BACKGROUND: Paracoccidioidomycosis is a neglected tropical disease caused by fungi of the genus Paracoccidioides. A wide range of symptoms is related to the disease; however, lungs and skin are the sites predominantly affected. The disease is mostly seen in people living in rural areas in Latin America.
METHODS: We present a pediatric case of severe disseminated paracoccidioidomycosis that slowly responded to the antifungal treatment. Within three months, symptoms evolved into hepatosplenomegaly, necrotic cervical and abdominal lymph nodes, and splenic abscess. Clinical response to amphotericin B deoxycholate and itraconazole was slow, resulting in pleural and peritoneal cavity effusions, heart failure and shock. Amphotericin B deoxycholate was replaced by the liposomal formulation, with no response. Subsequently, prednisone was added to the treatment, which led to improvement in the clinical response. Serological Paracoccidioides antibody titers were atypical, with very low titers in the critical phase and significant increase during the convalescence phase. The infection was finally cleared up with amphotericin B deoxycholate, liposomal amphotericin B and the use of corticosteroids. Paracoccidioidomycosis serology was non-reactive two years post-discharge.
CONCLUSIONS: Due to the intense inflammatory response triggered by Paracoccidioides cells, giving low-dose prednisone for a short period of time modulated the inflammatory response and supported antifungal treatment.

Paracoccidioidomycosis is a systemic infection caused by the fungus Paracoccidioides. It may present in two forms: an acute/subacute form, whose most frequent manifestations include weight loss, fever, anemia, and adenopathy, and a chronic condition with mainly respiratory symptoms. Digestive symptoms, although they may occur, are not frequently reported. Paracoccidioidomycosis usually affects adult male agricultural workers; thus, its presentation in children is rare.
We describe the case of a 9-year-old male patient diagnosed with paracoccidioidomycosis, who showed abdominal pain and diarrhea as initial manifestations of the disease.
This case is reported not only because of the age of presentation but also due to the existence of digestive symptoms from the onset of the disease, both infrequently reported in the literature.
La paracoccidioidomicosis es una infección sistémica producida por el hongo Paracoccidioides. Se puede presentar de dos formasuna forma aguda/subaguda, cuyas manifestaciones más frecuentes incluyen pérdida de peso, fiebre, anemia y adenopatías, y una forma crónica con manifestaciones principalmente respiratorias. Las manifestaciones digestivas, aunque pueden presentarse, no se reportan frecuentemente. La paracoccidioidomicosis afecta usualmente a varones adultos que trabajan en labores agrícolas, por lo que su presentación en niños es poco frecuente.
Se describe el caso de un paciente de sexo masculino de 9 años de edad con diagnóstico de paracoccidioidomicosis, con dolor abdominal y diarrea como manifestaciones iniciales de la enfermedad.
Se reporta este caso, no solamente por la edad de presentación, sino también por la existencia de síntomas digestivos desde el inicio de la enfermedad, ambos reportados en forma infrecuente en la literatura.

Paracoccidioidomycosis is a progressive, chronic, systemic disease which is the second most common form of mycosis in South America, affecting approximately 10million people in this region. It occurs most commonly in adult male farmers and mainly affects the lungs. Oral paracoccidioidomycosis is the second most frequent chronic presentation. We report the case of an immunocompetent female patient whose oral mucosae was infected with paracoccidium and discuss oral paracoccidium.

