Disseminated Paracoccidioidomycosis in a Kidney Transplant Recipient

Abstract

Paracoccidioidomycosis (PCM) is an endemic fungal infection in Latin America, which manifests as an acute or chronic form and is more frequent in adult males. It is caused by Paracoccidioides brasiliensis or Paracoccidioides lutzii, which are thermodimorphic fungi. The disease can present as a severe and disseminated form involving the lungs, skin, lymph nodes, spleen, liver, and lymphoid organs of the gastrointestinal tract. Most of the primary infections are subclinical, and the cell-mediated immune response contains the infection. It is rare in transplant patients, and there are few cases described in the literature. In solid organ transplant patients, it usually results from the reactivation of a latent infection, manifesting itself after a few years of transplantation with frequent pulmonary and skin involvement. PCM is an endemic infection in Brazil; however, as it is not classified as a notifiable disease, there is no accurate database on its incidence, and case reports are important sources of information. Clinical disease in kidney transplant patients is rare and has a high mortality rate. In this scope, the present clinical case reports the challenges of the clinical management of disseminated PCM caused by Paracoccidioides brasiliensis in a kidney transplant recipient who used immunosuppressive drugs and was treated with Itraconazole.

Keywords: blastomycosis; immunosuppression; itraconazole; kidney transplantation; paracoccidioidomycosis.

Figure 1. High-resolution computed tomography scan of the chest showing consolidation (A) and an excavated nodule, with thickened walls and inverted halo sign (B).

Figure 2. Rounded cutaneous ulcerated lesions with erythematous fundus and elevated border, disseminated in the dorsal region (A) and upper limbs (B). Histopathology shows granulomatous inflammatory response characterized by macrophages, Langhans type multinucleated giant cells (thin arrow), and isolated and grouped fungi phagosomes (thick arrow) (C), confirming the presence of Paracoccidioides brasiliensis. Rudder wheel shape of the parasite (D).