Paracoccidioides spp. and Histoplasma capsulatum: Current and New Perspectives for Diagnosis and Treatment.

The thermally-dimorphic systemic fungal group includes several important human pathogens: Blastomyces dermatitides, Coccidioides immitis and C. posadasii, Histoplasma capsulatum, Paracoccidioides brasiliensis, P. lutzii, and Talaromyces (Penicillium) marneffei. They usually are geographically restricted and have natural habitats in soil or in plants, and when fungal propagules invade mammalian host by inhalation, they initiate an inflammatory reaction that can result in self-resolution of the infection or cause an acute or chronic disease. In the setting of the AIDS pandemic and the developments in modern medicine, such as immunosuppressive therapy in cancer surgery patients and in transplantation and autoimmune diseases, the incidence of endemic mycoses has progressively increased. Another important factor of the increased incidence of systemic mycoses in certain regions is the progressive devastation of tropical and subtropical forests. In this review, we focus on two of the most important systemic mycoses: paracoccidioidomycosis and histoplasmosis, and their major characteristics in epidemiology, clinical aspects and laboratorial diagnosis.

CHYLOTHORAX IN PARACOCCIDIOIDOMYCOSIS.

A previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions.

Validation and clinical application of a nested PCR for paracoccidioidomycosis diagnosis in clinical samples from Colombian patients

Paracoccidioidomycosis is a systemic and endemic mycosis, restricted to tropical and subtropical areas of Latin America. The infection is caused by the thermal dimorphic fungus Paracoccidioides brasiliensisand Paracoccidioides lutzii. The diagnosis of paracoccidioidomycosis is usually performed by microscopic examination, culture and immunodiagnostic tests to respiratory specimens, body fluids and/or biopsies; however these methods require laboratory personnel with experience and several days to produce a result. In the present study, we have validated and evaluated a nested PCR assay targeting the gene encoding the Paracoccidioides gp43membrane protein in 191 clinical samples: 115 samples from patients with proven infections other than paracoccidioidomycosis, 51 samples as negative controls, and 25 samples from patients diagnosed with paracoccidioidomycosis. Additionally, the specificity of the nested PCR assay was also evaluated using purified DNA isolated from cultures of different microorganisms (n= 35) previously identified by culture and/or sequencing. The results showed that in our hands, this nested PCR assay for gp43 protein showed specificity and sensitivity rates of 100%. The optimized nested PCR conditions in our laboratory allowed detection down to 1 fg of P. brasiliensisDNA.

Validation and clinical application of a nested PCR for paracoccidioidomycosis diagnosis in clinical samples from Colombian patients.

Paracoccidioidomycosis is a systemic and endemic mycosis, restricted to tropical and subtropical areas of Latin America. The infection is caused by the thermal dimorphic fungus Paracoccidioides brasiliensis and Paracoccidioides lutzii. The diagnosis of paracoccidioidomycosis is usually performed by microscopic examination, culture and immunodiagnostic tests to respiratory specimens, body fluids and/or biopsies; however these methods require laboratory personnel with experience and several days to produce a result. In the present study, we have validated and evaluated a nested PCR assay targeting the gene encoding the Paracoccidioides gp43 membrane protein in 191 clinical samples: 115 samples from patients with proven infections other than paracoccidioidomycosis, 51 samples as negative controls, and 25 samples from patients diagnosed with paracoccidioidomycosis. Additionally, the specificity of the nested PCR assay was also evaluated using purified DNA isolated from cultures of different microorganisms (n=35) previously identified by culture and/or sequencing. The results showed that in our hands, this nested PCR assay for gp43 protein showed specificity and sensitivity rates of 100%. The optimized nested PCR conditions in our laboratory allowed detection down to 1fg of P. brasiliensis DNA.

The monoclonal antibody against the major diagnostic antigen of Paracoccidioides brasiliensis mediates immune protection in infected BALB/c mice challenged intratracheally with the fungus.

