REVIEW ARTICLE

Simon Bolivars Medical Labyrinth: An Infectious Diseases Conundrum

Paul G. Auwaerter,1 John Dove,4 and Philip A. Mackowiak2,3
of Medicine, Johns Hopkins University School of Medicine, 2Medical Care Clinical Center, VA Maryland Health Care System, and of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and 4School of Literatures, Language and Cultures, University of Edinburgh, Edinburgh, United Kingdom
3Department 1Department

According to history books, tuberculosis was responsible for the death of Simon Bolivar at the age of 47 ` re Re ve rend, the French physician years in 1830. The results of an autopsy performed by Alexandre Prospe who cared for him during the terminal phase of his illness, have long been regarded as proof of the diagnosis. On careful reanalysis of Bolivars medical history and post mortem examination, we reach a different conclusion. On the basis of several critical clinical, epidemiological, and pathological features of his fatal disorder, we conclude that either paracoccidioidomycosis or bacterial bronchiectasis complicating chronic arsenic intoxication was more likely responsible for his death than was tuberculous consumption.

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

How will I get out of this labyrinth? ve rend, 1830 Simon Bolivar on his death bed to Dr. Re (1). Simon Bolivar (Figure 1), the Liberator, died in 1830 after a protracted illness. According to history books, he died of tuberculosis (2). However, in 2008, the controversial president of the Bolivarian Re vez, deed convenpublic of Venezuela, Hugo Cha tional wisdom in announcing that General Bolivar, his spiritual father, did not die of disease but was assassinated by treacherous conspirators (3). Were it vez and his verbal attacks on the United not for Cha States, few North Americans would take note of the controversy, knowing almost nothing of Bolivars life

Received 7 July 2010; accepted 10 September 2010 Presented in part: Historical Clinicopathological Conferences sponsored by the Veterans Affairs Maryland Health Care System and the University of Maryland School of Medicine. Correspondence: Dr Philip A. Mackowiak, Medical Service-111, VA Medical Center, 10 N Greene Street, Baltimore, MD (philip.mackowiak@med.va.gov). Clinical Infectious Diseases 2011;52(1):7885 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. 1058-4838/2011/521-0001$37.00 DOI: 10.1093/cid/ciq071

or legacy and much less of the mysterious illness that caused his death at age 47 years. Moreover, many persons in South America would argue that the uncertainty regarding the etiology of General Bolivars fatal illness is contrived, because of the compelling evidence of tuberculous consumption found during post mortem examination by Dr. ` re Re ve rend (Figure 2), the French Alexandre Prospe physician who cared for the general during his nal fortnight (1). What were the character and the anatomy of Bolivars terminal illness? Was the illness diagnosed correctly? If not, what was the correct diagnosis? Before Bolivars emergence as revolutionary leader, apart from Brazil and the 3 Guyanas, the continent of South America had been ruled by Spain for nearly 300 San years (4). By 1825, Bolivar (with the help of Jose Martin, the national hero of Argentina) had wrested from Spanish domination a new world empire that was 5 times more vast than all of Europe (5). His conquests, which began in 1811, involved 100 battles and covered 80,000 miles of forced marches (6). In 1819, he liberated New Granada as victor in the battle ; in 1821, Venezuela (battle of Carabobo); of Boyaca in 1822, Ecuador (battle of Pinchincha); in 1824, n and Ayacucho); and in 1825, Peru (battles of Jun

78

CID 2011:52 (1 January)

Auwaerter et al.

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

var, Libertador de Colombia, by Jose n Boli Gil de Castro, Lima 1827. The John Carter Brown Library at Brown University. Figure 1. Simo

Bolivia (as victor in the battle of Tumusla, his last battle), freeing the bulk of Spains American empire (4; p. 54201). Shortly after these campaigns ended, the generals health declined, and his former commanders began to desert him in earnest. sima Trinidad Bol var y Pal n Jose Antonio de la Sant Simo acios was born in Caracas on 24 July 1783. His parents were Spanish-Americans of Basque descent (4). Both reputedly died of tuberculosis (4); his father died at age 56 years, when Bolivar was 2 years old, and his mother died at age 33 years, when he was

