Paracoccidioidomycosis of external genitalia: report of six new cases and review of the literature

BACKGROUND: Paracoccidioidomycosis is a systemic mycosis of dermatological interest due to the frequency of cutaneous and mucosal lesions. The involvement of the external genitalia is extremely rare and few cases have been reported.OBJECTIVE: To study the prevalence of external genitalia lesions in paracoccidioidomycosis patients, identify clinical characteristics and compare with what is observed in the specific literature.METHODS: This is a cross-sectional, descriptive study, with focus on paracoccidioiodomycosis patients with external genitalia lesions. The demographic and clinical aspects of cases were compared with what has been reported so far on LILACS, SciELO e MEDLINE data bases.RESULTS: Data of 483 cases of paracoccidioidomycosis were studied in a 42-year period. Six (1.2%) patients showed specific lesions on external genitalia. Five patients were male with mean age of 47.2 years and all of them presented with the chronic multifocal clinical form. Only one, a 15-year-old female patient was observed who showed a subacute clinical form, juvenile type.CONCLUSIONS: Compromise of the genitourinary tract among paracoccidioidomycosis patients is rare and even rarer when only the external genitalia are considered. As observed in the classical picture of paracoccidioidomycosis patients, the male gender and the chronic multifocal clinical form prevailed in the present study.

Paracoccidioidomycosis

Paracoccidioidomycosis is an endemic systemic mycosis that predominates in southern Mexico, parts of Central America, and South America. It is caused by a dimorphic fungus and is generally acquired through the lungs, from where it disseminates. Paracoccidioidomycosis has different clinical manifestations that require differentiation with tuberculosis, Hodgkin disease, several systemic and subcutaneous mycoses, and squamous cell carcinoma. Diagnosis is made by finding the organism in a biopsy specimen and isolating it in fungal culture. Treatment includes sulfamethoxazole-trimethoprim for mild forms and itraconazole for moderate cases. Fluconazole and voriconazole can be used for meningeal involvement, and amphotericin B is indicated for severe disease. (C) 2012 Elsevier B.V. All rights reserved.

Imunologia da paracoccidioidomicose

Paracoccidioidomicose é a mais prevalente micose sistêmica na América Latina, em pacientes imunocompetentes, sendo causada pelo fungo dimórfico Paracoccidioiddes brasiliensis. O estudo da sua imunopatogênese é importante na compreensão de aspectos relacionados à história natural, como a imunidade protetora, e à relação entre hospedeiro e parasita, favorecendo o entendimento clínico e a elaboração de estratégias terapêuticas. O polimorfismo clínico da doença depende, em última análise, do perfil de resposta imune que prevalece expresso pelo padrão de citocinas teciduais e circulantes, além da qualidade da resposta imune desencadeada, que levam ao dano tecidual

Paracoccidioidomycosis: infiltrated, sarcoid-like cutaneous lesions misinterpreted as tuberculoid leprosy

Os Autores relatam um caso de paracoccidioidomicose diagnosticado como se fora hanseníase tuberculóide, tanto do ponto de vista clínico como histopatológico. Lesão cutânea de padrão sarcoídico é raramente observada como lesão inicial da paracoccidioidomicose em jovens e pode simular outras dermatoses infecciosas ou inflamatórias. O achado histológico de granuloma tuberculóide apresenta dificuldade diagnóstica similar. O tratamento realizado com dapsone, um derivado sulfamídico, pode ter retardado a evolução clínica esperada para o padrão clássico da paracoccidioidomicose tipo juvenil, o qual apenas se materializou 24 meses após a paciente ter iniciado tratamento como hanseníase.

Dysphonia and laryngeal sequelae in paracoccidioidomycosis patients: a morphological and phoniatric study

The larynx is the third most commonly involved organ in paracoccidioidomycosis (PCM). While a few studies have evaluated laryngeal sequelae, there have not been any investigations of voice abnormalities in PCM patients. To evaluate persistent dysphonia and laryngeal lesions, we studied 15 normal subjects and 30 post-treatment PCM patients, i.e., 15 with only pulmonary and 15 with both laryngeal and pulmonary involvement. Perceptual and acoustic voice analysis were performed with all patients, while endoscopic studies were also conducted with the 15 laryngeal patients. Voice analysis showed instability by perceptual analysis (P < 0.01) in both groups, but more severe dysphonia was noted in the laryngeal group (P < 0.01). The dysponia, seen in 66.7% of these patients (dysphonia index < 7.0), was characterized by roughness and breathness. The Dr. Speech (Tiger Electronics) analysis program did not accept five voices from the laryngeal group due to the severe dysphonia. Jitter was elevated in five laryngeal lesion patients. Endoscopy showed that 80% of patients with laryngeal lesion had two or more laryngeal structures involved. Vocal fold alterations were seen in all laryngeal lesion patients, which included involvement of the arythenoids, epiglottis, and vestibular folds. This first functional study of laryngeal sequelae in PCM revealed frequent and severe dysphonia that may have important social consequences for patients.

