Tropical/Infectoparasitary Dermatology
Paracoccidioidomycosis: an uncommon clinical presentation
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"Bruno Augusto Alvares, Cláudia Alves Lapa Gracia, Mariangela Esther Alencar Marques, Silvio Alencar Marques" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Bruno Augusto" "apellidos" => "Alvares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Cláudia Alves Lapa" "apellidos" => "Gracia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mariangela Esther Alencar" "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "Silvio Alencar" "apellidos" => "Marques" "email" => array:1 [ 0 => "silvio.marques@unesp.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology and Radiotherapy, Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Private Clinic, Birigui, SP, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 235159 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis: chronic granulomatous inflammatory infiltrate with the presence of fungal cells within the cytoplasm of giant cells and macrophages. (Hematoxylin & eosin, ×400).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis is a systemic mycosis caused by dimorphic fungi of the genus <span class="elsevierStyleItalic">Paracoccidioides</span> (<span class="elsevierStyleItalic">P. brasiliensis</span> or <span class="elsevierStyleItalic">P. lutzii</span>),<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> which, in the chronic clinical presentation in adults, mainly affects men (male/female ratio: up to 22/1) in the range from 30 to 59 years old.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Lung and oral mucosa involvement is usual in this clinical form.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors report a case of a 76-year-old female patient with painful skin lesions two months prior to presentation. The patient denied trauma or fever; she had undergone treatment with antibiotics, without improvement. She reported type II diabetes mellitus and systemic arterial hypertension. The dermatological examination showed phagedenic ulcers, with necrotic areas, surrounded by an inflammatory halo (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The lesions were more exuberant in the deltoid regions, with satellite lesions on the shoulders and forearms. The supplemental clinical examination was normal, although the patient presented depression symptoms and was suffering from her illness.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The clinical hypothesis was that of pyoderma gangrenosum, due to the presence of painful ulcers, of rapid growth and geographical aspect; however, no violet halo was observed and the edges were not undermined. Another hypothesis was primary cutaneous cryptococcosis, due to the inflammatory aspect associated with necrosis, localized in exposed areas; however, the bilateral aspect of the lesions did not correspond to this hypothesis. Biopsies and laboratory investigation were performed; the final diagnosis of paracoccidioidomycosis was surprising and confirmed by histopathological examination (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>) and direct mycological examination. Complementary tests, including chest and abdominal computed tomography (CT), ruled out involvement of other organs. Laboratory tests revealed elevated CRP and glycemia, negative HIV and anti-<span class="elsevierStyleItalic">P. brasiliensis</span> serology, and negative culture for bacteria and fungi. The clinical response was complete after treatment with itraconazole 400<span class="elsevierStyleHsp" style=""></span>mg/day in the first month, decreased to 200<span class="elsevierStyleHsp" style=""></span>mg/day until the sixth month of treatment.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The present case differs from the usual pattern of paracoccidioidomycosis in several aspects. The disease is uncommon in both female and elderly patients. As a rule, lung involvement is present in adult patients, being the source of metastatic spread of the infection to other organs.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Pulmonary involvement was not observed in the present case, even using high-resolution CT.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Nonetheless, the most unusual finding was the pattern of skin lesions. In paracoccidioidomycosis, skin lesions are observed in up to 62.1% of cases, usually on the face, such as acneiform lesions, in infiltrated plaques, or vegetating and simultaneously with multiple organ involvement, including the lungs.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Ulcers with necrotic areas are uncommon, as the skin ulcers in paracoccidioidomycosis are generally shallow, granular, and usually with hemorrhagic spots, similar to what is observed in mucosal lesions; they are not phagedenic or painful.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient's advanced age, immunosenescence, and diabetes probably contributed to the rapid evolution and atypical presentation in this case.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> Itraconazole has been considered as the first treatment option and is effective at a dose of 200<span class="elsevierStyleHsp" style=""></span>mg/day for 9–18 months.