Print version ISSN 0365-0596
An. Bras. Dermatol. vol.86 no.6 Rio de Janeiro Nov./Dec. 2011
IMAGENS EM DERMATOLOGIA TROPICAL
Cutaneous and pulmonary paracoccidioidomycosis in a patient with a malignant visceral tumor*
Adriana Maria PorroI; Osmar RottaII
IPhD. Adjunct Professor, Department of Dermatology, São Paulo School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
IIPhD. Associate Professor and Head, Department of Dermatology, São Paulo School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
Paracoccidioidomycosis is a systemic mycosis caused by the fungus Paracoccidioides brasiliensis that is characterized by polymorphous clinical manifestations principally affecting the skin, mucous membranes, lungs, lymph nodes, adrenal glands and the central nervous system. Depending on the site of inoculation and the individual's immunological status, the disease may take various different forms, affecting the skin, lymph nodes, viscera or a combination of these. The present report describes a patient with extensive cutaneous and pulmonary paracoccidioidomycosis, with disseminated papules and pustules, fever and pulmonary symptoms, probably related to immunosuppression caused by a renal carcinoma.
Keywords: Carcinoma; Immunocompromised host; Kidney neoplasms; Paracoccidioidomycosis
A 68-year old man presented with acute fever, a dry cough and disseminated papules and pustules (Figures 1 and 2). Direct examination of the skin lesion: round-shaped, multi-budding, birefringent walled yeasts. Histopathology of the skin: Suppurative granuloma, round-shaped structures compatible with Paracoccidioides sp (Figures 3 and 4). Positive serology (1:4 dilution) for Paracoccidioides (immunodiffusion - antigen gp43). Chest x-ray: Perihilar infiltrates. Computed tomography of the abdomen: Image suggestive of renal carcinoma. Treatment was initiated with itraconazole 400 mg/day and both the patient's general state of health and his skin lesions improved. Resection of the renal carcinoma was performed (multilocular cystic renal cell carcinoma, a variant of clear cell renal cell carcinoma). This exuberant and atypical manifestation that resulted in the inclusion of numerous differential diagnoses emphasizes the importance of direct examination, a simple and inexpensive tool, for confirmation of diagnosis. The clinical behavior of this deep mycosis as an opportunistic disease should also be emphasized, this finding also being present in patients who are immunocompromised due to other causes such as organ transplantation or human immunodeficiency virus (HIV) infection. 1-6
1. Marques SA. Paracoccidioidomicose: atualização epidemiológica, clínica e terapêutica. An Bras Dermatol. 2003;78:135-50. [ Links ]
2. Marques SA, Cortez DA, Lastória JC, Camargo RMP, Marques MEA. Paracoccidioidomicose: freqüência, morfologia e patogênese de lesões tegumentares. An Bras Dermatol. 2007;82:411-7. [ Links ]
3. Sugar AM, Restrpo A, Stevens DA. Paracoccidioidomycosis in the immunosuppressed host: report of a case and review of the literature. Am Rev Respir Dis. 1984;129:340-2. [ Links ]
4. Goldani LZ, Sugar AM. Paracoccidioidomycosis and AIDS: an overview. Clin Infect Dis. 1995;21:1275-81. [ Links ]
5. Moraes-Vasconcelos D, Grumach AS, Yamaguti A, Andrade ME, Fieschi C, de Beaucoudrey L, et al. Paracoccidioides brasiliensis disseminated disease in a patient with inherited deficiency in the beta1 subunit of the interleukin (IL)-12/IL-23 receptor. Clin Infect Dis. 2005;41:e31-7. [ Links ]
6. Morejón KM, Machado AA, Martinez R. Paracoccidioidomycosis in patients infected with and not infected with human immunodeficiency virus: a case-control study. Am J Trop Med Hyg. 2009;80:359-66. [ Links ]
Mailing address: Received on 28.03.2010. * This study was conducted at the Department of Dermatology, São Paulo School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.
Adriana Maria Porro
Rua Tuim, 554 apto 221, Moema
04514-102 São Paulo, SP, Brazil
Approved by the Advisory Board and accepted for publication on 21.09.2010.
Conflict of interest: None
Financial funding: None
Received on 28.03.2010.
* This study was conducted at the Department of Dermatology, São Paulo School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.