US CASE-REPORT OF CEREBRAL PHEOHYPHOMYCOSIS CAUSED BY RAMICHLORIDIUM-OBOVOIDEUM (R-MACKENZIEI) - CRITERIA FOR IDENTIFICATION, THERAPY, AND REVIEW OF OTHER KNOWN DEMATIACEOUS NEUROTROPIC TAXA

We report a case of cerebral phaeohyphomycosis in a 36-year-old male c aused by the neurotropic fungus Ramichloridium obovoideum (Matushima) de Hoog 1977 (Ramichloridium mackenziei Campbell et Al-Hedaithy 1993). This man resided in the Middle East, where the fungus appears to be e ndemic and, possibly, geographically restricted, since all previous re ports of brain abscesses due to this organism have been for patients i ndigenous to this area. As a servant of the Saudi Arabian royal family , he appeared in the United States seeking treatment for chronic weigh t loss, fatigue, decreased memory, and a more recent 2-week history of right-hand weakness which worsened to involve the entire right upper extremity. On the day prior to his admission, he had a focal motor sei zure with rotation of the head and eyes to the right, followed by seco ndary generalization. A computerized tomogram showed a ring-enhancing hypodense lesion in the left parietal subcortical region with associat ed edema and mass effect. Diagnosis of a fungal etiology was made foll owing a parietal craniotomy and excisional biopsy by observation of se ptate, dematiaceous hyphal elements 2 to 3 mu m in width on hematoxyli n-and-eosin-stained sections from,within areas of inflammation and nec rosis. Culture of the excised material grew out a dematiaceous mould w hich was subsequently identified as R. obovoideum. At two months posts urgery and with a regimen of 200 mg of itraconazole twice a day, the p atient was doing well and returned to Saudi Arabia. His condition subs equently deteriorated, however, and following a 7-month course of itra conzole, he expired. We use this case to alert clinicians and personne l in clinical mycology laboratories of the pathogenicity of this organ ism and its potential occurrence in patients with central nervous syst em signs and symptoms who have resided in the Middle East and to revie w and/or compare R. obovoideum with other neurotropic, dematiaceous ta xa and similar nonneurotropic, dematiaceous species.