An immunocompetent 45-year-old female presented with a 2-week history of progressive lower back pain, paresthesias, and paraparesis. Within a few days, the patient progressed from 3/5 to 1/5 lower extremity weakness; her neurological findings also included diffuse hyperreflexia, bilateral Babinski signs, and urinary retention. The magnetic ressonance imaging (MRI) of the spine demonstrated an intramedullary expansive lesion at the T8-T9 level that markedly enhanced with contrast [Figures 1 and 2]. Moreover, an MRI of the brain revealed no intraparenchymal lesions, and the computed tomography of the chest/abdomen failed to reveal any other focus of histoplasmosis (i.e., specifically no pulmonary involvement). A lumbar puncture for cerebrospinal fluid (CSF) analysis revealed; 94 cells; 84% neutrophils; 1% glucose; proteins 1779; and lactic acid 13.4 mmol/L. The serology was negative for: toxoplasmosis immunoglobulin M (IgM), human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), venereal disease research laboratory (VDRL), and the patient denied a history of tuberculosis. Notably, the patient had a longstanding history of requiring a ventriculoperitoneal shunt (with multiple revisions), and later, a ventriculoatrial shunt, despite an undiagnosed or apparent cause.
Utilizing neuronavigation, an operative microscope, and intraoperative monitoring, the patient underwent a T8-10 laminectomy. As soon as the dura and arachnoid were opened, an expansile intramedullary cord lesion was visualized, and xanthochromic/purulent fluid immediately drained under increased pressure. A well-demarcated cleavage plane between the lesion and cord facilitated gross-total lesion resection. The pathological analysis was diagnostic for histoplasmosis [Figure 3]. Postoperatively, the patient's paraparesis markedly improved, with full recovery of the motor/sensory deficits, and sphincter function.