Disseminated Coccidioidomycosis Complicated by Vasculitis: A Cause of Fatal Subarachnoid Hemorrhage in Two Cases
William K. Erly
,a,
Enrique Labadiea,
Paul L. Williamsa,
Darlene M. Leea,
Raymond F. Carmodya and
Joachim F. Seegera
a From the Departments of Radiology (W.K.E., R.F.C., J.F.S.) and Pathology (D.M.L.), The University of Arizona, Tucson, AZ; the Veterans Affairs Medical Center (E.L.), Tucson, AZ; and the Visalia Medical Clinic (P.L.W.), Visalia, CA.
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FIG 1. ;t1Case 1.
A, CT scan, obtained on the first day of final hospital admission, shows a large left lentiform nucleus and left sylvian fissure hematomas.
B, Left common carotid injection with long area of vasospasm in the left middle cerebral artery with focal aneurysm (arrow).
C, Pathologic specimen from left middle cerebral artery with local inflammation within the vessel wall (arrows).
D, Higher magnification shows the coccidioidal spherule (arrow) more readily.
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FIG 2. ;t1Case 2.
A, Nineteen months after presentation, axial contrast-enhanced T1-weighted MR image shows abnormal enhancement within the prepontine cistern, to the left of the basilar artery (arrow).
B, Two weeks before death, a follow-up examination shows enlargement and change in morphology of the prepontine granuloma (arrow) despite improving CSF parameters. Enhancement is present along the left middle cerebral artery (open arrows).
C, Photomicrograph of basilar artery cross section shows fungal stain of the same lesion shown in B, with innumerable hyphae invading the basilar artery. The lumen (L) and intimal surface (arrows) are shown.
D, Photomicrograph of basilar artery cross section shows the same section at higher magnification, depicting the hyphae (arrows) more clearly.
E, Photomicrograph of basilar artery cross section shows the basilar artery slightly more proximal than shown in C. Elastin stain shows medial necrosis and interruption of the internal elastic laminae. The remaining intact lamina (arrows) can be seen. The luminal surface (L) is at the top of the image.
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