Paracoccidioidomycosis

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 silver 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