9 years of age. However, Bolivars father was a notorious womanizer (4), and some have speculated that he died of paralytic syphilis and that congenital syphilis was responsible for the death of a daughter (Bolivars sister) shortly after birth (7). Bolivar had 3 siblings: an older brother and 2 older sisters. None is known to have developed either syphilis or tuberculosis. His sisters died of unknown cause at ages 65 and 68 years (7), and his brother was lost at sea at age 30 years (4). Bolivar married at age 18 years, and his young bride died of malignant fever 8 months later (4). He never remarried
Bolivars Medical Labyrinth
d

CID 2011:52 (1 January)

79

 ve rend in 1874 (from Schael Martinez G. El Figure 2. Alexandre Re var. Edicion del Concejo Municipal del dico de Simo n Boli ltimo Me Distrito Federal, Caracas: 1985, p. 39).

but had numerous subsequent affairs with mistresses and prostitutes, none of which is known to have produced an offspring (4). During his prime, Bolivar was slightly below medium height (5#6), slim, and graceful. He ate frugally, avoided alcohol and tobacco (4), and enjoyed excellent health throughout most of his life, in spite of the privations and stresses of commanding an army at war for 20 years in some of South Americas most inhospitable terrain. Whereas his complexion had been very white as a youth, by age 44 years, it had become dark and rough. He required reading glasses by his late 30s (4). An unsubstantiated report states that, His genital organs [were] small, the testes hard and the cords short [8]. Before his nal illness, Bolivar had several other notable episodes of illness. When he was aged 29 years, campaigning in the Magdalena River basin (in north-central Colombia), he had a febrile illness and furunculosis of unknown etiology from which he recovered (9). During the ensuing decade, he had repeated episodes of fever; during some of these episodes, he at rst looked ushed and then pale and shivering with cold.and then lost consciousness (10). These episodes were
80
d

treated, in some instances, with quinine and, in others, with arsenic. On one occasion, the latter treatment is reported to have induced a severe attack of dysentery (11). Although Bolivar also experienced recurrent colic, rheumatism, and chronic hemorrhoids (4), he was reasonably t until age 40 years, when he developed a high fever and collapsed, possibly as a result of heat stroke (4). For 7 days, Bolivar was near death in a small village north of Lima, and for 2 months, he was so weak and emaciated that he was hardly recognizable. Nevertheless, within 4 months, he had recovered sufciently to lead his army to Pasco (in central Peru; elevation, 4262 meters) over some of the most mountainous land in the world, in what was described later as a mightier feat than Hannibals passage of the Alps (12). Exactly when the generals nal illness began is uncertain. Although some believe that the rst symptoms of the pulmonary disorder of which he died began at age 35 years (9), others claim that, besides the aforementioned episodes of illness, he was physically t until age 45 years, when his health began decline (4). According to the patients letters, of which a great many have been preserved (13), shortly before he turned 46 years of age, Bolivar was tormented by persistent headaches and bilious attacks that left him weak and exhausted. Within 6 months, his appearance was cadaveric, and his voice was barely audible (4). Within a year, his associates marveled that, given his extreme wasting, he was still alive (4). ve rend (1), when rst seen just 2 weeks According to Dr. Re before he died, Bolivar was apathetic, emaciated, weak, and so dyspneic that he was unable to walk. His countenance was yellow. He was hoarse and coughed constantly, producing copious green sputum. He also hiccoughed repeatedly. Of interest, his sense of smell was unusually keen. Whether it had always been so or had increased in acuity during his illness is uncertain. Over the ensuing 16 days, Bolivar coughed constantly and was intermittently febrile, with a hot head and cold extremities. His pulse was thready. Initially, he was brighter during the day than at night, but he slept little and gradually drifted into delirium. He also had episodes of indigestion and vomiting, sternal pain, both right and left ank pain, a sore tongue (which was dry, rough, and colored along its edges), and urinary incontinence (1). Throughout this phase of his illness, the general received many drugs, potions, poultices, and maneuvers. These included pectoral elixirs, narcotics, expectorants, quinine, turpentine poultices, blistering plasters (derived from Cantharides beetles), anodyne ointments, gum arabic, antispasmodics, cold compresses, leg rubs, purgatives, enemas, mustard plasters, linseed water, and Gondrets pomade (a concoction of beef marrow and ammonia) (1).

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

CID 2011:52 (1 January)

Auwaerter et al.

