Paracoccidioidomycosis

doi:10.1016/j.clindermatol.2012.01.006

Clinics in Dermatology

Volume 30, Issue 6, November–December 2012, Pages 610-615

https://doi.org/10.1016/j.clindermatol.2012.01.006 Get rights and content

Abstract

Paracoccidioidomycosis is an endemic systemic mycosis that predominates in southern Mexico, parts of Central America, and South America. It is caused by a dimorphic fungus and is generally acquired through the lungs, from where it disseminates. Paracoccidioidomycosis has different clinical manifestations that require differentiation with tuberculosis, Hodgkin disease, several systemic and subcutaneous mycoses, and squamous cell carcinoma. Diagnosis is made by finding the organism in a biopsy specimen and isolating it in fungal culture. Treatment includes sulfamethoxazole-trimethoprim for mild forms and itraconazole for moderate cases. Fluconazole and voriconazole can be used for meningeal involvement, and amphotericin B is indicated for severe disease.

Introduction

Paracoccidioidomycosis is an acute-to-chronic systemic mycosis that is endemic in the Americas from Mexico to Argentina. The clinical picture of the disease is characterized by pulmonary involvement and potential spreading to other organs and systems, mostly to oral mucosa and skin.¹

Section snippets

Etiology

The etiologic agent of paracoccidioidomycosis is the thermodimorphic fungus Paracoccidioides brasiliensis, which belongs to the Phylum Ascomycota, Order Oxygenales, and Family Onygenaceae, the same of Blastomyces dermatitidis, Coccidioides immitis, C posadasii, Histoplasma capsulatum, and Lacazia loboi.² The natural habitat of P brasiliensis is, presumably, the soil, and the infection is due to inhalation of its propagules.2., 3. The fungi grow in a mycelial form at room temperature and as

Historical aspects

Paracoccidioidomycosis was first reported by Adolf Lutz in 1908 in Brazil.⁴ Lutz pointed out the presence of oral lesion, similar but distinct from squamous cell carcinoma, the budding aspect of the fungus found on tissue, and its distinct mycelial aspect in culture at 25°C. He did not suggest a name for the disease or for the fungus, but did recognize its “pseudococcidica” aspect and believed he had found a new “American hyphoblastomycosis.” Soon after, in 1911, Alfonse Splendore⁴ reported new

Epidemiology

Paracoccidioidomycosis has been reported as an autochthonous disease from southern Mexico to northern Argentina. There have been no reports from Belize and Nicaragua in Central America, or from Chile, French Guiana, Guiana, and Suriname in South America.2., 5. Paracoccidioidomycosis is prevalent in Brazil, Colombia, Venezuela, and Argentina and is classically associated with individuals from rural areas. The typical patient is a man aged 30 to 50 years.1., 5.

Paracoccidioidomycosis can become a

Natural history of the disease

Like the natural history of coccidioidomycosis and histoplasmosis, there is strong evidence that the fungus causing paracoccidioidomycosis infects the host through the respiratory tract.1., 2. A possible postinfection event is progression to overt disease or, more commonly, regression of the primary pulmonary complex with persistence of viable fungi, the so-called latent foci. Another possible outcome is transitory hematogenic dissemination with placement of an extrapulmonary latent foci.¹¹

Clinical classification

The large spectrum of clinical manifestation of paracoccidioidomycosis has prompted the appearance of many classifications of the disease that are derived mainly on the infected organs or systems. In 1987, however, a group of experts proposed a classification that has become a reference for the disease. Its main points are:

1.
Paracoccidioidomycosis infection: subclinical, detected only by skin-test positivity.
2.
Paracoccidioidomycosis disease:
- 2.1
  Acute or subacute form: usually young patients, both

Diagnosis

The gold standard for diagnosis is based on correct identification of P brasiliensis in clinical specimens or in tissue. Direct examination, using 10% potassium hydroxide applied to a smear sample, is effective and inexpensive. A histologic examination of tissue specimens using silver methenamine or periodic acid-Schiff stain is common and practical when patients present with oral or other skin lesions. Culture in Sabouraud agar should always be ordered but has low sensitivity.1., 5. Serologic

Treatment

Treatment must be based on the severity in every individual. Possible association with comorbidities must be investigated, and a realistic inquiry about patient access to specific drug therapy should be performed. Attention should be paid to the nutritional status of patients, and patients must halt alcohol and tobacco consumption.

Many drugs are useful in treating paracoccidioidomycosis. Itraconazole is considered the best option for mild to moderate clinical forms. The recommended dose is 200

Conclusions

Paracoccidioidomycosis still is a common and severe systemic mycosis in endemic countries. The incidence in non-endemic countries as an imported disease is growing and physicians have to be aware of it and to know its main clinical manifestations.

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