The protective role of specific antibodies against Paracoccidioides brasiliensis is controversial. In the present study, we analyzed the effects of monoclonal antibodies on the major diagnostic antigen (gp43) using in vitro and in vivo P. brasiliensis infection models. The passive administration of some monoclonal antibodies (MAbs) before and after intratracheal or intravenous infections led to a reduced fungal burden and decreased pulmonary inflammation. The protection mediated by MAb 3E, the most efficient MAb in the reduction of fungal burden, was associated with the enhanced phagocytosis of P. brasiliensis yeast cells by J774.16, MH-S, or primary macrophages. The ingestion of opsonized yeast cells led to an increase in NO production by macrophages. Passive immunization with MAb 3E induced enhanced levels of gamma interferon in the lungs of infected mice. The reactivity of MAb 3E against a panel of gp43-derived peptides suggested that the sequence NHVRIPIGWAV contains the binding epitope. The present work shows that some but not all MAbs against gp43 can reduce the fungal burden and identifies a new peptide candidate for vaccine development.

Paracoccidioidomicose: correlação entre achados clínicos e laboratoriais na região de São José do Rio Preto / Paracoccidioidomycosis: correlation between clinical and laboratorial findings in São José do Rio Preto region

A paracoccidioidomicose (Pbmicose) é uma doença granulomatosa de comprometimento sistêmico causada pelo fungo dimórfico Paracoccidioides brasiliensis. As manifestações clínicas são diversas e têm relação com a resposta imune do hospedeiro. O diagnóstico de Pbmicose tem evoluído nos últimos anos devido o advento das provas sorológicas. Estas são usadas não só para diagnósticos como também para determinar a eficácia terapêutica antifúngica durante e após o tratamento. O objetivo do estudo foi correlacionar os resultados dos testes sorológicos por imunodifusão dos pacientes com pbmicose com as formas clínicas da doença na população de São José do Rio Preto. Para tanto foram utilizadas informações de 79 prontuários de pacientes atendidos no Hospital de Base da Faculdade de Medicina de São José do Rio Preto, no período de2000 a 2003. O resultado obtido mostra prevalência para população masculina, com idade entre 35 e 55 anos, sendo a maioria trabalhadora ou moradora da zona rural. Os pulmões, a mucosa oral e gânglios foram as áreas anatômicas mais comprometidas. O método diagnóstico mais utilizado foi a biópsia de lesão (70,4%), seguido de imagens radiológicas, compatíveis em 49% dos casos, e prova sorológica por imunodifusão radial positiva em 29 pacientes (40,8%). O tratamento de escolha foi a sulfadiazina, seguida pelo uso de sulfametoxazol +trimetoprim. Foi possível correlacionar os títulos de anticorpos com a forma clínica apresentada, tendo em vista a diminuição destes frente ao sucesso terapêutico.

Paracoccidioidomycosis (Pbmicosis) is a granulomatous disease with systemic impairment caused by dimorphic fungi Paracoccidioides brasiliensis. The clinical manifestations are diverse and have relation with the immune answer of the host. Paracoccidiodomycosis diagnosis has evolved in these last years due to the advent of the serologic tests. These are used not only for diagnosis, but also to determine the antifungical therapeutic effectiveness during and after the treatment. The objective of this study was to correlate the results of immunodiffusion serologic tests of patients with Paracoccidioidomycosis with the clinical forms of the disease in the population of São José do Rio Preto. Seventy nine medical records of patients assisted in the Hospital de Base of Medical School , São José do Rio Preto from 2000 to 2003 were used. The results showed that male population aged between 35 to 55 was the most significant ; the majority was workers or inhabitants from rural area. Lungs, oral mucosa and lymph nodes were the structures more frequently impaired.The biopsy of injury was the diagnostic method most used (70.4%), the radiological images were compatiblein 49% of the cases and serologic tests had been positive in 29 patients (40.8%). The chosen treatment was the sulfadiazine, followed by the administration of sulfametaxazol + trimetoprim. It was possible to correlate antibodies titers with the clinic tests; consequently the reduction of these regarding the therapeutical success.

