Tropical/Infectoparasitary Dermatology
Paracoccidioidomycosis: an uncommon clinical presentation
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Pápulas e placas satélites. Localizadas no braço e antebraço esquerdo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Bruno Augusto Alvares, Cláudia Alves Lapa Gracia, Mariangela Esther Alencar Marques, Silvio Alencar Marques" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Bruno Augusto" "apellidos" => "Alvares" ] 1 => array:2 [ "nombre" => "Cláudia Alves Lapa" "apellidos" => "Gracia" ] 2 => array:2 [ "nombre" => "Mariangela Esther Alencar" "apellidos" => "Marques" ] 3 => array:2 [ "nombre" => "Silvio Alencar" "apellidos" => "Marques" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059620302117" "doi" => "10.1016/j.abd.2020.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620302117?idApp=UINPBA00008Z" ] ] "EPUB" => 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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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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 26 | 10 | 36 |
| 2024 Outubro | 111 | 63 | 174 |
| 2024 Setembro | 179 | 91 | 270 |
| 2024 Agosto | 187 | 106 | 293 |
| 2024 Julho | 194 | 111 | 305 |
| 2024 Junho | 140 | 81 | 221 |
| 2024 Maio | 115 | 59 | 174 |
| 2024 Abril | 131 | 90 | 221 |
| 2024 Março | 78 | 79 | 157 |
| 2024 Fevereiro | 91 | 81 | 172 |
| 2024 Janeiro | 67 | 49 | 116 |
| 2023 Dezembro | 62 | 52 | 114 |
| 2023 Novembro | 85 | 85 | 170 |
| 2023 Outubro | 71 | 84 | 155 |
| 2023 Setembro | 79 | 82 | 161 |
| 2023 Agosto | 72 | 48 | 120 |
| 2023 Julho | 65 | 35 | 100 |
| 2023 Junho | 65 | 51 | 116 |
| 2023 Maio | 63 | 16 | 79 |
| 2023 Abril | 55 | 17 | 72 |
| 2023 Março | 70 | 53 | 123 |
| 2023 Fevereiro | 50 | 29 | 79 |
| 2023 Janeiro | 52 | 38 | 90 |
| 2022 Dezembro | 60 | 28 | 88 |
| 2022 Novembro | 83 | 49 | 132 |
| 2022 Outubro | 89 | 53 | 142 |
| 2022 Setembro | 50 | 56 | 106 |
| 2022 Agosto | 51 | 41 | 92 |
| 2022 Julho | 44 | 44 | 88 |
| 2022 Junho | 43 | 59 | 102 |
| 2022 Maio | 37 | 56 | 93 |
| 2022 Abril | 39 | 51 | 90 |
| 2022 Março | 50 | 69 | 119 |
| 2022 Fevereiro | 20 | 46 | 66 |
| 2022 Janeiro | 49 | 71 | 120 |
| 2021 Dezembro | 39 | 56 | 95 |
| 2021 Novembro | 48 | 62 | 110 |
| 2021 Outubro | 55 | 81 | 136 |
| 2021 Setembro | 38 | 47 | 85 |
| 2021 Agosto | 44 | 63 | 107 |
| 2021 Julho | 37 | 44 | 81 |
| 2021 Junho | 34 | 61 | 95 |
| 2021 Maio | 55 | 61 | 116 |
| 2021 Abril | 131 | 196 | 327 |
| 2021 Março | 111 | 88 | 199 |
| 2021 Fevereiro | 54 | 23 | 77 |
| 2021 Janeiro | 71 | 25 | 96 |
| 2020 Dezembro | 38 | 24 | 62 |
| 2020 Novembro | 45 | 12 | 57 |
| 2020 Outubro | 13 | 15 | 28 |
| 2020 Setembro | 12 | 21 | 33 |
| 2020 Agosto | 1 | 0 | 1 |
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