Tropical/Infectoparasitary Dermatology
Disseminated paracoccidioidomycosis in a liver transplant patient
Flávia de Oliveira Valentim, Giuliane Minami Tsutsui, Luciana Patrícia Fernandes Abbade, Silvio Alencar Marques
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Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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array:1 [ "total" => 0 ] "pt" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Dermatologia Tropical/Infectoparasitária</span>" "titulo" => "Paracoccidioidomicose disseminada em paciente transplantado hepático" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "346" "paginaFinal" => "348" ] ] "contieneResumen" => array:1 [ "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 678 "Ancho" => 900 "Tamanyo" => 147680 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomicose e 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The gold standard diagnosis is the detection of the fungus by direct mycological examination, histopathological analysis, or fungal isolation in culture.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In immunosuppressed individuals, it is more frequently associated with HIV infection, followed by solid, hematological neoplasms and, finally, post-solid organ transplants, particularly kidney transplantation under immunosuppression induced by prednisone, azathioprine, or cyclosporine. As seen in the researched literature to date (PubMed, SciELO, LILACS), there is only one described case after liver transplantation, and in this case, using tacrolimus.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This is the report of a 47-year-old female patient, a former resident in the rural area of the state of São Paulo, who was submitted to a liver transplant one year before, due to cirrhosis of alcoholic etiology associated with hepatitis B, undergoing specific therapy consisting of 1 mg/day of tacrolimus and 720 mg/day of mycophenolate mofetil. She was referred to the Dermatology service for multiple lesions, with a 15-day exacerbation associated with high fever, malaise, and weakness. She also reported weight loss, lack of appetite, dry cough, and dyspnea for approximately three months. On physical examination, she had numerous acneiform and solid erythematous-normochromic papules (with an ulcerated center or covered with crusts) spread throughout the skin, including the face (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnostic hypotheses were histoplasmosis, cryptococcosis, and paracoccidioidomycosis. The histopathological analysis of a skin lesion biopsy showed epidermal hyperplasia and granulomatous and dermal suppurative inflammatory infiltrate, with the presence of fungal elements inside giant cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Grocott-Gomori staining showed multi-budding fungal cells, characteristic of the <span class="elsevierStyleItalic">Paracoccidioides</span> spp genus (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The biopsy fragment culture, general biochemical analyses, blood cultures, and serology, including anti-HIV, and anti-Paracoccidioides, were normal or negative. The chest CT (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) showed coalescent pulmonary consolidations, septal thickening and excavated lesions in the lower portions and lymph node enlargement, compatible with the diagnosis of paracoccidioidomycosis due to the likely reactivation of a quiescent pulmonary focus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment was carried out with 3 mg/kg/day of liposomal amphotericin B for 4 weeks, on an in-hospital basis, requiring transfer to the ICU due to hemodynamic instability associated with the amphotericin B infusions and the precarious overall status. The patient was discharged after stabilization and clinical recovery, remission of paracoccidioidomycosis, and was prescribed itraconazole 200 m g/day as a maintenance treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In immunosuppressed patients, the clinical picture of histoplasmosis, cryptococcosis, paracoccidioidomycosis and even disseminated sporotrichosis converges to similar manifestations: a relatively short history of fever, lack of appetite, weight loss, and asthenia, followed by or concomitant with the appearance of skin lesions showing an acneiform, disseminated ulcerated papular-nodular or ulcerated-necrotic pattern, frequent facial involvement, associated with signs and symptoms of systemic involvement.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9</span></a> The prognosis of paracoccidioidomycosis is reserved in post-transplant cases, resulting from the use and maintenance of immunosuppressants, disease dissemination and possible complications associated with therapy. The options of itraconazole, sulfamethoxazole-trimethoprim, amphotericin B deoxycholate, or liposomal are defined by the overall clinical picture and availability.<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, but also the good final result.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Flávia de Oliveira Valentim: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case; critical review of the literature.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Giuliane Minami Tsutsui: Approval of the final version of the manuscript; critical review of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Luciana Patrícia Fernandes Abbade: Approval of the final version of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case; critical review of the literature; critical review of the manuscript.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres1521066" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1379242" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:2 [ "identificador" => "xack534265" "titulo" => "Acknowledgements" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-23" "fechaAceptado" => "2020-07-30" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1379242" "palabras" => array:4 [ 0 => "Dermatology" 1 => "Liver" 2 => "Paracoccidioidomycosis" 3 => "Transplant" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis is an endemic systemic mycosis caused by <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span> complex and <span class="elsevierStyleItalic">P. lutzii</span>. It is a rare disease in non-HIV-induced immunosuppressed individuals. In organ transplant recipients, it is more frequently associated with immunosuppression after kidney transplantation. In a liver transplant patient, only one case has been published in the literature to date. The present report comprises the case of a 47-year-old female patient with disseminated skin lesions associated with signs and symptoms of systemic involvement of paracoccidioidomycosis that manifested one year after liver transplantation and under an immunosuppression regimen with tacrolimus and mycophenolate mofetil.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Valentim FO, Tsutsui GM, Abbade LPF, Marques SA. Disseminated paracoccidioidomycosis in a liver transplant patient. An Bras Dermatol. 2021;96:346–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 908 "Ancho" => 750 "Tamanyo" => 103185 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis and liver transplantation. Acneiform lesions and erythematous papules, some with an ulcerated center, disseminated on the face.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 678 "Ancho" => 900 "Tamanyo" => 147680 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis and liver transplant: inflammatory process detail, showing fungal cells in the giant cell cytoplasm (Hematoxylin & eosin, ×100).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 133949 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis and liver transplantation: multi-budding fungal cells, characteristic of the <span class="elsevierStyleItalic">Paracoccidioides</span> genus (Grocott-Gomori. Immersion).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 742 "Ancho" => 900 "Tamanyo" => 104048 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis and liver transplantation: CT scan showing peribronchial and perivascular parenchymal consolidations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecology of <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span>, <span class="elsevierStyleItalic">P. lutzii</span> and related species: infection in armadillos, soil occurrence and mycological aspects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.F. 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