Case and Research Letters
Acute Disseminated Paracoccidioidomycosis with Molluscoid Lesions in a Young Woman
Paracoccidioidomicosis aguda diseminada moluscoide en mujer joven
B. Di Martino Ortiz
, T. Moreno, G. Galeano, M. Rodríguez
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Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
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Di Martino Ortiz, T. Moreno, G. Galeano, M. Rodríguez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Di Martino Ortiz" "email" => array:1 [ 0 => "beatrizdimartino@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Moreno" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Galeano" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Rodríguez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paracoccidioidomicosis aguda diseminada moluscoide en mujer joven" ] ] "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" => 1250 "Ancho" => 771 "Tamanyo" => 132164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph showing round erythematous-violaceous papules and plaques, some with a central depression and bloodstained scab, on the patient's face. There was also facial edema and jaundice.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis (PCM) is a systemic mycosis caused by a dimorphic fungus.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The fungus <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span> lives in the ground and on plants in tropical and subtropical regions. It is endemic to South America and is the most common of the deep mycoses in Paraguay.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Infection occurs by the inhalation of spores during the first decades of life; these spores reach the lungs and can spread to other parts of the body via the blood or lymphatics. The fungus can affect the skin, mucosas, adrenal glands, and other organs.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The 2 main clinical presentations of PCM are the chronic form and the acute/subacute form. The chronic form, which accounts for up to 90% of cases, typically affects male farmers between 30 and 60 years of age. The higher frequency in men is due to the presence of 17-β-estradiol receptors in the cytoplasm of <span class="elsevierStyleItalic">P. brasiliensis</span>. The interaction between the receptors and the female hormone inhibits transformation of the fungus from the mycelial form to the yeast form; this transformation is essential for infection to develop.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The acute/subacute form (juvenile type) accounts for less than 10% of cases and is mainly observed in young individuals with a depression of cell-mediated immunity. This form has a rapid clinical course (4 to 12 weeks), with alterations of the monocyte-macrophage system and polymorphous skin lesions (nodular, furunculoid, verrucous, ulcer-granulomatous, molluscoid).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,7–9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The gold standard for diagnosis is culture, which must be performed under strict biosafety measures. The fungus grows as mycelia at room temperature and as the yeast in vitro and in tissues at 37°C.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1-5</span></a> Other diagnostic methods include serology (immunodiffusion), and molecular studies such as polymerase chain reaction.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,10</span></a> Histopathology reveals fungal structures, with well or poorly organized granulomas, depending on the immune response.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Commonly associated infectious diseases include tuberculosis (5%-10%), intestinal parasitoses, Chagas disease, syphilis, other superficial and deep mycoses, and AIDS. Important noninfectious diseases that may be associated with PCM are non-Hodgkin lymphoma and some carcinomas.