Manifestaciones orales de patologías tropicales / Oral manifestations of tropical diseases

El presente trabajo expone las características clínias e histopatológicas de las pricnipales patologías tropicales (micóticas, parasitarias y virales) que presentan manifestaciones bucales, poniendo énfasis en la paracoccidioidomicosis, histoplasmosis, critpcocosis, dengue, leishmaniasis e infección micótica (AU)

Paracoccidioidomicose na criança / Paracoccidioidomycosis in children

No presente trabalho estuda-se a Paracoccidioidomicose na criança, que tem sido assunto frequente de estudo nomeio universitário, devido a sua incidência relativamente elevada, constituindo-se, mesmo numa patologia regional de destaque. O objetivo principal foi situar a real participação da criança segundo a concepção atual da história natural da doença. Para tanto fez-se uma abrangente revisão da literatura, comparando-se os aspectos epidemiológicos, clínicos e imunopatológicos com o estudo retrospectivo dos prontuários de 30 pacientes menores de 12 anos de idade, portadores de paracoccidioidomicose, confirmada pelo encontro do parasito em exames diretos e internados em 3 hospitais de referência de Goiânia, no período de janeiro de 1970 a julho de 1990. Os dados dos prontuários foram sintetizados em 17 tabelas. Dos resultados definiram-se 3 grupos de formas clínicas: Linfático abdominal; Linfático hepatoesplênica e Linfática; dos exames específicos: no hemograma a anemia e a eosinofilia foram achados marcantes, na eletroforese de proteínas séricas a hipoalbuminemia e hiperglobulinemia às custas de gama foram evidenciadas; as sorologias e as intradermorreações foram provas que denunciaram o envolvimento do sistema imune com elevação da imunidade humoral e depleção da imunidade celular; dos exames radiológicos (torax, trânsito e enema)e ultrossonográficos do abdomen verifica-se que o pulmão é raramente comprometido dos RX do torax realizados; o trânsito intestinal detecta lesões da mucosa, sugestivas do envolvimento dos linfáticos da parede; a USG é um recurso diagnóstico não invasivo as massas intrabdominais e pode sugerir fibrose hepática

Paracoccidioidomicose subaguda progressiva: tratamento de um doente com anfotericina B e nutriçäo parenteral / Progressive subacute paracoccidioidomycosis: treatment of a patient with amphotericin B and parenteral feeding

Os Autores descrevem um caso de paracoccidioidomicose subaguda progressiva, com quadro clínico sugestivo de síndrome de má absorçäo, em que o doente näo se beneficiara apenas com o tratamento antifúngico convencional. Ao se introduzir como medida auxiliar a nutriçäo parenteral houve evidente melhora clínica e laboratorial. Desta maneira os Autores propöem o uso associado da nutriçäo parenteral no tratamento de doentes com esta forma clínica de paracoccidioidomicose

Contribuiçäo ao estudo da Paracoccidioidomicose na República do Equador / Contribution to study of the Paracoccidioidomycosis in Ecuador Republic

A partir dos dados de 133 pacientes com paracoccidioidomicose, obtidos do arquivo do Departamento de Micologia, do INHMT - LIP de Guayaquil, Equador, apresentamos consideraçöes sobre o diagnóstico micológico, epidemiologia clínica, e radiologia da doença. Demonstramos que a enfermidadde já é um problema de saúde pública no país, apesar de näo se conhecer sua real magnitude, em número de pacientes e extensäo das áreas endêmicas. Ressaltamos a importância do diagnóstico precoce nas regiöes rurais e damos sugestöes, visando ao adestramento do médico rural e do pessoal paramédico. Destacamos a facilidade do diagnóstico direto, pelo exame a fresco de fragmentos de simplicidade de execuçäo do teste de IDD. Assinalamos a bacia do Rio Guayas como a regiäo endêmica mais importante e discutimos o papel de outras regöes como zonas endêmicas atuais ou futuras. Apresentamos casos considerados ilustrativos de diversos quadros clínicos e radiológicos. Damos, finalmente, sugestöes tendentes a melhorar o conhecimento da doença, limitar as áreas endêmicas e favorecer o diagnóstico e tratamento da paracoccidioidomicose no Equador