Systematic review of neuroparacoccidioidomycosis: The contribution of neuroimaging.

BACKGROUND: Advanced neuroimaging demonstrated that neurological involvement occurs in up to 30% of paracoccidioidomycosis (PCM) cases. Current knowledge of neuroparacoccidioidomycosis (NPCM) is based on a 2009 systematic review. However, in the last decade, several new cases have been published, with modern neuroimaging techniques. OBJECTIVES: We believe a new systematic review is needed to summarise these advances. METHODS: We searched PubMed/MEDLINE, Embase and LILACS for studies from January 2010 to May 2022. Case series and case reports of NPCM were included. We performed a metaproportion to estimate a summary proportion with 95% confidence intervals (CI). RESULTS: Thirty-four studies including 104 patients were evaluated. We combined our data with the results from the previous review that included 257 cases, totalling 361 patients. We found no new important demographic, clinical or laboratory characteristics. On magnetic resonance imaging (MRI), we found that 72% (95%CI: 38-91) had hyperintensity on T1-weighted image; 84% (95%CI: 71%-92%) had hypointensity on T2-weighted image; 80% (95%CI: 66-89) had contrast enhancement with the classical ring-enhancing pattern. All 8 patients undergoing spectroscopy presented lipid peaks. We found a 16% mortality, lower than in the previous review (44%). CONCLUSION: NPCM presents a characteristic pattern on MRI that may help to differentiate it from other causes of single or multiple brain lesions. Albeit there is a frequent pattern, it is not specific, as other granulomatous diseases may show similar findings. Advances in neuroimaging with early diagnosis and appropriate management of the disease may have contributed to reducing its mortality.

A scoping study of pulmonary paracoccidioidomycosis: severity classification based on radiographic and tomographic evaluation

The lungs have great importance in patients with paracoccidioidomycosis since they are the portal of entry for the infecting fungi, the site of quiescent foci, and one of the most frequently affected organs. Although they have been the subject of many studies with different approaches, the severity classification of the pulmonary involvement, using imaging procedures, has not been carried out yet. This study aimed to classify the active and the residual pulmonary damage using radiographic and tomographic evaluations, according to the area involved and types of lesions.

Automatic algorithm for quantifying lung involvement in patients with chronic obstructive pulmonary disease, infection with SARS-CoV-2, paracoccidioidomycosis and no lung disease patients.

In this work, we aimed to develop an automatic algorithm for the quantification of total volume and lung impairments in four different diseases. The quantification was completely automatic based upon high resolution computed tomography exams. The algorithm was capable of measuring volume and differentiating pulmonary involvement including inflammatory process and fibrosis, emphysema, and ground-glass opacities. The algorithm classifies the percentage of each pulmonary involvement when compared to the entire lung volume. Our algorithm was applied to four different patients groups: no lung disease patients, patients diagnosed with SARS-CoV-2, patients with chronic obstructive pulmonary disease, and patients with paracoccidioidomycosis. The quantification results were compared with a semi-automatic algorithm previously validated. Results confirmed that the automatic approach has a good agreement with the semi-automatic. Bland-Altman (B&A) demonstrated a low dispersion when comparing total lung volume, and also when comparing each lung impairment individually. Linear regression adjustment achieved an R value of 0.81 when comparing total lung volume between both methods. Our approach provides a reliable quantification process for physicians, thus impairments measurements contributes to support prognostic decisions in important lung diseases including the infection of SARS-CoV-2.

Multifocal Pseudotumorous Form of Neuroparacoccidioidomycosis in an Immunocompetent Patient: A Clinicopathological Review Based on a Case Report