Modulatory effect of prostaglandins on human monocyte activation for killing of high- and low-virulence strains of Paracoccidioides brasiliensis

The effect of indomethacin (Indo), a cyclo-oxygenase inhibitor, on the monocyte-mediated killing of a low-(Pb265) and a high-(Pb18) virulence strain of Paracoccidioides brasiliensis was examined. The Pb18 strain was not killed by either non-activated or interferon-gamma (IFN-gamma)-activated human monocytes but these cells did show fungicidal activity if pretreated with Indo. In contrast with IFN-gamma tumour necrosis factor-alpha (TNF-alpha) was very effective at stimulating the fungicidal activity of monocytes. While the low-virulence strain, Pb265, could not be killed by monocytes, cells preincubated with IFN-gamma demonstrated fungicidal activity. The killing of this strain was also induced by pretreatment of monocytes with Indo. The results suggest a negative role for prostaglandins, which are synthesized via the cyclo-oxygenase pathway, in the regulation of monocyte-mediated killing of virulent and avirulent strains of P. brasiliensis and that TNF-alpha generation during the fungus-monocyte interaction is more important in the killing of Pb265 than Pb18.

Paracoccidioides brasifiensis killing by IFN-gamma, TNF-alpha and GM-CSF activated human neutrophils: role for oxygen metabolites

Paracoccidioidomycosis, a deep mycosis endemic in Latin America, is a chronic granulomatous disease caused by the fungus Paracoccidioides brasiliensis. Phagocytic cells play a critical role against the fungus and several papers show the effects of activator and suppressive cytokines on macrophage and monocyte functions. However, the studies focusing on polymorphonuclear neutrophils (PMNs) antifungal functions are scarcer. Thus, the objective of the present paper was to assess the capacity of human PMNs to kill virulent P brasiliensis strain in vitro, before and after priming with different cytokines. Moreover, the involvement of oxygen metabolites in this activity was evaluated. Nonactivated cells failed to exhibit antifungal activity. However, when these cells were IFN-gamma, TNF-alpha or GM-CSF activated, a significative fungicidal activity was detected. This process was significantly inhibited when P brasiliensis challenge occurred in presence of catalase (CAT - a scavenger of H2O2) and superoxide dismutase (SOD - a scavenger of superoxide anion). From these results it is concluded that cytokines activation is required for P brasiliensis killing by human PMNs, and that H2O2 and Superoxide anion participate as effectors molecules in this process.

Granulocyte macrophage colony-stimulating factor enhances the modulatory effect of cytokines on monocyte-derived multinucleated giant cell formation and fungicidal activity against Paracoccidioides brasiliensis

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Interleukin-15 increases Paracoccidioides brasiliensis killing by human neutrophils

Interleukin-15 is a pro-inflammatory cytokine produced by a wide range of different cell types, especially monocytes and macrophages, in response to infective agents, playing a crucial and modulatory role in innate and adaptive immune response. Infections by intracellular microorganisms such as some bacteria, protozoa and fungi point out the role of IL-15 in the activation of monocytes/macrophages and neutrophils, a process that represents an important defense mechanism in early periods of infection during the development of innate immune response. The aims of the present study were to evaluate the effects of IL-15 on human neutrophil fungicidal activity against a high virulent Paracoccidioides brasiliensis strain ( Pb18) and to verify whether this activity was mediated by oxidative metabolism such as the production of superoxide anion and H2O2 and if it was associated with an alteration of cytokine ( IL-8 and TNF-alpha) levels. Neutrophils from peripheral blood of healthy individuals were incubated in the presence and absence of IL-15 ( 12.5 - 250ng/ml) for 18h, at 37 degrees C, under tension of 5% CO2, then infected with Pb18 for 4h and evaluated for fungicidal activity, production of superoxide anion and H2O2, and quantification of cytokines IL-8 and TNF-a in the supernatant. Preincubation of neutrophils with IL-15 induced a significant increase in the fungicidal activity of such cells in a dose-dependent manner. After activation, there was an increase in the production of superoxide anion and H2O2 by these cells, suggesting participation of such metabolites in fungicidal activity. Catalase inhibits fungicidal activity, confirming the role of H2O2 in fungus killing. However, the levels of TNF-alpha and IL-8 were not modified after incubation with IL-15, which suggests that its role is not mediated by those cytokines. Taken together, results showed that IL-15 had a modulatory effect on human neutrophils infected in vitro with a high virulent strain of P. brasiliensis, which was characterized by an increased fungicidal activity mediated by a dependent mechanism of oxidative metabolism.

Interleukin-6 treatment enhances human monocyte permissiveness for Paracoccidioides brasiliensis growth by modulating cytokine production

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)