BACKGROUND: Pulmonary mycoses resemble clinically and radiologically chronic pulmonary tuberculosis. Studies describing the prevalence, etiology and clinical features of pulmonary mycosis are of crucial importance in the Brazilian Amazon.
OBJECTIVE: To estimate the frequency of pulmonary mycoses in smear-negative tuberculosis patients; to describe their demographic, epidemiological, and clinical characteristics; and to evaluate diagnostic methods.
METHODS: A cross-sectional study was conducted at two tuberculosis reference institutions in Amazonas, Brazil. We included 213 patients and collected clinical data, blood and induced sputum to perform serological, direct microscopy, microbiologic culture and PCR-based assays to identify infections caused by Aspergillus fumigatus, Paracoccidioides brasiliensis, Histoplasma capsulatum, Cryptococcus, and HIV. Chest computed tomography was also performed.
RESULTS: Pulmonary mycoses were diagnosed in 7% (15/213) of the cases, comprising ten aspergillosis cases, three cases of paracoccidioidomycosis and one case each of histoplasmosis and cryptococcosis. Among the patients with pulmonary mycoses, 86.7% were former tuberculosis patients. The most significant clinical characteristics associated with pulmonary mycoses were cavity-shaped lung injuries, prolonged chronic cough and hemoptysis.
CONCLUSIONS: Our study confirmed the high prevalence of pulmonary mycoses in smear-negative tuberculosis patients in the Brazilian Amazon.

BACKGROUND: Paracoccidioidomycosis (PCM) is an endemic disease in Latin America. In immunocompetent hosts, PCM occurs in two main clinical forms: acute and chronic. However, in HIV-infected patients PCM may show up simultaneous manifestations of acute and chronic forms.
METHODS: We present the case of a patient diagnosed with HIV who had disseminated skin lesions and generalized lymphadenopathy, as well as respiratory and central nervous system involvement. The PCM diagnosis was confirmed by direct KOH examination, double immunodiffusion and the isolation of the fungus in samples of an abscess in the subcostal region. The isolate was identified as Paracoccidioides brasiliensis S1 by species-specific PCR using primers for protein-coding gene GP43 (exon 2) followed by PCR-RFLP of the alpha-tubulin gene.
CONCLUSIONS: There are few data in literature reporting species-specific molecular identification of Paracoccidioides in HIV/PCM patients. Therefore, this case report may contribute to improve the knowledge about this severe disease, its causative cryptic species, and its consequences to patients.

BACKGROUND: Paracoccidioidomycosis (PCM) is a systemic mycosis of acute and chronic evolution, caused by species belonging to the genus Paracoccidioides. It is considered the most prevalent systemic endemic mycosis in Latin America, with cases in the tropical and subtropical regions. Residual PCM refers to the fibrotic scar sequelae resulting from the disease treatment which, when associated with collagen accumulation, leads to functional and anatomic alterations in the organs.
OBJECTIVE: The aim of this study was to evaluate the vocal function of patients with residual PCM in upper airways and digestive tract.
METHODS: We performed a cross-sectional study in 2010 in a cohort of 21 patients with residual PCM in upper airways and digestive tract.
RESULTS: The average age was 49.48±9.1 years, and only two (9.5%) patients were female. The study was performed in the 1-113 month-period (median 27) after the end of drug treatment. Five (23.8%) patients had alterations in the larynx as a sequela of the disease. However, all patients had vocal changes in vocal auditory perceptual analysis by GRBASI scale. The computerized acoustic analysis using the software Vox Metria, showed that 11 patients (52.4%) presented alterations in jitter, 15 (71.4%) in shimmer, 8 (38.1%) in F0, 4 (19%) in glottal to noise excitation (GNE), 7 (33.3%) in the presence of noise and 12 (57.1%) in the presence of vibratory irregularity.
CONCLUSIONS: The great frequency of alterations in residual PCM suggests that the patients in such phase could benefit from a multidisciplinary treatment, offering them integral monitoring of the disease, including speech rehabilitation after the PCM is healed.

In the second part of this review on the deep mycoses, we describe the main systemic mycoses-paracoccidioidomycosis, coccidioidomycosis, histoplasmosis, mucormycosis, and cryptococcosis-and their cutaneous manifestations. Skin lesions are only occasionally seen in deep systemic mycoses either directly, when the skin is the route of entry for the fungus, or indirectly, when the infection has spread from a deeper focus. These cutaneous signs are often the only clue to the presence of a potentially fatal infection. As with the subcutaneous mycoses, early diagnosis and treatment is important, but in this case, even more so.