</p><p id="par0040" class="elsevierStylePara elsevierViewall">An association with smoking has been reported in a high percentage of patients.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with severe forms of PCM, with weight loss of over 10%, respiratory difficulty, and neurological symptoms, must be hospitalized.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The treatment of choice is itraconazole, 200-400<span class="elsevierStyleHsp" style=""></span>mg/d, by mouth for 6 to 12 months; this regimen achieves cure in 88% to 100% of cases, though there is a recurrence rate of 3%. In severe forms, amphotericin B, 0.8-1<span class="elsevierStyleHsp" style=""></span>mg/kg/d, is administered by intravenous infusion until an improvement is achieved in the clinical manifestations, after which the patient can be changed to oral treatment.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3,7</span></a> Other alternatives include trimethoprim-sulfamethoxazole, voriconazole, and fluconazole. Periodic follow-up of clinical, mycologic, radiologic, and immunologic criteria must be performed to determine whether a favorable response to treatment is being achieved. Delays in the initiation of treatment can elevate mortality to up to 30%, and increase the risk of potentially disabling sequelae, such as pulmonary fibrosis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3,5,7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">We present the case of a 21-year-old housewife, an indigenous woman from a humid and wooded rural region of Paraguay. She had a 2-month history of skin lesions on her back, face, neck, abdomen, and limbs. The patient described a feeling of fever, mainly in the evening, jaundice, dyspnea, asthenia, anorexia, and unquantified weight loss. She denied any underlying diseases, smoking, alcohol consumption, or use of recreational drugs.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Physical examination revealed erythematous-violaceous papules and plaques, some with a central depression and bloodstained scab, mainly on the face (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, jaundice, ascites, and submandibular and cervical lymph nodes of 1.5 to 3<span class="elsevierStyleHsp" style=""></span>cm diameter were detected. Breath sounds were absent in both lung bases. The patient presented fever of 38.5°C, but her vital signs were stable.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Blood test results were as follows: hemoglobin, 7.4<span class="elsevierStyleHsp" style=""></span>g/dL; hematocrit, 21%; white cell count, 11<span class="elsevierStyleHsp" style=""></span>800/μL (neutrophils, 82%; lymphocytes, 10%; monocytes, 6%; and eosinophils, 2%); platelets, 124<span class="elsevierStyleHsp" style=""></span>x10<span class="elsevierStyleSup">3</span>/μL; aspartate aminotransferase, 127<span class="elsevierStyleHsp" style=""></span>U/L (normal value, 32<span class="elsevierStyleHsp" style=""></span>U/L); alanine aminotransferase 75<span class="elsevierStyleHsp" style=""></span>U/L (normal value, 33<span class="elsevierStyleHsp" style=""></span>U/L); alkaline phosphatase, 4694<span class="elsevierStyleHsp" style=""></span>IU/L (normal value, 300 IU/L); total bilirubin, 10.1<span class="elsevierStyleHsp" style=""></span>mg/dL; direct bilirubin, 4.8<span class="elsevierStyleHsp" style=""></span>mg/dL; indirect bilirubin, 6.1<span class="elsevierStyleHsp" style=""></span>mg/dL; albumin, 1.3<span class="elsevierStyleHsp" style=""></span>g/dL (normal value, ><span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>g/dL); prothrombin index, 50%; activated partial thromboplastin time, 45<span class="elsevierStyleHsp" style=""></span>seconds. Serology for human immunodeficiency virus, syphilis, hepatitis C virus, hepatitis B surface antigen, and hepatitis A virus was negative. Cultures of sputum and gastric fluid were negative for acid- and alkali-fast bacilli and for fungi.