Table 1. Diagnostic Considerations and Tests Worth Performing on Bolivar's Remains

Condition Infections Tuberculosis Paracoccidioidomycosis Histoplasmosis Meloidosis Syphilis Bronchiectasis Pathogens Mycobacterium tuberculosis Paracoccidioides brasiliensis Histoplasma capsulatum Burkholderia pseudomallei Treponema pallidum Haemophilus spp. Streptococcus pneumoniae Staphylococcus aureus Klebsiella spp. Pseudomonas aeruginosa Toxins Arsenicosis Cantharidin intoxication Genetic or acquired Hemochromatosis Wilson disease Diabetes mellitus Adrenal insufciency
Abbreviation: PCR, polymerase chain reaction.

Cause

Test PCR amplication and/or electron microscropy Inductively-coupled plasma mass spectrometry Gas chromatography mass spectrometry PCR mutational analysis, tissue iron analysis Tissue copper analysis None None

Arsenic Extract from Lytta vesicatoria genetic iron overload genetic copper overload insulin deciency steroid hormone deciency

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

When he was near death, Bolivars breathing was labored, his visage a facies Hippocraticus, and the small amount of urine that he produced was bloody. When he died in the early ve rend, morning of 17 December 1830, he weighed 27.7 kg. Re who had trained in anatomicopathological examination under Laennec and Dupuytren, performed an autopsy later that day (see Supplementary Appendix for the complete report). He diagnosed tuberculous consumption on the basis of the following ndings (1): [C]onvolutions of the cerebrum[were] covered by a brownish material with the consistency and transparency of gelatin.. both sides of the pleurae were adherent as the result of semi-membranous material; there was hardening of the superior two thirds of each lung. The right, which was almost completely disorganised, looked like a fountain [sic] the colour of wine dregs studded with tubercles of different sizes not very soft. The left lung although less disorganised showed the same tuberculous affection. Dividing this with a scalpel I found an irregular, angular, calcareous concretion about the size of a hazelnut. On opening the rest of the lungs with the instrument, I spilled some brown serous material which as a result of the pressure was rather frothy. The heart did not demonstrate anything particular although it was bathed in a liquid of a light green colour which was

contained within the pericardium.. The liver [was] of a considerable size and was a little excoriated on its convex surface.. The mesenteric glands [were] obstructed. ve rends diagnosis of fatal How well do these facts support Re tuberculosis? On the positive side, the general died of an illness with many of the cardinal features of galloping consumption (fever, productive cough, and cachexia). Even more compelling are the autopsy ndings of tubercles and cavities in the lungs. Nevertheless, if Bolivar had died of far-advanced cavitary tuberculosis, possibly with laryngeal involvement (as indicated by his terminal hoarseness), he would have been extraordinarily ve rend, who lived to the age of contagious. If so, how did Re enz, the 85 years, escape infection (14)? Furthermore, Manuela Sa generals long-time mistress, apparently died at age 60 years of diphtheria, not tuberculosis (15). His nephew Fernando, who was his uncles private secretary and condant throughout his terminal illness, lived to age 88 years (16). Why were episodes of hemoptysis not prominent? If Bolivar was infected by his parents as a child, as many believe, how did his 2 sisters and brother escape a similar fate? Perhaps most important, the chronic cavitary form of pulmonary tuberculosis and the disseminated form rarely coexist. If this is true, as reected in numerous case series of the latter (1719), how does one explain the presence of pulmonary cavities and evidence of simultaneous invasion of the brain, liver, and mesenteric glands on post mortem examination?
Bolivars Medical Labyrinth
d

CID 2011:52 (1 January)

81

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

Figure 3. The National Pantheon in Caracas, Venezuela (Photograph taken by the author, John Dove, July 2010).

If Bolivars fatal illness was not tuberculosis, what was it? Of the myriad possibilities (Table 1), which might be explored in tests performed on specimens recently removed from the generals casket in the national pantheon in Caracas (2022), 2 are of particular interest: arsenicosis and paracoccidioidomycosis. Bolivars headaches, weakness, apathy, gastrointestinal complaints, coarse dark skin, and cachexia are consistent with, although not diagnostic of, arsenicosis (23). Arsenic-based remedies were popular during Bolivars time, after the
82 CID 2011:52 (1 January) Auwaerter et al.

introduction in the 1770s of Fowlers solution, a potassium arsenatecontaining medicinal used to treat malaria, syphilis, and many other less-severe ailments. As noted above, Bolivars recurrent attacks of biliary fever (probably malaria) were treated with an arsenic-based medicine, although the particular one given to him is unknown. He likely received additional arsenic in the food and water that he consumed while campaigning in the Andes, where high levels of the element have been detected in soil and in the tissue samples from pre-Colombian mummies (24, 25).

