Paracoccidioidomycosis: unusual clinical presentation and utility of computerized tomography scanning for diagnosis.

A 57-year-old white man, born in Chaco in the north of Argentina, who had worked as a cotton picker until 20 years ago when he moved to the city of Buenos Aires, presented with an asymptomatic, 10 cm long, 3.5 cm wide ulcer on the back of the neck, with an erythematous, violaceous border and serosanguinous material in the micronodular center (Fig. 1). No enlargement of the lymph nodes was present and the patient's general condition was good. The results of laboratory tests were within normal values, and candidin and purified protein derivative (PPD) tests were negative; chest X-ray showed subtle interstitial infiltrates. Histopathologic study of the border and center of the ulcer showed a granulomatous infiltrate with giant cells and large, spherical to oval cells with multiple buds, typical of Paracoccidioides brasiliensis; Grocott stain showed yeast with various blastoconidia and the well-known image of the “pilot wheel” (Fig. 2). The study of fresh tissue confirmed the existence of yeast (10–40 µm) including buds. Culture was negative. Skin test with Fava Neto antigen (polysaccharides of P. brasiliensis) was positive (17 mm). Tests of contraimmunoelectrophoresis with paracoccidioidin antigen showed two negative and one positive band. As the initial chest X-ray was not decisive, computerized axial tomography of the lung was carried out. The latter showed a pulmonary interstitial infiltrate of the right inferior lobe and a small infiltrate of the left inferior lobe. (Fig. 3). Figure 1. Painless ulcer with sharp border and serosanguinous crust Figure 2. Grocott stain (× 400). Etiologic agent from the border of the ulcer Figure 3. Computerized tomography scan of the chest showing pulmonary involvement Once a diagnosis of skin–lung paracoccidioidomycosis had been confirmed, 6 months of treatment with daily oral doses of 100 mg of itraconazole was started, leading to the healing of the skin lesion in 6 weeks (Fig. 4). Pulmonary compromise improved a few weeks after the initiation of treatment. Figure 4. Ulcer healed after 4 weeks of treatment with itraconazole