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> In the present study, itraconazole was successfully used at 400<span class="elsevierStyleHsp" style=""></span>mg/day in the first month with the aim of promoting quick resolution of injuries, improving quality of life, and reducing the psychological stress experienced by the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">Bruno Augusto Alvares: Approval of the final version of the manuscript; conception and planning of the study; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cláudia Alves Lapa Gracia: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mariangela Esther Alencar Marques: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques: Approval of the final version of the manuscript; conception and planning of the study; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1418421" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1297630" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contribution" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-24" "fechaAceptado" => "2020-06-06" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1297630" "palabras" => array:5 [ 0 => "Aged" 1 => "Diagnosis" 2 => "Paracoccidioidomycosis" 3 => "Skin and connective tissue diseases" 4 => "Treatment outcome" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paracoccidoiomycosis is a systemic mycosis with a higher incidence in males with history of exposure to the rural environment; its classic clinical manifestation is an oro-pulmonary lesion. The authors report a case of a female, urban, 76-year-old patient with atypical clinical-dermatological presentation and diagnostic conclusion after histopathological examination. The clinical response was quick and complete after treatment with itraconazole 400<span class="elsevierStyleHsp" style=""></span>mg/day in the first month, decreased to 200<span class="elsevierStyleHsp" style=""></span>mg/day until the sixth month of treatment.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Alvares BA, Gracia CAL, Marques MEA, Marques SA. Paracoccidioidomycosis: an uncommon clinical presentation. An Bras Dermatol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.abd.2020.06.001">https://doi.org/10.1016/j.abd.2020.06.001</span></p>" ] 1 => array:2 [ "etiqueta" => "⋆⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology and Radiotherapy, Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, SP, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1203 "Ancho" => 905 "Tamanyo" => 122595 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis: ulcerative-necrotic, phagedenic lesions, with areas covered by crusts, affecting the right arm and forearm.</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" => 1092 "Ancho" => 905 "Tamanyo" => 138500 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis: extensive ulcerative necrotic lesion, areas covered by crusts and with an intense inflammatory halo. Papules and satellite plaques, located on the left arm and forearm.</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" => 680 "Ancho" => 905 "Tamanyo" => 235159 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis: chronic granulomatous inflammatory infiltrate with the presence of fungal cells within the cytoplasm of giant cells and macrophages. (Hematoxylin & eosin, ×400).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 681 "Ancho" => 905 "Tamanyo" => 160251 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis: <span class="elsevierStyleItalic">Paracoccidioides</span><span class="elsevierStyleItalic">spp</span>. Fungal cells, resembling a Mickey Mouse head. (Grocott-Gomori, immersion, 1000×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and epidemiological features of paracoccidioidomycosis due to <span class="elsevierStyleItalic">Paracoccidioides lutzii</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.C. Hahn" 1 => "A.M. Rodrigues" 2 => "P.P.D. Terra" 3 => "A.F. Nery" 4 => "H.D. Hoffman-Santos" 5 => "H.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 26 | 10 | 36 |
| 2024 October | 111 | 63 | 174 |
| 2024 September | 179 | 91 | 270 |
| 2024 August | 187 | 106 | 293 |
| 2024 July | 194 | 111 | 305 |
| 2024 June | 140 | 81 | 221 |
| 2024 May | 115 | 59 | 174 |
| 2024 April | 131 | 90 | 221 |
| 2024 March | 78 | 79 | 157 |
| 2024 February | 91 | 81 | 172 |
| 2024 January | 67 | 49 | 116 |
| 2023 December | 62 | 52 | 114 |
| 2023 November | 85 | 85 | 170 |
| 2023 October | 71 | 84 | 155 |
| 2023 September | 79 | 82 | 161 |
| 2023 August | 72 | 48 | 120 |
| 2023 July | 65 | 35 | 100 |
| 2023 June | 65 | 51 | 116 |
| 2023 May | 63 | 16 | 79 |
| 2023 April | 55 | 17 | 72 |
| 2023 March | 70 | 53 | 123 |
| 2023 February | 50 | 29 | 79 |
| 2023 January | 52 | 38 | 90 |
| 2022 December | 60 | 28 | 88 |
| 2022 November | 83 | 49 | 132 |
| 2022 October | 89 | 53 | 142 |
| 2022 September | 50 | 56 | 106 |
| 2022 August | 51 | 41 | 92 |
| 2022 July | 44 | 44 | 88 |
| 2022 June | 43 | 59 | 102 |
| 2022 May | 37 | 56 | 93 |
| 2022 April | 39 | 51 | 90 |
| 2022 March | 50 | 69 | 119 |
| 2022 February | 20 | 46 | 66 |
| 2022 January | 49 | 71 | 120 |
| 2021 December | 39 | 56 | 95 |
| 2021 November | 48 | 62 | 110 |
| 2021 October | 55 | 81 | 136 |
| 2021 September | 38 | 47 | 85 |
| 2021 August | 44 | 63 | 107 |
| 2021 July | 37 | 44 | 81 |
| 2021 June | 34 | 61 | 95 |
| 2021 May | 55 | 61 | 116 |
| 2021 April | 131 | 196 | 327 |
| 2021 March | 111 | 88 | 199 |
| 2021 February | 54 | 23 | 77 |
| 2021 January | 71 | 25 | 96 |
| 2020 December | 38 | 24 | 62 |
| 2020 November | 45 | 12 | 57 |
| 2020 October | 13 | 15 | 28 |
| 2020 September | 12 | 21 | 33 |
| 2020 August | 1 | 0 | 1 |
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