2. Introduction
• Paracoccidioidomycosis is a chronic granulomatous
disease that characteristically produces a primary
pulmonary infection, often inapparent, and then
disseminates to form ulcerative granulomata of the
buccal, nasal and occasionally the gastrointestinal
mucosa.
• The disease in its inception and development is
similar to blastomycosis and coccidioidomycosis.
• The only etiological agent, