LA CONSULTA SEMANAL

 

SEPTIEMBRE 2000

 

 

CONSULTA

Diagnůstico de Paracoccidioidomicosis

 

J Clin Microbiol 2000 Sep;38(9):3478-3480
PCR for Diagnosis of Paracoccidioidomycosis.
Gomes GM, Cisalpino PS, Taborda CP, de Camargo ZP
Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, Brazil.
A PCR assay based on oligonucleotide primers derived from the sequence of the gene coding for the 43,000-Da (gp43) antigen was developed to detect Paracoccidioides brasiliensis DNA in sputa. In the standardized conditions, it could detect 10 cells/ml of sputum, providing sufficient accuracy to be useful for diagnosis of paracoccidioidomycosis.

Rev Inst Med Trop Sao Paulo 2000 Mar-Apr;42(2):59-66 [Texto completo]
Fibrotic sequelae in pulmonary paracoccidioidomycosis: histopathological aspects in BALB/c mice infected with viable and non-viable paracoccidioides brasiliensis propagules.
Cock AM, Cano LE, Velez D, Aristizabal BH, Trujillo J, Restrepo A
Laboratorio de Patologia, Clinica de las Vegas, Medellin, Colombia.
Patients with paracoccidioidomycosis often present pulmonary fibrosis and exhibit important respiratory limitations. Based on an already established animal model, the contribution of viable and non-viable P. brasiliensis propagules to the development of fibrosis was investigated. BALB/c male mice, 4-6 weeks old were inoculated intranasally either with 4x10(6) viable conidia (Group I), or 6. 5x10(6) fragmented yeast cells (Group II). Control animals received PBS. Six mice per period were sacrificed at 24, 48, 72h (initial) and 1, 2, 4, 8, 12 and 16 weeks post-challenge (late). Paraffin embedded lungs were sectioned and stained with H&E, trichromic (Masson), reticulin and Grocotts. During the initial period PMNs influx was important in both groups and acute inflammation involving 34% to 45% of the lungs was noticed. Later on, mononuclear cells predominated. In group I, the inflammation progressed and granulomas were formed and by the 12th week they fussed and became loose. Thick collagen I fibers were observed in 66.6% and 83.3% of the animals at 8 and 12 weeks, respectively. Collagen III, thick fibers became apparent in some animals at 4 weeks and by 12 weeks, 83% of them exhibited alterations in the organization and thickness of these elements. In group II mice, this pattern was different with stepwise decrease in the number of inflammatory foci and lack of granulomas. Although initially most animals in this group had minor alterations in thin collagen I fibers, they disappeared by the 4th week. Results indicate that tissue response to fragmented yeast cells was transitory while viable conidia evoked a progressive inflammatory reaction leading to granuloma formation and to excess production and/or disarrangement of collagens I and III; the latter led to fibrosis.

Mycopathologia 1999;145(2):63-7
Chronic pulmonary paracoccidioidomycosis in the state of Rio Grande do Sul, Brazil.
dos Santos JW, Severo LC, Porto N da S, Moreira J da S, da Silva LC, Carmargo JJ
Pulmonary Service, Universidade Federal de Santa Maria Hospital, RS, Brazil. jwell@husm.ufsm.br
Since 1942, when paracoccidioidomycosis was first identified in the state of Rio Grande do Sul, paracoccidioidal pulmonary lesions became a great concern to physicians. The present study focuses on 53 patients diagnosed over a seven-year period who presented paracoccidioidal lesions circumscribed to the lungs. These patients presented clinical and radiological features that simulated several pulmonary infectious and non-infectious conditions. Four unusual cases are briefly discussed. A sequence of laboratorial tests should be established for the diagnosis of pulmonary paracoccidioidomycosis.

Am J Trop Med Hyg 1999 Sep;61(3):390-4
Endemic regions of paracoccidioidomycosis in Brazil: a clinical and epidemiologic study of 584 cases in the southeast region.
Blotta MH, Mamoni RL, Oliveira SJ, Nouer SA, Papaiordanou PM, Goveia A, Camargo ZP
Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas, SP, Brazil.
This paper describes the clinical-seroepidemiologic characteristics of patients with paracoccidioidomycosis (PCM) who visited the University Hospital at the State University of Campinas (Campinas, Sao Paulo, Brazil). The study group consisted of 584 individuals (492 males and 92 females) with ages ranging from 5 to 87 years. The highest incidence of the disease occurred between the ages of 41 and 50 years for men and between 11 and 40 years for women. Rural activities were the principal occupation of 46% of the patients. The diagnosis was confirmed by histopathologic examination and demonstration of fungus in scrapings, secretions, or in the sputum. Serologic test results for PCM were positive in 80% of the 584 patients studied. The significant number of patients, including 33 children less than 14 years old, indicates the presence of the fungus in the area and that this region is an important endemic area for PCM.

AJR Am J Roentgenol 1999 Jul;173(1):59-64
Chronic pulmonary paracoccidioidomycosis (South American blastomycosis): high-resolution CT findings in 41 patients.
Funari M, Kavakama J, Shikanai-Yasuda MA, Castro LG, Bernard G, Rocha MS, Cerri GG, Muller NL
Department of Radiology, Hospital das Clinicas, University of Sao Paulo, SP, Brazil.
OBJECTIVE: To assess the pulmonary parenchymal findings on high-resolution CT in 41 patients with the chronic form of paracoccidioidomycosis (South American blastomycosis). SUBJECTS AND METHODS: The study included 41 consecutive patients in whom chronic paracoccidioidomycosis had been proven. All patients underwent high-resolution CT (1-mm collimation, high-spatial-frequency reconstruction algorithm) at 12 equally spaced intervals through the chest. The images were analyzed by two radiologists, and each final decision was reached by consensus. RESULTS: Thirty-eight (93%) of the 41 patients had CT scans with abnormal findings. The findings included interlobular septal thickening in 36 patients (88%), 1-25 mm diameter nodules in 34 (83%), peribronchovascular interstitial thickening in 32 (78%), centrilobular opacities in 26 (63%), intralobular lines in 24 (59%), ground-glass opacities in 14 (34%), cavitation in seven (17%), air-space consolidation in five (12%), traction bronchiectasis in 34 (83%), and paracicatricial emphysema in 28 (68%). In approximately 90% of patients, the abnormalities were bilateral and symmetrical and involved all lung zones. CONCLUSION: High-resolution CT findings of paracoccidioidomycosis consist predominantly of interstitial abnormalities and nodules associated with traction bronchiectasis and paracicatricial emphysema in a bilaterally symmetrical distribution.

Mycopathologia 1998;143(2):65-9
Fine needle aspiration in the diagnosis of pulmonary paracoccidioidomycosis.
dos Santos JW, Severo LC, Porto N da S
Servico de Pneumologia, Hospital Universitario de Santa Maria, Universidade Federal de Santa Maria, RS, Brazil. jwell@husm.ufsm.br
Six cases of pulmonary paracoccidioidomycosis diagnosed only by transthoracic fine needle aspiration are presented. The clinical and radiological presentation is varied. The most frequent use of this technique will permit the diagnosis of early lesions of mycosis.

Rev Hosp Clin Fac Med Sao Paulo 1998 Jul-Aug;53(4):184-8
[Immunohistochemistry diagnosis of fungal infections].
Rocha DC, Duarte MI, Pagliari C, de Oliveira MS
Laboratorio da Disciplina de Molestias Transmissiveis, Faculdade de Medicina-USP.
Because the mycosis incidence has increased a lot with the appearing of AIDS, the Immunohistochemistry study among fungus shows the importance of fast methods for their identification that have advantage of been a durable method in comparison with immunofluorescence and the possibility of making retrospective studies in material embedded in paraffin. The Immunohistochemistry reaction with Histoplasma capsulatum, Pneumocystis carinii; and Criptococcus neoformans antibodies were sensitive, specifics, and intensely positive in all the cases previously diagnosed as Histoplasmosis, Pneumocystosis and Cryptococcosis, without cross-reaction with other fungus; while the anti-Candida albicans antibody showed weak positiveness in four Histoplasmosis cases, in one of Paracoccidioidomycosis cases and Sporotrichosis case; and the reactions with the antibody anti-P. brasiliensis were intensely positive in all the Paracoccidioidomycosis cases and weakly positive in two Histoplasmosis and two of the four Candidiasis cases. The previous identification of each fungi on tissue sample was made by Grocott method. This preliminary study showed that it is necessary to use other kinds of antibody and fungus, in order to get more details about the possible occurrence of cross-reactions. We suggest the use of new antibodies, with new standardizations in order to find the best titles for each reaction and eliminate the cross-reactions.

Clin Diagn Lab Immunol 1998 Nov;5(6):826-30 [Texto completo]
Use of the 27-kilodalton recombinant protein from Paracoccidioides brasiliensis in serodiagnosis of paracoccidioidomycosis.
Ortiz BL, Diez S, Uran ME, Rivas JM, Romero M, Caicedo V, Restrepo A, McEwen JG
Biochemistry and Molecular Biology Units and Mycology Group, Corporacion para Investigaciones Biologicas (CIB), Medellin, Colombia.
Paracoccidioidomycosis (PCM) is one of the most important endemic mycoses in Latin America; it is usually diagnosed by observation and/or isolation of the etiologic agent, Paracoccidioides brasiliensis, as well as by a variety of immunological methods. Although the latter are effective, two circumstances, cross-reactions with other mycotic agents and antigen preparation that is marked by extreme variability among lots, hinder proper standardization of the procedures. To circumvent this lack of reproducibility, molecular biology tools were used to produce a recombinant 27-kDa-molecular-mass antigen from this fungus; a sizable quantity of this antigen was obtained through fermentation of Escherichia coli DH5alpha, which is capable of expressing the fungal protein. The latter was purified by the Prep-Cell System (Bio-Rad); the recovery rate of the pure protein was approximately 6%. A battery of 160 human serum samples, consisting of 64 specimens taken at the time of diagnosis from patients with PCM representing the various clinical forms plus 15 serum specimens each from patients with histoplasmosis and aspergillosis, 10 each from patients with cryptococcosis and tuberculosis, 6 from patients with coccidioidomycosis, and 40 from healthy subjects, were all tested by an indirect enzyme-linked immunosorbent assay with the purified 27-kDa recombinant protein. The latter was used at a concentration of 1.0 microgram/well; there were three serum dilutions (1:1,000, 1:2,000, and 1:4,000). The experiment was repeated at least twice. The average sensitivity for both experiments was 73.4%; in comparison with the healthy subjects, the specificity for PCM patients was 87.5% while for patients with other mycoses, it was 58.7%. Important cross-reactions with sera from patients with aspergillosis and histoplasmosis were detected. The positive predictive value of the test was 90.4%. These results indicate that it is possible to employ recombinant antigenic proteins for the immunologic diagnosis of PCM and, by so doing, achieve high coverage rates. Furthermore, antigen reproducibility can now be ensured, thus facilitating inter- and intralaboratory standardization.

J Clin Microbiol 1998 Nov;36(11):3309-16 [Texto completo]
Antigenemia in patients with paracoccidioidomycosis: detection of the 87-kilodalton determinant during and after antifungal therapy.
Gomez BL, Figueroa JI, Hamilton AJ, Diez S, Rojas M, Tobon AM, Hay RJ, Restrepo A
Corporacion para Investigaciones Biologicas, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia.
Serological diagnosis and follow-up of paracoccidioidomycosis (PCM) patients have relied mainly on the detection of antibody responses by using techniques such as complement fixation (CF) and immunodiffusion. We recently described a novel inhibition enzyme-linked immunosorbent assay (inh-ELISA) which proved to be useful in the diagnosis of PCM via the detection of an 87-kDa determinant in patient sera (B. L. Gomez, J. I. Figueroa, A. J. Hamilton, B. Ortiz, M. A. Robledo, R. J. Hay, and A. Restrepo, J. Clin. Microbiol. 35:3278-3283, 1997). This test has now been assessed as a means of following up PCM patients. A total of 24 PCM patients, classified according to their clinical presentation (6 with the acute form of the disease, of whom two had AIDS, 12 with the multifocal form of the disease, and 6 with the unifocal form of the disease), were studied. The four human immunodeficiency virus-negative patients with acute PCM showed a statistically significant decrease in circulating antigen levels after the start of antifungal therapy. Antigen levels in this group became negative by our criteria (</=2.3 microgram/ml) before week 20 and remained so in three of four of these patients. In contrast, the two AIDS patients who also presented with the acute form of PCM showed no statistically significant decrease in circulating antigen levels even after 68 weeks of therapy. Taken together as a group, the patients with the multifocal form showed a statistically significant decrease in antigenemia after 28 weeks of therapy. In addition, five of six patients with the unifocal form became antigen negative by week 40. Antigen level decrease mirrored clinical cure in the majority of patients in all
clinical groups; in contrast, measurement of anti-PCM antibodies via the CF test showed wide fluctuations in titers during the follow-up period. The inh-ELISA for the detection of the 87-kDa Paracoccidioides brasiliensis determinant would appear to be a valuable additional tool in the follow-up of PCM patients.