Neuroparacoccidiodimycosis (NPDM) is an uncommon granulomatous disease, which more frequently affects immunocompromised male patients over 30 years of age in the course of chronic lung disease. Paracoccidioides brasiliensis (PB) is an endemic fungus in Brazil, and grows as thick-walled yeast (with round to oval bodies) measuring 10 µm to 60 µm in diameter. Neuroparacoccidiodimycosi may develop many years after transmission and/or primary lung involvement. The authors describe a case of NPDM affecting a male patient, 52 years of age, farmer, heavy smoker, with clinical complaint of headache, asthenia, seizures, and prostration in the previous nine months. Upon physical examination, the patient presented regular general condition, without other relevant physical alterations. Computed tomography (CT) showed multiple bilateral pulmonary nodules associated to enlargement of the mediastinal lymph node. Magnetic resonance imaging (MRI) and CTscans of the central nervous system showed six heterogeneous nodular lesions compromising the frontal and parietal lobes, the largest one measuring 3.8 3.2 3.2 cm. The hypothesis of a neoplastic process compromising the lung and brain was considered. A biopsy of the mediastinal lymph node showed epithelioid granulomas, which exhibited round, thin-walled fungal structures in Grocott silver stain. The stereotactic biopsy of the frontal lesion was constituted by necrotic tissue admixed with some round to oval, thin-walled fungi measuring 10 µm to 60 µm, compatible with PB (identified on Grocott silver stain/confirmed in culture). The diagnosis of NPDM was then established. The employed therapeutic regimen was intravenous amphotericin B, itraconazole, and sulfamethoxazole-trimetropin. After ninety days of clinical follow-up, no episodes of seizures/neurological deficits were identified, and a marked decrease in the number and size of the lung and brain lesions were found.

Disseminated paracoccidioidomycosis in a liver transplant patient

Abstract Paracoccidioidomycosis is an endemic systemic mycosis caused by Paracoccidioides brasiliensis complex and P. lutzii. It is a rare disease in non-HIV-induced immunosuppressed individuals. In organ transplant recipients, it is more frequently associated with immunosuppression after kidney transplantation. In a liver transplant patient, only one case has been published in the literature to date. The present report comprises the case of a 47-year-old female patient with disseminated skin lesions associated with signs and symptoms of systemic involvement of paracoccidioidomycosis that manifested one year after liver transplantation and under an immunosuppression regimen with tacrolimus and mycophenolate mofetil.

Paracoccidioidomycosis in the Central Nervous System

Paracoccidioidomycosis is a systemicmycosis caused by the Paracoccidioides brasiliensis fungus, which is endemic in Latin America. Brazil is the country with the highest number of cases. The affection of the central nervous system (CNS), a potentially fatal condition, occurs in 12% of the cases. The following forms of presentation are identified:meningeal, which is unusual;meningoencephalitic; and pseudotumoral, the latter two being more frequent. Imaging tests are essential for the diagnosis, but the histological identification of the fungus is required for confirmation of the pathology. The clinical picture depends on the neuraxial location.We present a case of amale rural worker, with expansive lesions in the CNS compatible with paracoccidioidomycosis.

Comparison of clinico-epidemiological and radiological features in paracoccidioidomycosis patients regarding serological classification using antigens from Paracoccidioides brasiliensis complex and Paracoccidioides lutzii.

Genotyping of the genus Paracoccidioides showed its diversity and geographical distribution. Four species constituting the Paracoccidioides brasiliensis complex and Paracoccidioides lutzii are etiological agents of paracoccidioidomycosis (PCM). However, there are no studies comparing the clinical and epidemiological aspects between PCM caused by the P. brasiliensis complex and by P. lutzii. Demographic and clinical data from 81 patients with PCM-confirmed by mycological and/or histopathological examination-from Mato Grosso do Sul state (Brazil) were studied. All patients underwent serology by immunodiffusion with antigens obtained from the P. brasiliensis complex (ExoPb and gp43) and Cell Free Antigens obtained from P.lutzii (CFAPl).The cases were classified regarding their serological profile into three groups: G1: PCM patients seropositive to ExoPb and/or gp43 and seronegative to CFAPl (n = 51), assumed to have PCM caused by P. brasiliensis complex; G2: PCM patients seronegative to gp43 and seropositive to CFAPl (n = 16), with PCM caused by P. lutzii; and G3: PCM patients seropositive to ExoPb or gp43 and seropositive to CFAPl (n = 14), with undetermined serological profile, was excluded from the analyses. The Fisher's exact test or the Mann-Whitney U test, and cluster analysis according to Ward's method and Euclidean distance were used to analyze the results. Patients with serological profile suggestive of P. lutzii lived predominantly in municipalities in the Central and Southern regions of the state, while those with serological profile indicative of the P. brasiliensis complex were distributed throughout the state. No differences were found between the two groups regarding gender, age, schooling, rural work, clinical form, severity, organs involved, intensity of pulmonary involvement, degree of anemia, erythrocyte sedimentation rate values, and therapeutic response. PCM patients with serological profile suggestive of P. lutzii and PCM patients with serological profile indicative of P. brasiliensis complex showed the same clinical and radiological presentations.

Paracoccidioidomycosis of the Central Nervous System: CT and MR Imaging Findings.