Bolivars complexion, as noted above, changed from white as a youth to dark and rough 3 years before he died. The transformation might simply have been the result of years of exposure to the harsh elements during his campaigns. However, it is also possible that it was an additional manifestation of arsenicosis, because diffuse melanosis, papules, and keratoses are among the earliest signs of such intoxication (26). Of interest, facial ushing, which Bolivar manifested during episodes of biliary fever, is a reaction to arsenic tonics, which practitioners during Bolivars time regarded as desirable (27). Peripheral neuropathy is another complication of arsenicosis, but Bolivar apparently did not develop this. Arsenic intoxication also might have contributed to the generals pulmonary difculties, the onset of which coincided with and were likely precipitated by an assassination attempt in 1828 (4). Bolivar was in Lima at the time. To escape his attackers, he spent 3 h shivering under a bridge in the murky water of the San Agustin River. Shortly thereafter, his respiratory difculties ared. The clinical and pathological characteristics of his pulmonary disorder are typical of a refractory bacterial pneumonia that degenerated into nontubercular bronchiectasisa process that evolves over months to years and manifests as productive cough, fatigue, dyspnea, and weight loss. Moreover, it is a disorder easily confused with tuberculosis (28, 29). If Bolivars green pericardial uid indicated a purulent pericarditis, it would likely have been caused by bacteria spreading from pre-existing bronchiectasisa dreaded complication of such infections before the advent of antibiotics (30). Chronic arsenic exposure, for reasons not entirely clear, predisposes one to both bronchiectasis and cancer (31, 32). The latter complication might explain Bolivars hoarseness (due to paralysis of the left recurrent laryngeal nerve) and, if metastatic, also his yellow countenance, his enlarged liver, and his obstructed mesenteric glands. His terminal hematuria might have also been precipitated by metastatic cancer. However, more likely, the hematuria resulted from a low-grade coagulopathy caused by the cathardin-based blistering plasters administered by Dr. ve rend (33). Re Paracoccidioidomycosis, although not a perfect t, is in certain respects an even better explanation for the clinical, epidemiological, and pathological facts concerning Bolivars case. In fact, it might account for nearly all the features of his terminal illnessthe fever, the weight loss, the apathy, the hoarseness, the productive cough, the ank pain, the skin changes, the thready pulse, the heightened sense of smell, the hematuria, the absence of secondary cases, and the presence of both cavitary pulmonary disease and disseminated granulomatosis in the same patient (3441).

Paracoccidioidomycosis (also known as South American blastomycosis) is one of the most common deep-seated mycoses of tropical Latin America. Although Brazil has the highest incidence, the infection is endemic throughout much of the region in which Bolivar campaigned. Unlike tuberculosis, with which it is often confused, paracoccidioidomycosis is not transmitted from person to person. Therefore, whereas Bolivar would likely have transmitted his infection to intimate contacts if he had had fulminate tuberculosis, he would not have done so if he had died of paracoccidioidosis. Soil is believed to be the microbes natural habitat; its portal of entry is the lungs. The disease has a long latent period, rarely manifesting clinically before the age of 30 years. Men are affected 15-times more often than are women (41). In advanced cases of paracoccidioidomycosis, unlike those of tuberculosis, progressive cavitary lung lesions regularly coexist with disseminated foci of infection in sites, such as the tongue, liver, mesenteric lymph nodes, and adrenal glands (41). Productive cough is common, hemoptysis less so. Fever and weight loss occur in more than half the cases, hoarseness (due to laryngeal involvement) in a fth, and hepatomegaly in 18%. In the rare instances in which calcied pulmonary nodules have been encountered, they have been attributed to coinfection with either tuberculosis or histoplasmosis (35), which occurs in 15% of cases (41). Myocarditis has also been observed in paracoccidioidomycosis, although infrequently. Invasion of the adrenal glands is common in this disease, occurring in as many as 85% of symptomatic adults (41). Seven percent of cases exhibit evidence of Addisonian crisis, such as profound weakness, cold extremities, and the thready pulse exhibited by Bolivar. In the generals case, destruction of the adrenal glands was indicated further by his dark, coarse skin and, perhaps also, by his heightened sense of smell, a little-known feature of adrenal insufciency (42). Shortly before midnight on 16 July 2010, Venezuelan President Hugo Chavez and a team of soldiers, forensic specialists, and presidential aides entered the National Pantheon in Caracas (Figure 3), unscrewed the lid of the Liberators casket, and removed several fragments of bone and some teeth (2022). These have been sent to a newly inaugurated state forensic laboratory for analysis (20). An attempt will rst be made to verify the remains as those of El Libertador by comparing DNA retrieved from the specimens with that extracted from the bones of Bolivars sisters Juana and Maria Antonia (43). Other tests to be performed have not yet been revealed to the public but presumably will include assays for arsenic, Mycobacterium tuberculosis and Paracoccidioidomyces braziliensis. If and when these analyses have been completed, the challenge will
Bolivars Medical Labyrinth
d