OBJECTIVE: To describe magnetic resonance imaging (MRI) findings in musculoskeletal paracoccidioidomycosis (PCM).
METHODS: Retrospective case series study after IRB approval. Two musculoskeletal radiologists reviewed in consensus the MRI findings of 11 patients with microbiologically and/or pathologically proven osteoarticular PCM. The MRI evaluation included discrimination of abnormalities in joints, bones and soft tissues.
RESULTS: Mean age of patients was 29 years (10-55 years), eight men and three women. Musculoskeletal involvement was the only or the primary presentation of the disease in seven patients (63%). Osteomyelitis was the most common presentation, with seven cases (63%). Primary arthritis was found in one patient (9%). Isolated extra-articular soft tissue PCM was found in three patients: myositis (2) and subcutaneous infection (1). All cases showed regions with signal intensity higher than or similar to the signal of muscle on T1-weighted images. Penumbra sign was present in five cases (45%). T2-weighted images showed reactive soft tissue oedema in eight cases (72%). Post-gadolinium images showed peripheral (8/9) or heterogeneous (1/9) enhancement. Synovial enhancement was present in all cases of joint involvement (6/6). Lipomatosis arborescens was documented in one case of chronic knee involvement.
CONCLUSIONS: To our knowledge, this is the first case series describing MRI findings of musculoskeletal PCM. Musculoskeletal involvement was the primary presentation of the disease in most cases, and therefore, neoplasms were initially in the differential diagnosis. Osteomyelitis was the most common presentation, often with secondary involvement of joint and or soft tissue.

OBJECTIVE: To analyse hospital morbidity records due to paracoccidioidomycosis in Brazil, including its nationwide distribution in time and space, as well as key epidemiological and sociodemographic characteristics.
METHODS: Descriptive analysis of hospital morbidity records due to paracoccidioidomycosis covering the period January 1998 to December 2006. Hospital records were obtained from the Hospital Information System of the Brazilian Unified Health System (SIH/SUS).
RESULTS: There were 6732 hospitalisations (82% male) due to paracoccidioidomycosis in the period, representing 4.3 per 1.0 million inhabitants. Admissions due to this mycosis were recorded in 27% of the 5560 Brazilian municipalities, covering 35% of the country. Ten municipalities concentrated 52% of all admissions. The temporal distribution of admissions for paracoccidioidomycosis showed a slight increase. The geographical analysis showed two distinct patterns of the disease: (i) traditional areas of southern and south-eastern regions, covering 60% of admissions, and (ii) a second pattern in northern Brazil revealed a transverse band of higher concentration with about 27% of admissions, particularly along the southern border of the Amazon region.
CONCLUSIONS: This first nationwide analysis of hospitalisation due to paracoccidioidomycosis in Brazil shows that it is the most prevalent systemic mycosis in Brazil. Despite its importance, there are major deficits in its proper registry, diagnostics and treatment. The particular epidemiological and medical challenges of paracoccidioidomycosis will not be met while the disease continues to be perceived as an isolated infectious entity restricted to a few faraway regions of the globe.

BACKGROUND: Paracoccidioidomycosis is the most frequent systemic mycosis in Latin America, caused by the dimorphic fungus Paracoccidioides. Paracoccidioidomycosis in children is uncommon. Our aim is to describe clinical features of patients who had a confirmed diagnosis of paracoccidioidomycosis in our hospital in the last 10 years.
METHODS: We describe 4 cases of paracoccidioidomycosis in previously healthy children from the north of our country. Diagnoses were made by biopsy or culture.
CONCLUSIONS: The diagnosis of paracoccidioidomycosis should be considered in a patient coming from regions where Paracoccidioides is endemic, and presenting with a lymphoproliferative syndrome, anemia, eosinophilia and hypergammaglobulinemia.