Disseminated paracoccidioidomycosis prediagnosticated as neoplasm: An important challenge in diagnosis using rt-PCR

Abstract

This paper presents a case of disseminated paracoccidioidomycosis in a 62-year-old male patient, who lives in Belo Horizonte, MG, Brazil. The patient was hospitalized with icteric syndrome of cholestatic pattern and weight loss, with loss 30 kg in 5 months. The imaging of the abdomen showed lesion of infiltrative pattern, affecting gallbladder and intrahepatic bile ducts, suggesting neoplasia of malignant behavior, besides to presenting the yellow nail syndrome. Dermatological examination presented erythematous-infiltrated plaques in the occipital region. Also, the patient presented tegumentary lesions on the scalp and lumbar region from which the histopathological examination was carried out, which evidenced yeasts cells. The drug of choice for therapy was Liposomal Amphotericin-B. At the end of the antifungal treatment, liver enzyme dosages were normalized and there was improvement of the general condition of the patient, as well as the skin lesions. Here, we demonstrate the importance of molecular biology to confirm the diagnosis. Especially in cases of difficult diagnosis.

Keywords: Molecular markers; P. lutzii; Paracoccidioides brasiliensis; Paracoccidioidomycosis; rt-PCR Diagnosis.

Fig. 1

(A) Photo of nails of the hands and feet affected by yellow nail syndrome (YNS). Before treatment. (B)- Erythematous-Infiltrates and exulcero-crostosas in the occipital region. Before and during treatment. (C) -Lesion right infra-auricular, associated with erythematous-infiltrated papules and nodules. Before and after treatment.

Fig. 2

Magnetic resonance imaging presenting an infiltrative pattern lesion affecting gallbladder and intrahepatic bile ducts, with bilateral pleural effusion and hilar, per pancreatic and gastric curvature lymph node enlargement.

Fig. 3

Histological findings in the dermal fragment: Fragment showing pseudoepitheliomatous hyperplasia. There is, in the dermis, dense and diffuse inflammatory infiltrate of mono- and polymorphonuclear cells with formation of microabscesses and some multinucleated giant cells.

Fig. 4

Direct examination of pus from the patient's nose injury, showing yeast cells with multiple shoots.

Fig. 5

Double Radial immunodiffusion using Gp43 antigen. Serum is the patient sample and its dilutions. The antigen and the positive control were assigned by the Technological Center of Paraná (PR, Brazil).

Fig. 6

Amplification Curve by the rtPCR technique, using primers species-specific for the genus Paracoccidioides. A: Positive control; B: Patient sample; C: Negative control.