Cases and Research Letters
Chronic Multifocal Paracoccidioidomycosis in an Immunocompetent Adult
Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente
B. Di MartinoOrtiz
, M.L. Rodríguez-Oviedo, M. Rodríguez-Masi
Corresponding author
Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay
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Di MartinoOrtiz, M.L. Rodríguez-Oviedo, M. Rodríguez-Masi" "autores" => array:3 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Di MartinoOrtiz" "email" => array:1 [ 0 => "beatrizdimartino@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Rodríguez-Oviedo" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Rodríguez-Masi" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1116 "Ancho" => 900 "Tamanyo" => 107278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Multiple spotty erythematous plaques on the lower lip, mulberry-like in appearance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis (PCM) is a deep systemic mycosis caused by <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span>, a thermally dimorphic fungus that grows as a yeast at 37<span class="elsevierStyleHsp" style=""></span>°C and in mycelial form at 25<span class="elsevierStyleHsp" style=""></span>°C. It is endemic in rural areas of Central and South America. In natural conditions, humans are the only known host. The source of the infection is soil contaminated with the fungus and the most common route of entry is the airway, giving rise to a primary infection in the lungs, which is often asymptomatic, particularly in young patients. From the lungs, infection spreads via the blood and lymph to the skin, mucous membranes, lymph nodes, and other organs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 50-year-old male agricultural worker from Paraguay (South America) who presented with a 4-month history of lesions in the mouth, on the palmar surface of the third finger of his left hand, and on the plantar surface of his right great toe. These were accompanied by swelling of the lip, pain, weight loss of 10 kg since the onset of the condition, and a feeling of fever, particularly at night. The patient reported no underlying disease or any history of trauma. He had been a smoker for many years.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a swollen lower lip with marked infiltration and induration as well as multiple eroded, mulberry-like, erythematous papules giving the lesion a cobblestone appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesions on the fingers and toes were small ulcers with well-defined borders and clean bases (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most relevant laboratory findings were eosinophilia (7%) and an erythrocyte sedimentation rate of 78<span class="elsevierStyleHsp" style=""></span>mm in the first hour. The patient tested negative for human immunodeficiency virus (HIV) and had a Venereal Disease Research Laboratory test result of 1:2. Chest radiography showed a mild interstitial infiltrate at the base of both lungs and histopathology revealed an intense granulomatous reaction in the dermis, with numerous multinucleated giant cells containing small, round, thick-walled structures with double contour membrane, some with surface buds and others showing multiple budding. These cells stained positively with periodic acid-Schiff stain (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment with itraconazole 200 mg/d achieved a good therapeutic response at initial monthly assessments. The patient is now in his eighth month of treatment and the therapy will be continued for at least another 4 months.</p><p id="par0030" class="elsevierStylePara elsevierViewall">PCM is a deep mycosis that primarily affects male agricultural workers. The male to female ratio is approximately 9 to 1. In women, the infection occurs before menarche or after menopause. <span class="elsevierStyleItalic">P brasiliensis</span> has cytoplasmic receptors for 17-β-estradiol, a female hormone that inhibits the mycelial-to-yeast transformation, an essential step in the establishment of infection. The age of affected patients ranges between 15-24 years and 65-74 years, with incidence peaking in the older patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically, the condition can presents as PCM infection (which can be asymptomatic or subclinical or else a symptomatic primary infection) or PCM disease, which can be acute or chronic. There are several forms of PCM disease, including juvenile (affecting children and adolescents), adult (unifocal or multifocal), and residual disease. The most frequent clinical form is chronic multifocal disease with pulmonary and mucocutaneous involvement. In HIV-positive patients with acquired immunodeficiency syndrome the clinical features are those of the acute juvenile form but with the addition of granulomatous mucosal lesions and diffuse pulmonary involvement.