sensitivity/specificity MR / CTMR / CT –Parenchymal (60%) / Subarachnoid / Ventricular –4 stages (parenchymal) Vesicular → cyst w/ scolex, no inflammatory responseVesicular → cyst w/ scolex, no inflammatory response Colloid vesicular → cyst + inflammatory responseColloid vesicular → cyst + inflammatory response Granular nodular → inflammatory resp + calcificationGranular nodular → inflammatory resp + calcification Nodular calcified → calcificationNodular calcified → calcification –Scolex → absolute dx criterion Del Brutto OH et al. Neurology. 2001;57:177-183

13. Axial T1 Axial T2 Axial FLAIR Axial T1+Gd Lucato LT et al. AJNR 2007;28:1501-1504 Cysticercosis Scolex characterization

14. Axial T1+Gd Axial FLAIR Axial DWI Lucato LT et al. 34 th ESNR meeting. Athens, Greece. Sept 17-20,2009

15. Cysticercosis Granular nodular stage – viscous content Axial FLAIR Axial T2* Lucato LT et al. 34 th ESNR meeting. Athens, Greece. Sept 17-20,2009

16. Cysticercosis Granular nodular stage – viscous content Axial T1+Gd Axial DWI Lucato LT et al. 34 th ESNR meeting. Athens, Greece. Sept 17-20,2009

17. Chagas disease / American trypanosomiasis Trypanosoma cruzi http://www.dpd.cdc.gov/dpdx

18. Chagas disease Trypanosoma cruzi Reactivation of chronic diseaseReactivation of chronic disease –Immunosuppressed patients –AIDS-defining disease PresentationPresentation –Pseudotumoral –Acute diffuse meningoencephalitis Poor prognosisPoor prognosis MR/CT: no distinctive findingsMR/CT: no distinctive findings CSF → diagnosticCSF → diagnostic Lury KM, Castillo M. AJR. 2005; 185:550-552

19. Chagas disease T. cruzi trypomastigote forms – CSF

20. Chagas disease Male, 46 y, heart tx, left hemiparesis Contrast CT Coronal T1-Gd Axial FLAIR

21. Chagas disease Female, 33 y, HIV +, LOC Contrast CT Axial FLAIR – initial Axial FLAIR – 2 weeks Axial T1-Gd – 2 weeks Axial DWI – 2 weeks

22. Schistosomiasis Schistosoma mansoni http://www.dpd.cdc.gov/dpdx

23. Schistosomiasis Schistosoma mansoni Brain or spinal involvementBrain or spinal involvement TheoriesTheories –Ova transportation (retrograde venous flow) –Anomalous migration of adult worms MR / CTMR / CT –Variable –Linear and nodular enhancement pattern “Arborized” appearance“Arborized” appearance Sanelli PC et al. AJR 2001;177:1471–1474

24. Schistosomiasis Male, 26 y, headache, late-onset seizures Axial T1-Gd Axial T2 Sagittal T1-Gd

25. Schistosomiasis Male, 35 y, headache, generalized seizures Axial T1-Gd Axial T2 Sagittal T1-Gd

26. Schistosomiasis Male, 35 y, headache, generalized seizures Brain bx – H&E

27. Thank you! ltlucato@uol.com.br