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Corresponding author at: Department of Internal Medicine, University of Antioquia Medical School, Calle 15 Sur No 48-130, Medellin, Colombia. Tel.: +574 4481001.
Nowadays, paracoccidioidomycosis can be seen anywhere in the world
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Paracoccidioidomycosis clinical manifestations can be very diverse
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Paracoccidioidomycosis diagnosis often requires deep tissue biopsies
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Metastatic malignancies has to be ruled out when suspecting Paracoccidioidomycosis
1. Indication
A 49-year-old man, who works as a farmer in rural Colombia, consulted in the emergency department with a clinical picture of 5 months history of frontal and occipital headache, associated with dizziness, nausea, progressive dyspnea, dry cough, and shortness of breath. On physical examination, it was found that the patient had regular general conditions, is conscious, alert, and oriented, with marked signs of respiratory distress, bilateral crackles, normal abdominal palpation, mild left hemiparesis, 122/75 mmHg blood pressure, 116 beats per minute heart rate, 37.5 °C temperature, 40 breaths per minute respiratory rate, and 88% oxygen saturation on room air. Based on symptoms, chest images were performed showing bilateral infiltrates (Fig 1A and B ), and a brain MRI showed a right temporal lobe mass with vasogenic edema (Fig 1C). With all this findings, a metastasic tumor was suspected, and a right temporal lobe metastatic resection surgery was performed, where histopathologic Grocott's methenamine silver (GMS) stain showed the real diagnosis (Fig 1D).
Fig. 1(A) An anterior–posterior chest radiograph shows interstitial opacities in both lungs associated with multiple pneumonic consolidations that suggest a multilobar pneumonia, with a ground glass pattern in absent of pleural effusion.
(B) An unenhanced axial computed tomography (CT) shows a mediastinal lymphadenopathy, countless pulmonary nodular lesions, and bilateral tree-in-bud pattern.
(C) A magnetic resonance imaging (MRI) of the brain shows a right temporal lobe ring-enhancing mass of 30 mm of diameter, rounded, with extensive vasogenic edema that generates uncal and subfalcina herniation.
(D) Histopathology of brain biopsy on Grocott's methenamine silver (GMS) stain shows multiple, narrow base, budding yeast cells “steering wheels” of Paracoccidioides brasiliensis.
Paracoccidioidomycosis is prevalent in tropical and subtropical wet regions, which have acidic soil rich in organic material, with abundant streams, rivers, and vegetation. It occurs in countries like Mexico, Argentina, Uruguay, and Ecuador and has a higher prevalence in Colombia and most often in Brazil, where it has been reported up to the 80% of all patients with this fungal infection [
The infection is most prevalent in men than in women, with a ratio approximately of 13–15:1; this is due to the relationship with 17-b-estradiol in women, which has an important role of inhibiting the development and growth of the fungus [
In an immunocompetent host, this infection and fungal growth in general is limited and almost ends with no apparent damage, which is known as subclinical infection. In these cases, the primary focus of infection disappears, and the fungus is usually destroyed leaving immunity to future infection. Then the host–fungus balance is the one affected in the symptomatic forms of the infection, where it takes an important role the imbalance in patients with certain immunosuppression degree. It is an interesting fact that our patient had no record of impairment or compromise of any type on his immune response, and even more, that is infrequently a spread of the infection on an immunocompetent host, especially to the central nervous system [
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