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

CID 2011:52 (1 January)

83

be one of interpreting the results. Almost certainly disputes will arise not just about their meaning but also about their validity. For these reasons, Bolivars second post-mortem examination is not likely to close the book on the etiology of his fatal disorder. In all likelihood, the information contained in the clinical summary provided above and Reverends autopsy report will remain the principal evidence on which the solution to General Bolivars medical conundrum will have to be based.

Supplementary Material Supplementary materials are available at Clinical Infectious Diseases online (http://www.oxfordjournals.org/our_journals/ cid/). Supplementary materials consist of data provided by the author that are published to benet the reader. The posted materials are not copyedited. The contents of all supplementary data are the sole responsibility of the authors. Questions or messages regarding errors should be addressed to the author.
Acknowledgments
We thank Frank M. Calia, MD, for editorial advice; Steven D. Munger, PhD, for calling our attention to the information in [42]; and Adriana Naim and Richard J. Behles, for assisting in the literature review. Financial support. none reported. Potential conicts of interest. All authors: no conicts.

References
ve rend AP. La Ultima Enfermedad, Los Ultimos Momentos y Los 1. Re Funerales de Simon Bolivar. Paris, France: Hispano-Americana de Cosson and Co, 1866; 135. vez version of liberators death. The 2. Carroll R. It was murder: the Cha Guardian, 2008; 32. vez seeks to prove Bolivar was murdered. National Public 3. Forero J. Cha Radio, 2008. 4. Lynch J. Simon Bolivar. A life. New Haven, CT: Yale U. Press, 2006; 1304. 5. Marquez GG. The General in his labyrinth. [translated by E. Grossman]. New York, NY: Vintage Books, 1999; 3274. n Pulido LA. The delirium of the liberator. Bogota , Colombia: 6. Villamar o, 2006; 7. Penclips Publicidad y Desen 7. Carbonell D. Psicopatollogia de Bolivar. Lib. Franco-Espanola. P Rosier, Ed. Paris, France, 1916; 312. var. Lucas Ochoa (Ed.) Bedout, Medell n, n Bol 8. Gonzales F. Mi Simo 1930: 297. var. Ed. La Oveja Negra, Bogota , Colombia: 9. Puyo F. Muy cerco de Bol 1988: 140. 10. Figuero Marroquin H. De que murio Simon Bolivar? Guatemala: Imp. Galindo, 1969: 3. var frente a los medicos y la medicina. Tercer 11. Reales Orozco A. Bol , Columbia: 1988: 69. Mundo, Ed. Bogota 12. Bingham H. On the route of Bolivars great march. Geographical J 1908; 32:32947. var S. Obras completas. 3 vol. Ed. La Habana, Cuba: Lex, 1950. 13. Bol