J Clin Microbiol 1998 Jun;36(6):1723-8 [Texto completo]
Detection of circulating Paracoccidioides brasiliensis antigen in urine of paracoccidioidomycosis patients before and during treatment.
Salina MA, Shikanai-Yasuda MA, Mendes RP, Barraviera B, Mendes Giannini MJ
Departamento de Analises Clinicas, Faculdade de Ciencias Farmaceuticas, UNESP, Araraquara, Brazil.
For the diagnosis and follow-up of paracoccidioidomycosis patients undergoing therapy, we evaluated two methods (immunoblotting and competition enzyme immunoassay) for the detection of circulating antigen in urine samples. A complex pattern of reactivity was observed in the immunoblot test. Bands of 70 and 43 kDa were detected more often in urine samples from patients before treatment. The immunoblot method detected gp43 and gp70 separately or concurrently in 11 (91.7%) of 12 patients, whereas the competition enzyme immunoassay detected antigenuria in 9 (75%) of 12 patients. Both tests appeared to be highly specific (100%), considering that neither fraction detectable by immunoblotting was present in urine samples from the control group. gp43 remained present in the urine samples collected during the treatment period, with a significant decrease in reactivity in samples collected during clinical recovery and increased reactivity in samples collected during relapses. Reactivity of some bands was also detected in urine specimens from patients with "apparent cure." The detection of Paracoccidioides brasiliensis antigens in urine appears to be a promising method for diagnosing infection, for evaluating the efficacy of treatment, and for detecting relapse.

Clin Infect Dis 1996 Nov;23(5):1026-32
Paracoccidioidomycosis: case report and review.
Manns BJ, Baylis BW, Urbanski SJ, Gibb AP, Rabin HR
Department of Internal Medicine, Foothills Medical Center, Alberta, Canada.
A previously well 59-year-old man presented with paracoccidioidomycosis, more than 15 years after leaving South America. He failed to respond to conventional therapies, first with oral itraconazole and then with amphotericin B plus sulfadiazine, and eventually died of recurrent arterial emboli possibly due to
paracoccidioidomycotic aortitis. This patient's presentation demonstrates the difficulties that may be encountered in diagnosing and managing this disease. Paracoccidioidomycosis should be suspected in patients with an appropriate travel history who experience weight loss and have pulmonary, mucosal, and
cutaneous lesions. This article comprehensively reviews the literature, with emphasis on epidemiology, clinical presentation, diagnosis, and therapy with imidazole antifungal medications.
Publication Types:
  Review

Medicine (Baltimore) 1996 Jul;75(4):213-25
Paracoccidioidomycosis of bones and joints. A clinical, radiologic, and pathologic study of 9 cases.
Amstalden EM, Xavier R, Kattapuram SV, Bertolo MB, Swartz MN, Rosenberg AE
Department of Pathology, School of Medicine, State University of Campinas, Sao Paulo, Brazil.
Paracoccidioidomycosis is a systemic fungal infection endemic to Central and South America. It is associated with a broad spectrum of clinical manifestations and has been classified into acute and chronic forms. The latter is the most common type and usually affects male agricultural workers in rural communities. The disease typically begins in the lungs producing varying degrees of parenchymal damage, and in a significant number of cases the organism spreads through bronchogenic, lymphatic, or hematogenous routes to involve 1 or more organs. Bone and joint infection is relatively uncommon and has not been well described in the English literature. Much of the information on this form of the disease has been derived from radiographic and autopsy studies on patients with severe or fatal infections in whom skeletal involvement was a minor or incidental finding. We describe our experience with 9 cases in which osteoarticular manifestations were the sole or 1 of the few major complications of the disease. All 9 patients were male, from 9 to 49 years of age (mean, 36.6 yr). Six were farmers. Evidence of visceral infection was present in 6 patients, in all of whom the lungs were considered the primary site of disease. The osteoarticular lesions were symptomatic in all cases, with the duration of symptoms ranging from 1 week to 2 years. The lesions were centered in bone in 2 cases: they manifested radiographically as circumscribed areas of lysis with or without a rim of sclerosis. The disease was centered in joints in 7 cases; the associated radiographic changes included evidence of joint effusion, periarticular bony erosions, and narrowing of the joint space. Biopsy of the involved skeletal site revealed compact or loose granulomas containing variable numbers of fungi. Although follow-up information was not available for all patients, those treated with TMP-SMX (and 1 patient who also received amphotericin B) and who were followed had prompt resolution of their signs and symptoms. Our findings substantiate some of what is known about the epidemiology of bone and joint involvement in chronic paracoccidioidomycosis. Our patients exhibited features of skeletal infection that have not been emphasized previously, however, including 1) frequent involvement of large joints or long bones of the extremities, 2) presentation with relatively rapidly developing musculoskeletal symptoms, and 3) manifestation as a solitary joint or bone lesion with or without concurrent clinically detectable pulmonary disease. Bone and joint paracoccidioidomycosis should be considered in the differential diagnosis in patients who have skeletal lesions with or without pulmonary involvement and have either lived in or traveled through endemic areas. Early diagnosis and treatment with antifungal medications can achieve an excellent outcome with limited local sequelae.

