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Revista da Sociedade Brasileira de Medicina Tropical

versão impressa ISSN 0037-8682versão On-line ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.52  Uberaba  2019  Epub 18-Jul-2019

http://dx.doi.org/10.1590/0037-8682-0108-2019 

Images in Infectious Diseases

Bone involvement in paracoccidioidomycosis

Fernanda Lopes Franco1 

Bruno Niemeyer1  2  3 
http://orcid.org/0000-0002-1936-3026

Edson Marchiori3 

1Departamento de Radiologia, Hospital Casa de Portugal, Rio de Janeiro, RJ, Brasil.

2Departamento de Radiologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil.

3Departamento de Radiologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.


An 8-year-old immunocompetent boy presented with fever, adynamia, hepatosplenomegaly, and scattered erythematous pustular lesions on his upper limbs (Figure 1A) that occurred in the last three months and recently evolved to pain and functional inability of his left hand. Computed tomography showed multiple well-delimited osteolytic lesions without sclerotic halo or contrast enhancement affecting his left ulna, metacarpals, and phalanges (Figures 1B-D), with no evidence of periosteal reaction. Histopathological analysis of the bone lesion on the second right metacarpal revealed fungal elements compatible with Paracoccidioides brasiliensis. Treatment was initiated with itraconazole (5 mg/kg/day orally), and the patient showed progressive clinical improvement.

FIGURE 1: (A): erythematous pustular lesion on the lateral aspect of the elbow. (B-D): computed tomography showing multiple well-delimited osteolytic lesions without a sclerotic halo (arrows) affecting the left ulna, metacarpals, and phalanges (B-D), with no evidence of periosteal reaction. 

Osteoarticular involvement by paracoccidioidomycosis results from lymphohematogenous dissemination, with a primary focus in the lungs, predominantly in men aged 20-40 years1-3. Clinically, most cases are asymptomatic, but patients may present with pain, edema, and heat sensation in the lesion area.

The disease can affect any bone, but most frequently affects the clavicle, ribs, scapula, and sternum; although rare, lesions can develop in the radius and phalanges1-3. On the long bones, lesions usually originate in the medullary cavity of the diaphysis and extend to the metaphysis and epiphysis, which are the most affected sites owing to their greater vascularization1,3. The commonest radiographic characteristics are distinctly outlined lytic lesions with no marginal sclerosis and little or no periosteal reaction, similar to our case1-3. The most frequently considered differential diagnoses are neoplasms, bone metastases, histiocytosis, lymphoproliferative disorders, and infections caused by other agents, including sporotrichosis.

ACKNOWLEDGMENTS

We thank the institutions that provided technical support for the development and implementation of this study.

REFERENCES

1. Correa-de-Castro B, Pompilio MA, Odashiro DN, Odashiro M, Arão-Filho A, Paniago AM. Unifocal bone paracoccidioidomycosis, Brazil. Am J Trop Med Hyg 2012;86(3):470-3. [ Links ]

2. Lima Júnior FV, Savarese LG, Monsignore LM, Martinez R, Nogueira-Barbosa MH. Computed tomography findings of paracoccidiodomycosis in musculoskeletal system. Radiol Bras. 2015;48(1):1-6. [ Links ]

3. Monsignore LM, Martinez R, Simão MN, Teixeira SR, Elias J Jr, Nogueira-Barbosa MH. Radiologic findings of osteoarticular infection in paracoccidioidomycosis. Skeletal Radiol. 2012;41(2): 203-8. [ Links ]

Recebido: 15 de Março de 2019; Aceito: 06 de Junho de 2019

Conflict of Interest: The authors declare that there is no conflict of interest.

Corresponding author: Dr. Bruno Niemeyer. e-mail:bruno.niemeyer@hotmail.com

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License