A Retrospective Study of Oral Manifestations in Patients with Paracoccidioidomycosis

S o u t h A m e r i c a n b l a s t o m y c o s i s , paracoccidioidomycosis (Pb mycosis) or Lutz disease, a chronic granulomatous disease caused by the dimorphic fungus Paracoccidioidis brasiliensis is the most prevalent systemic mycosis on South America (Brazil, Argentina, Colombia, and Venezuela) that usually affects healthy, middle-aged adults, most of them men involved in rural activities. This disease causes cutaneous and/ or respiratory tract mucosal lesions ranging from oral ulcerations, extensive laryngeal lesions and diffuse interstitial pulmonary involvement (1,2). Pb mycosis presents a marked tendency to dissemination for any organ or system, such as lungs, lymph nodes, mucosa of the upper respiratory and digestive tracts, skin, adrenal glands, bones and joints, central nervous system, eyes, urogenital tract, and thyroid. A Retrospective Study of Oral Manifestations in Patients with Paracoccidioidomycosis


INTRODUCTION
S o u t h A m e r i c a n b l a s t o m y c o s i s , paracoccidioidomycosis (Pb mycosis) or Lutz disease, a chronic granulomatous disease caused by the dimorphic fungus Paracoccidioidis brasiliensis is the most prevalent systemic mycosis on South America (Brazil, Argentina, Colombia, and Venezuela) that usually affects healthy, middle-aged adults, most of them men involved in rural activities.This disease causes cutaneous and/ or respiratory tract mucosal lesions ranging from oral ulcerations, extensive laryngeal lesions and diffuse interstitial pulmonary involvement (1,2).
Pb mycosis presents a marked tendency to dissemination for any organ or system, such as lungs, lymph nodes, mucosa of the upper respiratory and digestive tracts, skin, adrenal glands, bones and joints, central nervous system, eyes, urogenital tract, and thyroid.
Due to such behavior, polymorphic manifestations are frequently observed, which impairs the establishment of a diagnosis by the clinical aspects.Thus, Pb mycosis is not always suspected and sometimes patients can be misdiagnosed, mainly in cases of females and younger individuals (3).However, the oral lesions are suggestive of the disease and of easy diagnosis.
Healthy subjects living in endemic areas may be infected by inhalation of propagules of fungus and develop one of the two clinical forms: (i) acute or subacute form, with severe involvement of the mononuclear phagocyte system; or (ii) the chronic form, with insidious evolution and involvement of one or more organs.Oral lesion morphology is variable, but the most common pattern is an infiltrative lesion with a fine granular surface which eventually resembles a mulberry (moriform stomatitis) or ulcerative lesions with infiltrated borders.Small lesions (0.5 cm) or extensive plaques may be seen, and different regions are frequently involved.Sometimes, the oral lesions are painful, especially with ingestion of hot or salty food (4).
Diagnosis of Pb mycosis is confirmed by the observation of multibudding and birefringent yeast cells by direct microscopic examination of biologic fluids (sputum, bronco-pulmonary secretions) or histopathological examination of skin and mucosal biopsies, and also by isolation of the fungus in cultures.Direct microscopic examination is definitive and the gold standard method to identify the fungus in lesions.Culture usually requires a long time, is less sensitive than direct examination and has a high rate of negative results, especially if the samples are contaminated or in small amount.Paracoccidioidal mucosa and lymph node lesions must be included in the differential diagnosis of other granulomatous infection diseases.Patients with mucocutaneous leishmaniosis can be differentiated by the presence of nasal lesions.Pb mycosis should also be differentiated from cancers of the oral cavity, oropharynx and larynx, most commonly the result of squamous cell carcinoma and lymphoma (5).
The aim of this work was to evaluate the prevalence of Pb mycosis oral lesions in patients assisted at a public specialized oral diagnosis center, with special focus on the different clinical forms of these lesions, its location, patients' occupation, deleterious habits, and diagnosis methodology.Students' and professionals' initial diagnoses were compared with the definitive diagnosis.The statistical analysis was undertaken with the discrepancies between final diagnosis (Pb mycosis) and the initial diagnosis was done to verify if there was statistical difference between the diagnoses made by the professionals who referred the patients to our Center and those made by the undergraduate dental students who received the patients at our Center.The results were compared by ANOVA at 5% significance level using the SPSS software (SPSS Inc., Chicago, IL, USA).