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Abdominal ultrasound revealed hepatomegaly and a large volume of free fluid in the abdominal cavity; there was a bilateral pleural effusion. Abdominal computed tomography showed no involvement of the adrenal glands.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Histopathology confirmed the presence of pseudoepitheliomatous hyperplasia and pandermal suppurative granulomatosis, with multinucleated giant cells and mycotic spores with birefringent cell walls and exosporulation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A smear from a lymph node revealed multinucleated giant cells with mycotic spores compatible with <span class="elsevierStyleItalic">P. brasiliensis</span>. Based on this information, we made a final diagnosis of acute disseminated PCM.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Treatment was prescribed with 3<span class="elsevierStyleHsp" style=""></span>g of amphotericin<span class="elsevierStyleHsp" style=""></span>B at a dose of 50<span class="elsevierStyleHsp" style=""></span>mg/d (although administration had to be interrupted for several days due to transitory alterations of kidney function), leading to an improvement in the skin lesions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), liver function (alkaline phosphatase, 1256<span class="elsevierStyleHsp" style=""></span>IU/L after 1 month of treatment), and in the patient's general state. Treatment was completed with itraconazole, 200<span class="elsevierStyleHsp" style=""></span>mg/d, for 6 months after discharge. At the time of writing, the patient has been on treatment for 2 months, with a cumulative dose of amphotericin of 2.5<span class="elsevierStyleHsp" style=""></span>g. There has been no recurrence.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">PCM is characterized by marked polymorphism of the skin lesions, which present as papules, nodules, desquamating erythematous verrucous plaques, and ulcers with a granulomatous base and petechiae; the molluscoid lesions seen in our patient, mainly affecting the face in the area of the nose and mouth, are very rare.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">This type of molluscoid lesion obliges us to rule out cryptococcosis, histoplasmosis, atypical mycobacteria, molluscum contagiosum, disseminated leishmaniasis, and leprosy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,5,7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We draw attention to the fact that the patient was a young woman of childbearing age who came from an endemic area with favorable environmental conditions for the fungus. She did not present immunosuppression except for malnutrition. Molluscoid lesions were visible mainly on the face, requiring us to rule out a long list of other diagnoses and comorbid conditions. Migratory phenomena make it necessary for dermatologists to be aware of infectious diseases that can arise in other continents.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Di Martino Ortiz B, Moreno T, Galeano G, Rodríguez M. Paracoccidioidomicosis aguda diseminada moluscoide en mujer joven. Actas Dermosifiliogr. 2015;106:597–599.</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" => 1250 "Ancho" => 771 "Tamanyo" => 132164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical photograph showing round erythematous-violaceous papules and plaques, some with a central depression and bloodstained scab, on the patient's face. There was also facial edema and jaundice.</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" => 760 "Ancho" => 950 "Tamanyo" => 218478 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology revealed mycotic spores with birefringent walls and exosporulation, giving the appearance of boat rudder. Periodic acid Schiff, original magnification<span class="elsevierStyleHsp" style=""></span>×40).