Clin Infect Dis 1996 Jun;22(6):1132-3
Paracoccidioidomycosis and AIDS.
Nishioka S de A
Publication Types:
  Comment
  Letter
Comments:
  Comment on: Clin Infect Dis 1995 Nov;21(5):1275-81

Clin Infect Dis 1995 Nov;21(5):1275-81
Paracoccidioidomycosis and AIDS: an overview.
Goldani LZ, Sugar AM
Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, Massachusetts 02118, USA.
The scarcity of reported cases of paracoccidioidomycosis and AIDS remains unexplained. We review the details of the 27 cases reported in the medical literature. Paracoccidioidomycosis occurs in patients with advanced AIDS who are not receiving prophylaxis for Pneumocystis carinii pneumonia with trimethoprim-sulfamethoxazole, which is also effective against Paracoccidioides brasiliensis. Clinical manifestations include prolonged fever, weight loss, generalized lymphadenopathy, splenomegaly, hepatomegaly, and skin rash. Diagnosis can often be made by direct microscopic examination and culture of the fungus from skin and lymph node specimens and occasionally from sputum, blood, spinal fluid, and bone marrow specimens. Since antibodies to P. brasiliensis are occasionally detected, the diagnosis should not be ruled out for patients whose serology is negative. Despite specific therapy with different regimens, the overall mortality of paracoccidioidomycosis among patients with AIDS is high (30%). The prognosis can be improved by earlier diagnosis and aggressive therapy with amphotericin B, followed by lifelong immunosuppressive therapy with trimethoprim-sulfamethoxazole. Health care providers caring for human immunodeficiency virus-infected patients who live or have resided in areas in which paracoccidioidomycosis is endemic must be aware of the possibility that this systemic mycosis may occur and have potentially severe consequences.

Publication Types:
  Review
  Review of reported cases
Comments:
  Comment in: Clin Infect Dis 1996 Jun;22(6):1132-3

Rev Argent Microbiol 1995 Jul-Sep;27(3):139-45
[Isolation of an Paracoccidioides brasiliensis exoantigen from solid culture media].
Gago J, Godio C, Ochoa L, Negroni R, Nejamkis MR
Departamento de Microbiologia, Facultad de Medicina, Universidad de Buenos Aires, Argentina.
The goal of this work was to develop in solid medium a fast method to obtain Paracoccidioides brasiliensis (Pb) with a high yield. Four culture media were assayed: Sabouraud honey-agar, Sabouraud dextrose-agar, tomato -agar-medium (TOM) and a medium based on grape pulp. The most exhuberant growth was observed in medium based on grape pulp. Antigen was prepared in microscale at 6, 10 and 15 days incubation of solid cultures and the crude product concentrated by means of Centriplus tubes (Helena, France). Isolated antigens were subjected to polyacrylamide gel electrophoresis, followed by immunolabelling and detection of the characteristic gp45 antigen employing human and Pb-infected rat sera. Best results were observed after 10 days culture in grape medium. None of the other three media afforded comparable results.

Diagn Cytopathol 1995 Jul;13(1):52-3
Paracoccidioidomycosis: diagnosis by fine-needle aspiration cytology.
Drut R
Servicio de Patologia, Hospital de Ninos, La Plata, Argentina.
A 4-yr-old girl presented with constitutional symptoms, abdominal swelling, ascites, and cervical lymphadenopathy. Fine-needle aspirate smears of a cervical lymph node revealed numerous round yeasts, many of them with several peripheral buds fitting the pattern of Paracoccidiodes brasilensis. This appears to be the first case in which the diagnosis of this deep mycosis was achieved by FNAC. The procedure may prove useful for rapid diagnosis in cases like the present one which represents the so-called acute disseminated form which affects mainly children and immunosuppressed patients and can be rapidly fatal.

 

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