RESULTS
Review of the records of 18 patients with a definitive diagnosis of Pb mycosis revealed that 16 (88.8%)were males and only 2 (11.2%) were females, with age varying from 24 to 73 years (mean age =50.22).A total of 31 lesions were detected in 18 patients.Fourteen patients (77.8%) were using some type of medication to treat other systemic conditions or to relieve pain/blazing caused by the oral lesion.Out of these, 2 were taking Itraconazole (patient #1) and Bactrim (patient #2) after previous evaluation at another specialized treatment center.Seven (39%) patients work(ed) with activities related to agriculture.
Sixteen (88.8%) patients were smokers, 13 (72.2%)were alcohol users sporadically or routinely and 3 (16.6%)used to put objects in mouth like sticks or to chew grass.Exfoliative cytology was performed in 12 (66.6%)lesions and incisional surgery in 6 (33.3%) of the patients.
Pb mycosis lesions presented different characteristics like a moriform aspect with bleeding points, infiltrative lesions with a fine granular surface which eventually resembles a mulberry (moriform stomatitis), or ulcerative lesions with infiltrated borders.
Comparing the initial with the definitive diagnosis made by the professionals their accuracy was 33% (6 out of 18 patients).Eight (44.5%) patients were referred without a diagnosis, 2 (11.1%) had defined the lesion as squamous cell carcinoma, 1 (5.5%) was referred with an initial diagnosis of leukoplakia, and 1 (5.5%) as epithelial hyperplasia.Students' diagnosis was more accurate demonstrating 72.5% of initial correct diagnosis (13 out of 18).In three patients (16.5%), the initial diagnosis was squamous cell carcinoma.Another one (5.5%)was initially diagnosed with candidiasis and in one (5.5%) the diagnostic was inconclusive (Fig. 2).Statistical analysis demonstrated a significant difference between the diagnosis of Pb mycosis made by students and professionals when considering initial and final (after histopathological analysis) diagnostic (p=0.25).