</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" => 1250 "Ancho" => 790 "Tamanyo" => 133068 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A marked improvement in the lesions was observed at follow-up after 1 month of treatment, with a cumulative dose of 2.5<span class="elsevierStyleHsp" style=""></span>g of amphotericin B.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paracoccidioidomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.A. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 9 | 15 |
| 2024 Octubre | 71 | 33 | 104 |
| 2024 Septiembre | 74 | 31 | 105 |
| 2024 Agosto | 110 | 68 | 178 |
| 2024 Julio | 83 | 38 | 121 |
| 2024 Junio | 93 | 30 | 123 |
| 2024 Mayo | 61 | 26 | 87 |
| 2024 Abril | 57 | 28 | 85 |
| 2024 Marzo | 84 | 29 | 113 |
| 2024 Febrero | 56 | 28 | 84 |
| 2024 Enero | 56 | 25 | 81 |
| 2023 Diciembre | 61 | 40 | 101 |
| 2023 Noviembre | 64 | 24 | 88 |
| 2023 Octubre | 52 | 31 | 83 |
| 2023 Septiembre | 45 | 30 | 75 |
| 2023 Agosto | 38 | 17 | 55 |
| 2023 Julio | 46 | 40 | 86 |
| 2023 Junio | 55 | 21 | 76 |
| 2023 Mayo | 62 | 29 | 91 |
| 2023 Abril | 44 | 19 | 63 |
| 2023 Marzo | 52 | 18 | 70 |
| 2023 Febrero | 54 | 21 | 75 |
| 2023 Enero | 39 | 28 | 67 |
| 2022 Diciembre | 43 | 34 | 77 |
| 2022 Noviembre | 36 | 42 | 78 |
| 2022 Octubre | 31 | 30 | 61 |
| 2022 Septiembre | 19 | 29 | 48 |
| 2022 Agosto | 28 | 45 | 73 |
| 2022 Julio | 26 | 22 | 48 |
| 2022 Junio | 21 | 33 | 54 |
| 2022 Mayo | 32 | 38 | 70 |
| 2022 Abril | 43 | 46 | 89 |
| 2022 Marzo | 56 | 62 | 118 |
| 2022 Febrero | 44 | 25 | 69 |
| 2022 Enero | 66 | 26 | 92 |
| 2021 Diciembre | 41 | 33 | 74 |
| 2021 Noviembre | 33 | 41 | 74 |
| 2021 Octubre | 46 | 38 | 84 |
| 2021 Septiembre | 36 | 33 | 69 |
| 2021 Agosto | 84 | 32 | 116 |
| 2021 Julio | 70 | 28 | 98 |
| 2021 Junio | 42 | 27 | 69 |
| 2021 Mayo | 32 | 43 | 75 |
| 2021 Abril | 74 | 84 | 158 |
| 2021 Marzo | 67 | 33 | 100 |
| 2021 Febrero | 42 | 30 | 72 |
| 2021 Enero | 27 | 23 | 50 |
| 2020 Diciembre | 30 | 24 | 54 |
| 2020 Noviembre | 22 | 19 | 41 |
| 2020 Octubre | 22 | 10 | 32 |
| 2020 Septiembre | 25 | 9 | 34 |
| 2020 Agosto | 19 | 15 | 34 |
| 2020 Julio | 24 | 18 | 42 |
| 2020 Junio | 31 | 27 | 58 |
| 2020 Mayo | 30 | 11 | 41 |
| 2020 Abril | 27 | 18 | 45 |
| 2020 Marzo | 30 | 16 | 46 |
| 2020 Febrero | 9 | 0 | 9 |
| 2020 Enero | 0 | 4 | 4 |
| 2019 Diciembre | 4 | 7 | 11 |
| 2019 Noviembre | 1 | 3 | 4 |
| 2019 Octubre | 1 | 3 | 4 |
| 2019 Septiembre | 0 | 8 | 8 |
| 2019 Agosto | 3 | 4 | 7 |
| 2019 Julio | 5 | 7 | 12 |
| 2019 Junio | 8 | 17 | 25 |
| 2019 Mayo | 7 | 14 | 21 |
| 2019 Abril | 14 | 13 | 27 |
| 2019 Marzo | 1 | 9 | 10 |
| 2019 Febrero | 8 | 4 | 12 |
| 2019 Enero | 12 | 5 | 17 |
| 2018 Diciembre | 5 | 6 | 11 |
| 2018 Noviembre | 6 | 3 | 9 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 8 | 1 | 9 |
| 2018 Agosto | 0 | 4 | 4 |
| 2018 Junio | 0 | 2 | 2 |
| 2018 Mayo | 0 | 5 | 5 |
| 2018 Abril | 0 | 3 | 3 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 34 | 1 | 35 |
| 2018 Enero | 34 | 6 | 40 |
| 2017 Diciembre | 26 | 8 | 34 |
| 2017 Noviembre | 19 | 5 | 24 |
| 2017 Octubre | 21 | 5 | 26 |
| 2017 Septiembre | 17 | 16 | 33 |
| 2017 Agosto | 22 | 10 | 32 |
| 2017 Julio | 20 | 8 | 28 |
| 2017 Junio | 32 | 14 | 46 |
| 2017 Mayo | 19 | 16 | 35 |
| 2017 Abril | 29 | 10 | 39 |
| 2017 Marzo | 11 | 70 | 81 |
| 2017 Febrero | 21 | 5 | 26 |
| 2017 Enero | 16 | 7 | 23 |
| 2016 Diciembre | 21 | 16 | 37 |
| 2016 Noviembre | 34 | 15 | 49 |
| 2016 Octubre | 24 | 23 | 47 |
| 2016 Septiembre | 0 | 1 | 1 |
| 2016 Julio | 6 | 0 | 6 |
| 2016 Junio | 9 | 1 | 10 |
| 2016 Mayo | 7 | 2 | 9 |
| 2016 Abril | 1 | 0 | 1 |
| 2016 Marzo | 4 | 0 | 4 |
| 2016 Enero | 0 | 1 | 1 |
| 2015 Octubre | 0 | 3 | 3 |
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