Paracoccidioidomycosis: acute-subacute clinical form, juvenile type^*

Abstract:

The authors report aspects of paracoccidioidomycosis, acute-subacute clinical form, juvenile type, in a 19-year-old female patient. Paracoccidioidomycosis, juvenile type, classically occurs in young patients, both sexes, with lymphoma-like aspects as initial presentation. However, following the natural history of the disease the lymph nodes assume patterns of infectious disease, as an abscess and fistulae. Systemic dissemination of the disease can occur and lethality and morbidity are significant in this clinical presentation.

Keywords:
Inflammation; Lymph nodes; Paracoccidioidomycosis

Female patient, 19-year-old, from the countryside of the state of São Paulo, Brazil. She reported onset of cervical tumors 3 months before the consultation, with progressively increasing and worsening of symptoms accompanied by evening fever of up to 38 °C in the last month. On examination, cervical and submandibular lymph nodes with increased volume were observed, at different developmental stages: from the absence of inflammation to clearly patterns of infectious disease, abscess consistency and fistulization, with ulcerated skin and purulent secretion (Figures 1 and 2).The diagnosis of acute/ subacute paracoccidioidomycosis, juvenile type, was confirmed by direct microscopic examination of lymph node secretion (obtained by aspiration), by histopathological examination, which revealed classical budding forms of Paracoccidioides spp., and by serology (double immunodiffusion technique), which showed a title of 1/32 (Figures 3 and 4). The patient was treated with itraconazole 400 mg/day for 2 months, reducing the medication to 200 mg/day until treatment completed 12 months. There was clinical and serological remission.

Figure 1 :
Paracoccidioidomycosis: swollen lymph nodes with inflammatory aspect and fistula, ulcerated skin and purulent secretion (cervical and submandibular regions)

Figure 2 :
Paracoccidioidomycosis: details of the lymph nodes with inflammatory aspect and fistulization

Figure 3 :
Paracoccidioidomycosis: presence of hyperplasia of the epidermis and deep dermal inflammatory infiltrate with multiple giant cells harboring fungi (HE, 40x; detail: 200x)

Figure 4 :
Paracoccidioidomycosis: numerous multi budding yest cells in the dermis (Grocott-Gomori, 40x)

DISCUSSION

Acute/ subacute paracoccidioidomycosis, juvenile type, classically occurs in young patients of both sexes and is characterized by tropism of the fungus to the monocyte-phagocyte system.^1-4

Clinically, it presents enlarged lymph nodes in superficial and deep chains, associated with liver, spleen and bone involvement. The initial framework resembles Hodgkin's lymphoma, with firm nodes, coalescing, associated with evening fever.^5,6 In the evolution without treatment, lymph nodes assume inflammatory aspect, abscessing and fistulizing, as in this case. In this clinical form, the skin lesions are frequent and mucosal lesions are rare. The lymphatic and hematogenous dissemination makes it a serious condition with high mortality rate.⁷

• Financial Support: None.
• *
  Study performed at Departamento de Dermatologia e Radioterapia da Faculdade de Medicina de Botucatuof Unesp

REFERENCES

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Publication Dates

• Publication in this collection
  May-Jun 2016

History

• Received
  21 July 2015
• Accepted
  16 Aug 2015