COVID-19 in patients with paracoccidioidomycosis

Abstract

Introduction: In 2020, we reported the first patient with concomitant COVID-19 and paracoccidioidomycosis (PCM). Since then, no other cases have been recorded in the literature. We aim to update information on the occurrence of COVID-19 in patients with PCM followed at a reference center for infectious diseases at Rio de Janeiro, Brazil.

Methods: We reviewed the medical records from patients diagnosed with PCM who presented with clinical symptoms, radiological findings, and/or laboratory diagnosis of COVID-19 at any time during their acute or follow-up care. The clinical profiles of these patients were described.

Results: Between March 2020 and September 2022, we identified six individuals with COVID-19 among the 117 patients with PCM evaluated. The median age was 38 years and the male to female ratio 2:1. Most patients (n = 5) presented for evaluation due to acute PCM. The severity of COVID-19 ranged from mild to severe in acute PCM and only the single patient with chronic PCM died.

Conclusions: There is a range of disease severity in COVID-19 and PCM co-infection and concomitant disease may represent a severe association, especially in the chronic type of the mycosis with pulmonary involvement. As COVID-19 and chronic PCM share similar clinical aspects and PCM is neglected, it is probable that COVID-19 has been hampering simultaneous PCM diagnosis, which can explain the absence of new co-infection reports. With the continued persistence of COVID-19 globally, these findings further suggest that more attention by providers is necessary to identify co-infections with Paracoccidioides.

Fig 1

(A) Chest tomography from a patient included in this study (case 2) showing peripheral and coalescent ground-glass opacities better seen in the right lung. This 57-year-old male patient was infected by Paracoccidioides sp. in the past, while developing construction activities during 20 years. He was a heavy smoker, developed chronic paracoccidioidomycosis (PCM), and was admitted at our institution presenting a 9-month painful tongue lesion, evolving with emaciation, cervical lymph nodes enlargement, and lung disease. PCM was diagnosed through histopathology from biopsies of the oral lesion and cervical lymph node, which revealed a chronic granulomatous inflammatory process along with multiple budding cells compatible with Paracoccidioides spp. yeast-like cells, better seen in the Grocott’s methenamine silver stain (B). The patient was treated with itraconazole and trimethoprim/sulfamethoxazole for 35 months due to poor adherence. When COVID-19 infection occurred, this patient was under the post-therapeutic follow-up, and presented lung sequelae, such as severe pulmonary fibrosis and chronic obstructive pulmonary disease (COPD). His COVID-19 disease was severe, requiring invasive ventilation, and he died four days after hospitalization.