BACKGROUND AND PURPOSE: Paracoccidioidomycosis is a fungal infection mainly caused by the thermodimorphic fungus Paracoccidioides. The purpose of our study was to demonstrate the neuroimaging findings from 24 patients with CNS paracoccidioidomycosis. MATERIALS AND METHODS: We performed a retrospective analysis focusing on the radiologic characteristics of CNS paracoccidioidomycosis. The 24 selected patients underwent MR imaging and/or CT, and the diagnosis was made by the presence of typical neuroimaging features, combined with fungus isolation, a serologic test, or the presence of disseminated disease. RESULTS: Headache was the most common neurologic symptom, while the pseudotumoral form was the most common pattern. The number of lesions ranged from 1 to 11, with most localized on the frontal lobe with >2-cm lesions. CT showed mainly hypoattenuating lesions, whereas MR imaging demonstrated mainly hyposignal lesions on T1WI and T2WI. Furthermore, ring enhancement was present in most patients. The "dual rim sign" on SWI occurred in 100% of our patients with lesions of >2 cm. CONCLUSIONS: The diagnosis of CNS paracoccidioidomycosis is difficult. Nevertheless, imaging examinations can play an important role in the diagnosis and evaluation of the disease.

Imaging paracoccidioidomycosis: A pictorial review from head to toe.

Paracoccidioidomycosis is an infectious disease characterized primarily by pulmonary involvement and potential dissemination to other organs, mainly mucosa and skin; however, it can affect any organ in the body. Although difficult to diagnose purely based on imaging, imaging is important for diagnosis, follow-up, and assessment of disease-related complications. We provide a comprehensive review of the most notable imaging findings of paracoccidioidomycosis.

67Ga Scintigraphy for Assessment of Disease Severity and Treatment Response in Patients With Paracoccidioidomycosis.

OBJECTIVE: The evaluation of therapy response of patients with deep mycosis is a major challenge. The aim of this study was to assess the severity of disease at admission and evaluate treatment response of patients with paracoccidioidomycosis using Ga scintigraphy. SUBJECTS AND METHODS: Seventy-three patients with fully active disease were enrolled. A scoring system based on clinicoradiological and serological evaluation and Ga scan was devised. Pretherapy Ga score of 73 patients was compared with clinicoradiological and serological scores. A subgroup of 23 patients was followed up during treatment, and the rates of improvement of their clinicoradiological, serological, and Ga scores during treatment were compared at 3 time points (fully active phase, after clinical improvement, and clinically inactive disease). RESULTS: The correlations between scores before therapy were statistically significant. Ga score correlated with clinical score (r = 0.47, P < 0.001). Serological score correlated with both Ga and clinical scores (r = 0.32, P = 0.006, and r = 0.25, P = 0.034, respectively). Concerning evaluation of therapy response, clinicoradiological, serological, and Ga scores decreased significantly after therapy (P < 0.001). Notably, Ga score was the single one to become negative in most patients at the end of treatment (20 of 23 patients compared with 7 on clinicoradiological evaluation and 10 on serology, P = 0.003). CONCLUSIONS: In patients with paracoccidioidomycosis, pretherapy Ga scintigraphy correlates with disease severity. Serial Ga scans seem to be helpful in evaluating the response to therapy.

Paracoccidioides brasiliensis Infection Mimicking Recurrent Hodgkin Lymphoma: A Case Report and Review of the Literature.

Paracoccidioides infection is a rare entity in the USA. This dimorphic fungus is found in Central and South America and is thought to be acquired by inhalation through the soil. We report a case of Paracoccidioides brasiliensis infection presenting as a clavicular bone lesion, peripancreatic mass, and various skin lesions. A 35-year-old man with a history significant for Hodgkin lymphoma presented with a left clavicular mass that was suspected clinically and radiologically as recurrent Hodgkin lymphoma. He was not experiencing any associated symptoms and was undergoing chemotherapy treatment for his known Hodgkin disease. On CT imaging, the mass was seen as a lytic bone lesion with an overlying soft tissue mass. This was biopsied and histologically diagnosed as a Paracoccidioides brasiliensis infection with associated necrotizing granulomatous inflammation. Also found on the CT scan was an enlarging peripancreatic mass which on endoscopic biopsy had similar histologic findings. In conclusion, this report presents a rare case of Paracoccidioides brasiliensis infection mimicking recurrent Hodgkin lymphoma.