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Key Features

  • Paracoccidioides brasiliensis and Paracoccidioides lutzii infections have only been found in patients who have resided in Mexico, Central and South America

  • Long asymptomatic periods enable persons to travel far from endemic area before symptoms occur

  • Primary infection is probably acquired through inhalation

  • An acute form of the disease affects predominately younger patients and involves the mononuclear phagocytic system resulting in progressive lymphadenopathy

  • A more chronic form affects mostly adult men and involves the lung, skin, mucous membranes, and lymph nodes

Clinical Findings

  • Weight loss, pulmonary complaints, or mucosal ulcerations are most common symptoms

  • Extensive coalescent ulcerations may eventually result in destruction of the epiglottis, vocal cords, and uvula

  • Extension to the lips and face may occur

  • Lymph node enlargement

    • May follow mucocutaneous lesions, eventually ulcerating and forming draining sinuses

    • It is the presenting symptom in some patients

  • Hepatosplenomegaly may be present

  • HIV-infected patients are more likely to have extra-pulmonary dissemination and a more rapid clinical disease course

Diagnosis

  • Routine laboratory tests are nonspecific

  • Immunodiffusion serologic tests positive in > 80% of cases

  • Complement fixation titers correlate with progressive disease and fall with effective therapy

  • Diagnosis is confirmed by finding P brasiliensis as spherical cells with many buds arising from it

  • If direct examination of secretions does not reveal the organism, biopsy with Gomori staining may be helpful

Treatment

  • Oral itraconazole, 100 mg twice daily

    • Treatment of choice

    • Response is usually seen within the first month, with effective control within 2–6 months

  • Trimethoprim-sulfamethoxazole (480 mg + 1200 mg) twice daily orally is as effective as itraconazole and less costly, but associated with more adverse effects and longer time to clinical cure

  • Oral voriconazole, 200 mg twice daily, appears to be as effective as itraconazole

  • Amphotericin B, 0.7–1.0 mg/kg/day intravenously, is the drug of choice for severe and life-threatening infection

  • Amphotericin B lipid complex, 3–5 mg/kg/day, has been shown to be effective and safe for severe disease

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