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are numerous clinical manifestations, which include general symptoms, enlarged lymph nodes and lesions in the lungs, bones, and other organs, including (in order of frequency) the gastrointestinal tract, liver, spleen, and adrenal glands. The lymph nodes may suppurate and become necrotic, giving rise to fistulas similar to those observed in tuberculosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common manifestations are mucocutaneous lesions; when these affect the mucosas of the nose, mouth, pharynx, and larynx, they can take 3 forms: <span class="elsevierStyleItalic">a)</span> de Aguiar Pupo stomatitis (mulberry stomatitis); <span class="elsevierStyleItalic">b)</span> inflamed and deformed lips (tapir lip); and <span class="elsevierStyleItalic">c)</span> infiltrative, vegetative, and ulcerative lesions. Cutaneous lesions take various forms as follows: papular, vegetating papular-pustular, ulcerative-vegetative, and papular-tuberous with pinpoint hemorrhages and a mulberry-like appearance. In the nasal region crusted ulcerated lesions that destroy the septum mimic American cutaneous leishmaniasis, one of the diseases that should be included in the differential diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PCM is diagnosed on the basis of 2 types of findings: <span class="elsevierStyleItalic">a)</span> Epidemiological information obtained from the medical history; and <span class="elsevierStyleItalic">b)</span> Demonstration and isolation of the fungus using any of the following methods: direct microscopic examination of exudate from lesions using potassium hydroxide smear or Giemsa or Groccot staining; culture on Saboureaud or blood agar; or histopathologic procedures demonstrating ‘pilot's wheel’ structures either within multinucleated giant cells or floating free in areas of suppuration. In the present case, the patient was a male agricultural worker and a smoker, and fungal structures were identified in a biopsy specimen.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first-line treatment is oral itraconazole 200-400 mg/d for 6 to 12 months in mild cases and 12 to 18 months in moderate cases. Severe disease is treated with intravenous amphotericin B.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Di Martino Ortiz B, Rodríguez-Oviedo ML, Rodríguez-Masi M. Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente. Actas Dermosifiliogr.2012;103:645-646.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1116 "Ancho" => 900 "Tamanyo" => 107278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Multiple spotty erythematous plaques on the lower lip, mulberry-like in appearance.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1057 "Ancho" => 900 "Tamanyo" => 105388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Small ulcer with smooth borders and a clean base on the plantar surface of the great toe on the right foot.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 581 "Ancho" => 1401 "Tamanyo" => 271254 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology. A, Capsule with intense granulomatous reaction (hemoxylin-eosin, original magnification ×10). B, Giant cell containing spores with surface budding (periodic acid-Schiff, original magnification ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paracoccidiodomicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Negroni" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Micología médica" "paginaInicial" => "263" "paginaFinal" => "273" "serieFecha" => "1993" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Micología médica ilustrada. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 11 | 16 |
| 2024 October | 57 | 40 | 97 |