DISCUSSION
After inhalation, fungal organisms penetrate the respiratory tract and lodge in the lungs, producing a primary infection.From the lungs, the fungi invade other organs and spread, leading to granulomatous mucosal and skin lesions appearance, with the majority of the cases involving rural workers or residents of these areas (6).The involvement of 10 (33%) of patients with activities related to agriculture found at this work is similar to other studies (3,7,8).The different clinical forms of Pb mycosis often lead the patients to have a delayed diagnosis, making the treatment of its disease more complicate, diminishing patients' survival and quality of life.The differential diagnosis of Pb mycosis is made observing some important signs such as localized or systemic adenopathy, presence of oral mucosa or skin lesions, and pulmonary involvement.Patients' general health can also be affected by some nonspecific systemic manifestations, including anemia, weight loss, headaches and fever (9).Pb mycosis may occur as a subclinical infection and, when clinically apparent, it may have some different characteristics such as acute or subacute and chronic stages.The acute or subacute form tends to be rapidly progressive and affects young individuals as moderate or severe.In both groups, mortality tends to be high if left untreated (10).The chronic form of Pb mycosis shows a male predominance, age between 30 and 60 years and it is the most common form of the disease.The male-to-female ratio is 19:1 due to a female hormone (β-estradiol) that prevents the differentiation of the fungi to pathogenic form.The present results demonstrate similar findings to those of other studies (6).
The signs and symptoms of Pb mycosis include oral pain, drooling, unpleasant mouth odor, and difficult of mastication being diagnosed in different oral regions.When located in the gingiva or palate, the lesion may have a moriform characteristic aspect with bleeding points.Often there is periapical and periodontal involvement, which can cause spontaneous exfoliation of teeth.It is quite common the patient report disease manifesting after extraction of a periodontally compromised tooth.Differential diagnosis is done with cancer, tuberculosis, syphilis, Wegener granuloma, leishmaniasis and other mycoses, such as histoplasmosis and coccidiodomicose (3).Meneses-Garcıa et al. (11) reported two cases of Pb mycosis mimicking squamous c e l l c a r c i n o m a , w h i c h highlights the importance of an adequate biopsy specimen not to avoid misdiagnosis.In general, granulomatous  infections exhibit a pseudoepitheliomatous hyperplasia and this may lead to a mistaken diagnosis of cancer.Also, Pb mycosis oral lesions may present different characteristics, but the most common pattern is defined as infiltrative lesions with a fine granular surface, which occasionally resemble a mulberry (moriform stomatitis) or ulcerative lesions with infiltrated borders, but small lesions or extensive plaques may be seen.In this study, different forms of these lesions in oral cavity were seen and the definitive diagnosis was done by means of incisional or exfoliative biopsy.
When the definitive diagnosis was compared with the initial diagnosis made by the professionals who referred the patients to our Center or by the students who assisted the patients at our Center, it was verified that only 33.3% of the professionals made the correct diagnosis while 72.5% of correct diagnosis was made by the students before any biopsy technique.The professional who referred the patients to our Center work in public dental offices and are general dentists that are not familiarize to oral lesions.Differently from professionals, the students of our specialized Center are effectively involved in pathological oral diagnosis with constant practice, demonstrating the importance of routine practice to detect and indicate correct treatment.Garcia et al. (12) described a 41-year-old man with paracoccidioidomycosis of the larynx mimicking carcinoma.After staining with Grocott (13) method, the diagnosis of Pb mycosis was conclusive with no histopathological evidence of malignancy.Those authors concluded that Pb mycosis should be suspected in individuals who have lived in endemic areas and who present lesion similar to carcinoma.
The diagnostic methods of Pb mycosis can be exfoliative cytology or incisional biopsy, the first being a valid and useful examination due to simplicity, low cost, minimal side effects and its routine use in outpatients to diagnosis suspicious oral lesions (14).Another advantage of this examination is its use in patients with compromised immune system, where the intervention of an incisional biopsy, as it may seem simple, can bring a huge risk to patient's life.Traditionally, the procedure used for the diagnosis of the suspicious oral lesions of Pb mycosis is the incisional biopsy with subsequent histopathological analysis using staining methods specific to the fungus (15).For Grocott (13), impregnation by silver metanamine was found to be superior when used for diagnosis of fungal lesions, with this method being used after obtaining the smears by exfoliative cytology.As cited above, the preferencial method for diagnosis of Pb mycosis is the isolation of the fungus in culture and the positive identification of multibudding and birefringent yeast cells by direct examination of biologic fluids or biopsy specimens (16).
The treatment of Pb mycosis is done even with fluconazole, ketoconazole or itraconazole, drugs that cause a disturbance in fungal membrane permeability, inhibiting ergosterol synthesis.Fluconazole presents the best results, knowing that 80% of its dose is excreted in the urine and its absorption is not affected by food or acidity.Amphotericin B is a potentially nephrotoxic drug and it is no longer used as routine due to its capability of producing systemic effects.An important information is that dental interventions in patients with active lesions should not be performed unless the patient uses appropriate medications for at least 3 months uninterrupted in order to avoid the risk of fungus spread (17).
In conclusion, oral lesions were found in all patients with Pb mycosis, confirming their high stomatological incidence.It was also demonstrated the importance of specialized oral care professionals in a multidisciplinary team to achieve the best treatment outcome and follow up of patients affected by this disease.

Figure 1 .
Figure 1.Location of Pb lesions in the oral cavity.