216 An Introduction to Medical Mycology 



gation is usually of no help until the spinal fluid is examined. This is usually 

 under increased pressure and contains an increased number of cells, 

 mainly lymphocytes. An increase in the amount of albumin and of globulin 

 and a meningitic colloidal gold curve are sometimes observed; the chlorides 

 may be diminished. There is a progressive loss of weight; after several 

 weeks, months or even years the patient becomes comatose and dies of 

 respiratory failure. 



Cutaneous lesions, alone or associated with the lesions in the central 

 nervous system, are noted in approximately 5 per cent of patients. These 

 consist of localized abscesses and tumefactions; later, ulcers may form. 

 Enlargement of lymph nodes is present in about 15 per cent of infections 

 and Hodgkin's disease has been confused in at least one case (Wile). 



According to Weidman, the usual cutaneous lesion is a granuloma, which 

 develops so rapidly that abscess formation is simulated. There is usually no 

 surrounding erythema or pain. The lesion may regress spontaneously in 

 four to eight weeks. In all instances the cutaneous variety later assumes 

 the cerebrospinal form. Wile noted subcutaneous and deep-seated nodules 

 resembling ecchymoses, ranging from a small plaque to involvement the 

 size of a hand and having no tendency to ulceration. 



Generalization with particular involvement of the lungs is a rare possi- 

 bility. In the case reported by Fitchett and Weidman, there was wide- 

 spread visceral involvement and Hodgkin's disease was also present. It is 

 uncommon for the disease to affect the mucous membranes, the bones or 

 the joints. 



(c) Differential diagnosis.— Tumors of the brain, tuberculous menin- 

 gitis, syphilis and other disorders affecting the central nervous system 

 may be ruled out by the symptoms, by the physical findings and by cul- 

 turing spinal fluid on dextrose agar. The last-mentioned procedure may 

 be the only possible means of definitely deciding the diagnosis. Torulosis 

 should be considered whenever symptoms are referable to the central 

 nervous system. The diagnosis is rarely made before death. 



(d) Pathology.— Various sites of the central nervous system may be 

 involved, and the findings are various. Cysts and gelatinous tumors are 

 common. The inflammatory reaction is usually slight, but endothelial hyper- 

 plasia is marked, and giant cells are usually noted. Caseation is sometimes 

 seen, and in the case of Cudmore and Lisa there was a cicatrix in the 

 brain. The organism may usually be seen in large numbers. 



In cutaneous torulosis a granulomatous process is present, with enor- 

 mous numbers of giant cells of the foreign body type, very little inflam- 

 matory reaction and a peculiar form of caseation which may lead to 

 ulceration. 