| 2024 September | 71 | 25 | 96 |
| 2024 August | 89 | 56 | 145 |
| 2024 July | 93 | 38 | 131 |
| 2024 June | 87 | 46 | 133 |
| 2024 May | 89 | 29 | 118 |
| 2024 April | 77 | 23 | 100 |
| 2024 March | 89 | 26 | 115 |
| 2024 February | 77 | 21 | 98 |
| 2024 January | 58 | 31 | 89 |
| 2023 December | 93 | 19 | 112 |
| 2023 November | 74 | 26 | 100 |
| 2023 October | 64 | 20 | 84 |
| 2023 September | 66 | 32 | 98 |
| 2023 August | 49 | 18 | 67 |
| 2023 July | 52 | 33 | 85 |
| 2023 June | 56 | 22 | 78 |
| 2023 May | 56 | 28 | 84 |
| 2023 April | 39 | 18 | 57 |
| 2023 March | 50 | 24 | 74 |
| 2023 February | 63 | 18 | 81 |
| 2023 January | 43 | 25 | 68 |
| 2022 December | 70 | 32 | 102 |
| 2022 November | 26 | 28 | 54 |
| 2022 October | 46 | 19 | 65 |
| 2022 September | 29 | 25 | 54 |
| 2022 August | 33 | 43 | 76 |
| 2022 July | 27 | 26 | 53 |
| 2022 June | 31 | 25 | 56 |
| 2022 May | 30 | 34 | 64 |
| 2022 April | 40 | 32 | 72 |
| 2022 March | 31 | 54 | 85 |
| 2022 February | 33 | 30 | 63 |
| 2022 January | 49 | 36 | 85 |
| 2021 December | 59 | 36 | 95 |
| 2021 November | 74 | 38 | 112 |
| 2021 October | 78 | 48 | 126 |
| 2021 September | 54 | 36 | 90 |
| 2021 August | 25 | 27 | 52 |
| 2021 July | 78 | 26 | 104 |
| 2021 June | 47 | 34 | 81 |
| 2021 May | 58 | 34 | 92 |
| 2021 April | 71 | 44 | 115 |
| 2021 March | 45 | 24 | 69 |
| 2021 February | 48 | 18 | 66 |
| 2021 January | 30 | 15 | 45 |
| 2020 December | 33 | 12 | 45 |
| 2020 November | 30 | 19 | 49 |
| 2020 October | 24 | 7 | 31 |
| 2020 September | 26 | 9 | 35 |
| 2020 August | 25 | 16 | 41 |
| 2020 July | 31 | 12 | 43 |
| 2020 June | 36 | 25 | 61 |
| 2020 May | 32 | 20 | 52 |
| 2020 April | 33 | 15 | 48 |
| 2020 March | 43 | 20 | 63 |
| 2020 February | 8 | 0 | 8 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 1 | 9 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 10 | 1 | 11 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 1 | 5 |
| 2019 June | 4 | 2 | 6 |
| 2019 May | 7 | 18 | 25 |
| 2019 April | 4 | 1 | 5 |
| 2019 March | 0 | 9 | 9 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 5 | 0 | 5 |
| 2018 November | 6 | 0 | 6 |
| 2018 October | 7 | 0 | 7 |
| 2018 September | 4 | 0 | 4 |
| 2018 June | 0 | 17 | 17 |
| 2018 May | 0 | 42 | 42 |
| 2018 April | 0 | 20 | 20 |
| 2018 March | 3 | 6 | 9 |
| 2018 February | 33 | 11 | 44 |
| 2018 January | 37 | 5 | 42 |
| 2017 December | 38 | 10 | 48 |
| 2017 November | 32 | 3 | 35 |
| 2017 October | 32 | 12 | 44 |
| 2017 September | 38 | 20 | 58 |
| 2017 August | 55 | 19 | 74 |
| 2017 July | 29 | 16 | 45 |
| 2017 June | 50 | 9 | 59 |
| 2017 May | 53 | 6 | 59 |
| 2017 April | 38 | 6 | 44 |
| 2017 March | 39 | 17 | 56 |
| 2017 February | 32 | 17 | 49 |
| 2017 January | 28 | 6 | 34 |
| 2016 December | 43 | 4 | 47 |
| 2016 November | 53 | 9 | 62 |
| 2016 October | 70 | 7 | 77 |
| 2016 September | 56 | 7 | 63 |
| 2016 August | 44 | 10 | 54 |
| 2016 July | 45 | 13 | 58 |
| 2016 June | 8 | 12 | 20 |
| 2016 May | 4 | 19 | 23 |
| 2016 April | 3 | 0 | 3 |
| 2016 March | 8 | 0 | 8 |
| 2016 February | 5 | 3 | 8 |
| 2016 January | 7 | 2 | 9 |
| 2015 December | 5 | 3 | 8 |
| 2015 November | 13 | 1 | 14 |
| 2015 October | 10 | 3 | 13 |
| 2015 September | 10 | 8 | 18 |
| 2015 August | 11 | 2 | 13 |
| 2015 July | 89 | 12 | 101 |
| 2015 June | 45 | 6 | 51 |
| 2015 May | 84 | 9 | 93 |
| 2015 April | 69 | 12 | 81 |
| 2015 March | 63 | 11 | 74 |
| 2015 February | 63 | 5 | 68 |
| 2015 January | 61 | 11 | 72 |
| 2014 December | 59 | 6 | 65 |
| 2014 November | 46 | 9 | 55 |
| 2014 October | 65 | 18 | 83 |
| 2014 September | 65 | 13 | 78 |
| 2014 August | 22 | 5 | 27 |
| 2014 July | 18 | 3 | 21 |
| 2014 June | 37 | 2 | 39 |
| 2014 May | 42 | 5 | 47 |
| 2014 April | 43 | 4 | 47 |
| 2014 March | 47 | 8 | 55 |
| 2014 February | 39 | 11 | 50 |
| 2014 January | 46 | 8 | 54 |
| 2013 December | 50 | 11 | 61 |
| 2013 November | 26 | 9 | 35 |
| 2013 October | 35 | 10 | 45 |
| 2013 September | 17 | 10 | 27 |
| 2013 August | 14 | 8 | 22 |
| 2013 July | 10 | 10 | 20 |
| 2013 June | 14 | 23 | 37 |
| 2013 May | 20 | 12 | 32 |
| 2013 April | 18 | 14 | 32 |
| 2013 March | 21 | 9 | 30 |
| 2013 February | 39 | 9 | 48 |
| 2013 January | 47 | 4 | 51 |
| 2012 December | 27 | 4 | 31 |
| 2012 November | 0 | 2 | 2 |
| 2012 October | 0 | 2 | 2 |
| 2012 September | 0 | 2 | 2 |
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