nez G. El ultimo medico de S mon Bol var. Ed. Caracas, 14. Schael Mart Venezuela: Concejo Municipal, 1983: 348. 15. Murray PS. For Glory and Bolivar: the remarkable life of Manuela enz. Austin, TX: Univ. of Texas Press, 2008: 154. Sa 16. http://www.simon-bolivar.org/Principal/bolivar/biograasfamiliasb .html; Accessed 11 May 2010. 17. Sahn SA, Neff TA. Miliary tuberculosis. Am J Med 1974; 56:495505. 18. Alvarez S, McCabe WR. Extrapulmonary tuberculosis revisited: a review of experience at Boston City and other hospitals. Medicine 1984; 63:2555. 19. Kim JH, Langston AA, Gallis HA. Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis, and outcome. Rev Infect Dis 1990; 12:58390. 20. Rondon P. Venezuela exhumes hero Bolivars bones for tests. (Reuters). http://www.publicbroadcastingnet/wyps/news.newsmain? action=articles&ARTICLE_1051. Accessed 19 July 2010. vars bones. http:// vez dug up Bol 21. Padgett T. Why Venezuelas Cha time.com/time/printout/0,8816,2004526,00.html. Accessed On 20 July 2010. 22. Halvorssen T. Behind exhumation of Simon Bolivar is Hugo Chavezs warped obsession. The Washington Post, 2010. 23. Sengupta SR, Das NK, Datta PK. Pathogenesis, clinical features and pathology of chronic arsenicosis. Indian J Dermatol Venereol Leprol 2008; 74:55970. 24. Zaldivar R. Arsenic contamination of drinking water and foodstuffs causing endemic chronic poisoning. Beitr Pathol 1974; 151:384400. 25. Pringle H. Archaeology. Arsenic old mummies: poison may have spurred rst mummies. Science 2009; 324:1130. 26. Chowdhury UK, Biswas BK, Chowdhury TR, et al. Groundwater arsenic contamination in Bangladesh and West Bengal, India. Environ Health Perspect 2000; 108:3937. 27. Scheindlin S. The duplicitous nature of inorganic arsenic. Mol Interv 2005; 5:604. 28. Blake WC. Should non-tuberculous lung diseases be treated in the tuberculosis sanatorium? Chest 1939; 5:114. 29. Barker AF. Bronchiectasis. N Engl J Med 2002; 346:138393. 30. Parikh SV, Memon N, Echols M, Shah J, McGuire DK, Keeley EC. Purulent pericarditis: report of 2 cases and review of the literature. Medicine (Baltimore) 2009; 88:5265. 31. Guha Mazumder DN. Arsenic and non-malignant lung disease. J Environ Sci Health A Tox Hazard Subst Environ Eng 2007; 42:185967. 32. Mazumder DN, Steinmaus C, Bhattacharya P, et al. Bronchiectasis in persons with skin lesions resulting from arsenic in drinking water. Epidemiology 2005; 16:7605. 33. Karras DJ, Farrell SE, Harrigan RA, Henretig FM, Gealt L. Poisoning from "Spanish y" (catharidin). Am J Emerg Med 1996; 14:47883. 34. Marsiglia I, Pinto. Adrenal cortical insufciency associated with paracoccidioidomycosis (South American blastomycosis). Report of four patients. J Clin Endocr 1966; 26:110915. 35. Salfelder K, Doehnert G, Doehnert H-R. Paracoccidioidomycosis. Anatomic study with complete autopsies. Virchows Arch Abt Path Anat 1969; 348:5176. 36. Restrepo A, Robledo M, Gutierrez M, Sanclemente M, Castaneda E, Calle G. Paracoccidioidomycosis (South American blastomycosis). A study of 39 cases observed in Medillin, Colombia. Am J Trop Med Hyg 1970; 19:6876. 37. Londero AT, Ramos CD. Paracoccidioidomycosis. A clinical mycologic study of forty-one cases observed in Santa Maria, RS Brazil. Am J Med 1972; 52:7715. 38. Restrepo A, Robledo M, Giraldo R, Hernandez H, Sierra F, et al. The gamut of paracoccidioidomycosis. Am J Med 1976; 61:3342. 39. Ferreira MS. Paracoccidioidomycosis. Pediatr Respir Rev 2009; 10:1615.

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

84

CID 2011:52 (1 January)

Auwaerter et al.

40. Pedroso VS, Vilela C, Pedroso ER, Teixeira AL. Paracoccidioidomycosis compromising the central nervous system: a systematic review of the literature. Rev Soc Bras Med Trop 2009; 42:6917. 41. Restrepo A, Tobon AM. Paracoccidioides brasiliensis. Mandell GL, Bennett JE, Dolin R (eds.), Principles and practice of infectious diseases, seventh edition. Philadelphia, PA: Churchill Livingston Elsevier, 2010; 335763.

42. Henkin R, Barter FC. Studies on olfactory thresholds in normal man and in patients with adrenal cortical insufciency: the role of adrenal cortical steroids and o serum sodium concentration. J Clin Invest 1966; 45:16319. 43. http://www.washingtonpost.com/wp-dyn/content/article/2010/08/30/ AR2010083004125.html.

Downloaded from http://cid.oxfordjournals.org/ by guest on April 5, 2014

Bolivars Medical Labyrinth

CID 2011:52 (1 January)

85