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malaise&#44; and weakness&#46; She also reported weight loss&#44; lack of appetite&#44; dry cough&#44; and dyspnea for approximately three months&#46; On physical examination&#44; she had numerous acneiform and solid erythematous-normochromic papules &#40;with an ulcerated center or covered with crusts&#41; spread throughout the skin&#44; including the face &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnostic hypotheses were histoplasmosis&#44; cryptococcosis&#44; and paracoccidioidomycosis&#46; The histopathological analysis of a skin lesion biopsy showed epidermal hyperplasia and granulomatous and dermal suppurative inflammatory infiltrate&#44; with the presence of fungal elements inside giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Grocott-Gomori staining showed multi-budding fungal cells&#44; 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resulting from the use and maintenance of immunosuppressants&#44; disease dissemination and possible complications associated with therapy&#46; The options of itraconazole&#44; sulfamethoxazole-trimethoprim&#44; amphotericin B deoxycholate&#44; or liposomal are defined by the overall clinical picture and availability&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The present report of paracoccidioidomycosis in a patient under immunosuppressive medication highlights treatment difficulties&#44; but also the good final result&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fl&#225;via de Oliveira Valentim&#58; 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critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Tropical/Infectoparasitary Dermatology
Disseminated paracoccidioidomycosis in a liver transplant patient
Flávia de Oliveira Valentim, Giuliane Minami Tsutsui, Luciana Patrícia Fernandes Abbade, Silvio Alencar Marques
Corresponding author
silvio.marques@unesp.br

Corresponding author.
Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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particularly kidney transplantation under immunosuppression induced by prednisone&#44; azathioprine&#44; or cyclosporine&#46; As seen in the researched literature to date &#40;PubMed&#44; SciELO&#44; LILACS&#41;&#44; there is only one described case after liver transplantation&#44; and in this case&#44; using tacrolimus&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This is the report of a 47-year-old female patient&#44; a former resident in the rural area of the state of S&#227;o Paulo&#44; who was submitted to a liver transplant one year before&#44; due to cirrhosis of alcoholic etiology associated with hepatitis B&#44; undergoing specific therapy consisting of 1&#8239;mg&#47;day of tacrolimus and 720&#8239;mg&#47;day of mycophenolate mofetil&#46; She was referred to the Dermatology service for multiple lesions&#44; with a 15-day exacerbation associated with high fever&#44; malaise&#44; and weakness&#46; She also reported weight loss&#44; lack of appetite&#44; dry cough&#44; and dyspnea for approximately three months&#46; On physical examination&#44; she had numerous acneiform and solid erythematous-normochromic papules &#40;with an ulcerated center or covered with crusts&#41; spread throughout the skin&#44; including the face &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnostic hypotheses were histoplasmosis&#44; cryptococcosis&#44; and paracoccidioidomycosis&#46; The histopathological analysis of a skin lesion biopsy showed epidermal hyperplasia and granulomatous and dermal suppurative inflammatory infiltrate&#44; with the presence of fungal elements inside giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Grocott-Gomori staining showed multi-budding fungal cells&#44; 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on an in-hospital basis&#44; requiring transfer to the ICU due to hemodynamic instability associated with the amphotericin B infusions and the precarious overall status&#46; The patient was discharged after stabilization and clinical recovery&#44; remission of paracoccidioidomycosis&#44; and was prescribed itraconazole 200&#8239;m g&#47;day as a maintenance treatment&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In immunosuppressed patients&#44; the clinical picture of histoplasmosis&#44; cryptococcosis&#44; paracoccidioidomycosis and even disseminated sporotrichosis converges to similar manifestations&#58; a relatively short history of fever&#44; lack of appetite&#44; weight loss&#44; and asthenia&#44; followed by or concomitant with the appearance of skin lesions showing an acneiform&#44; disseminated ulcerated papular-nodular or ulcerated-necrotic pattern&#44; frequent facial involvement&#44; associated with signs and symptoms of systemic involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;9</span></a> The prognosis of paracoccidioidomycosis is reserved in post-transplant cases&#44; resulting from the use and maintenance of immunosuppressants&#44; disease dissemination and possible complications associated with therapy&#46; The options of itraconazole&#44; sulfamethoxazole-trimethoprim&#44; amphotericin B deoxycholate&#44; or liposomal are defined by the overall clinical picture and availability&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The present report of paracoccidioidomycosis in a patient under immunosuppressive medication highlights treatment difficulties&#44; but also the good final result&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fl&#225;via de Oliveira Valentim&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Giuliane Minami Tsutsui&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Luciana Patr&#237;cia Fernandes Abbade&#58; Approval of the final version of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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