CHYLOTHORAX IN PARACOCCIDIOIDOMYCOSIS

Abstract

A previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions.

Fig. 1. Contrast-enhanced computed tomography scan of the neck, chest and abdomen. A) Transverse image of the neck shows multiple bilateral cervical necrotic lymphadenopathy (arrows), some coalescent. B) Oblique coronal reformatted image of the chest shows left breast mass (curved arrow), bilateral coalescent necrotic axillary lymphadenopathy (straight arrows), and ascites (stars). C) Transverse image of the chest shows bilateral necrotic hilar lymph nodes (arrows), and bilateral pleural effusion (stars). D) Coronal reformatted image of the abdomen shows periportal (long arrows), periaortic (short arrow), and bilateral external iliac (curved arrows) necrotic lymphadenopathy; and ascites.