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Paracoccidioidomycosis
South American blastomycosis
Paracoccidioidomycosis refers to the endemic disease produced by Paracoccidioides brasiliensis. The infection is found beginning at about 23 degrees North latitude in Mexico and extends southwards to Argentina. It is not seen in Chile and the Caribbean Islands. The ecologic niche for P. brasiliensis remains obscure and the fungus has only been isolated four times from soil [328, 2107]. Inhalation of conidia is presumably the route of acquisition. Primary infection is asymptomatic in most cases. The fungus can remain dormant for years within lymph nodes to appear later probably in relation to some type of immunodeficiency [756, 1430, 1896]. Interestingly, paracoccidiodomycosis affects primarily men (Men/women ratio 15:1) and people older than 30. A juvenile form with a peculiar poor prognosis occurs rarely [1362]. The adult form usually manifests with painful ulcerated lesions in the mouth. Other clinical presentations include cutaneous lesions, lymphadenopathy, dysphagia, and hoarseness [2139]. Finally a clinical picture identical to pulmonary tuberculosis (fever, weight loss, and productive cough with blood-tinged sputum) may also occur [328, 1362].
| CATEGORIES |
NOTES |
| Asymptomatic |
- Occurs in a large proportion of cases
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| Mucosal lesions |
- Ulcerative lesions that may affect any structure within the mouth, nose, larynx and oropharynx
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| Pulmonary |
- Confluent nodular bilateral infiltrates mainly affecting the central and basal zones of the lungs
- Cavitary lesions may also be found. Hilar adenopathy is usually absent.
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| Skin |
- Ulcerative, crusty lesions that tend to infiltrate the subcutaneous tissues
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| Others |
- May affect spleen, GI tract, liver, bones, central nervous system, and male genitourinary tract
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The prognosis of paracoccidioidomycosis is good when treated, however treatment regimens are very long and relapse is frequent. P. brasiliensis has the peculiarity among the fungi of responding to treatment with sulfa drugs. However, regimens with these agents require maintenance treatment for up to 5 years. Amphotericin B is not curative by itself and should be given with sulfas or azoles. The azole antifungals have provided a significant advance in the treatment of paracoccidioidomycosis. Ketoconazole, itraconazole, and fluconazole have all been used [589, 1897, 2294]. Current data favors itraconazole as it appears to have the lowest rate of relapse [1459, 1618]. In vitro data suggest that voriconazole may be an alternative in the future [1152].
Areas of granulomatous inflammation containing a focal area of central caseation mixed with pyogenic abscesses are usually present. Many giant cells are present in the granulomata which contain the organisms. The fungus occurs as a budding yeast with cells 12-14 um in diameter. The central cell is surrounded by numerous blastoconidia of various sizes that are attached by narrow necks.
Direct examination of sputum, biopsy material (base and outer edge of ulcers), or crusts/pus from suppurative draining lymph nodes typically contain the yeast form. Material mounted in 10% KOH for examination will show the fungus, which is characterized by multiple budding with globose young cells 2-10 um in diameter to globose mature cells 30 um in diameter or greater at the center. Some cells may reach 60 um in diameter.
Inoculate the clinical material onto Sabouraud dextrose agar and a medium containing cycloheximide. Incubate cultures at 30°C and do not discard as negative until 4 weeks. The colony may require 10 or more days to reach 1 cm in diameter.
The mould-form-to-yeast-form conversion is necessary since Paracoccidioides brasiliensis is usually sterile and DNA confirmation probes are usually cross reactive with the Blastomyces dermatitidis probe. Conidia may be formed which are similar to those produced by the genus Chrysosporium. Inoculate the fungus on brain heart infusion agar supplemented with glutamine and incubate at 37°C.
Soil, wood
Standardized testing procedures are not available. Microbiological resistance has not been demonstrated.
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Distribution of P. brasiliensis. |
Lung
X rays of patient with P. brasiliensis |
Lung X rays of patient with P. brasiliensis |
Lung X rays of patient with P. brasiliensis |
Mouth lesion of patient with paracoccidioidomycosis |
skin lesions of patient with paracoccidioidomycosis |
H & E stained tissue with P. brasiliensis |
KOH preparation of tissue with the yeast phase of P. brasiliensis
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References
328. Brummer, E., E. Castaneda, and A. Restrepo. 1993. Paracoccidioidomycosis: An update. Clin. Microbiol. Rev. 6:89-117.
589. Diaz, M., R. Negroni, F. Montero-Gei, L. G. Castro, S. A. Sampaio, D. Borelli, A. Restrepo, L. Franco, J. L. Bran, E. G. Arathoon, and et al. 1992. A Pan-American 5-year study of fluconazole therapy for deep mycoses in the immunocompetent host. Pan-American Study Group. Clin Infect Dis. 14 Suppl 1:S68-76.
756. Franco, M., M. T. Peracoli, A. Soares, R. Montenegro, R. P. Mendes, and D. A. Meira. 1993. Host-parasite relationship in paracoccidioidomycosis. Curr Top Med Mycol. 5:115-49.
1152. Kappe, R. 1999. Antifungal activity of the new azole UK-109, 496 (voriconazole). Mycoses. 42:83-86.
1362. Londero, A. T., and C. D. Ramos. 1990. [Estudo clinico-micológico de 260 casos observados no interior do Estado do Rio Grande do Sul]. J Pneumol (Bras). 16.
1430. Manns, B. J., B. W. Baylis, S. J. Urbanski, A. P. Gibb, and H. R. Rabin. 1996. Paracoccidioidomycosis: case report and review. Clin Infect Dis. 23:1026-32.
1459. Martins, R., S. Marques, M. Alves, D. Fecchio, and M. F. de Franco. 1997. Serological follow-up of patients with paracoccidioidomycosis treated with itraconazole using Dot-blot, ELISA and western-blot. Rev Inst Med Trop Sao Paulo. 39:261-9.
1618. Naranjo, M. S., M. Trujillo, M. I. Munera, P. Restrepo, I. Gomez, and A. Restrepo. 1990. Treatment of paracoccidioidomycosis with itraconazole. J Med Vet Mycol. 28:67-76.
1896. Restrepo, A., C. de Bedout, L. E. Cano, M. D. Arango, and V. Bedoya. 1981. Recovery of Paracoccidioides brasiliensis from a partially calcified lymph node lesion by microaerophilic incubation of liquid media. Sabouraudia. 19:295-300.
1897. Restrepo, A., I. Gomez, L. E. Cano, M. D. Arango, F. Gutierrez, A. Sanin, and M. A. Robledo. 1983. Treatment of paracoccidioidomycosis with ketoconazole: a three-year experience. Am J Med. 74:48-52.
2107. Silva-Vergara, M. L., R. Martinez, Z. P. Camargo, M. H. Malta, C. M. Maffei, and J. B. Chadu. 2000. Isolation of Paracoccidioides brasiliensis from armadillos (Dasypus novemcinctus) in an area where the fungus was recently isolated from soil [In Process Citation]. Med Mycol. 38:193-9.
2139. Sposto, M. R., O. D. P. Almeida, and J. Jorge. 1993. Oral paracoccidioidomycosis. A study of 36 South American patients. Oral Med Oral Pathol. 75:464-465.
2294. Vargas, J., and M. Recacoechea. 1988. Ketoconazole in the treatment of paracoccidioidomycosis (South American blastomycosis). Experience in 30 cases in Bolivia. Mycoses. 31:187-97.
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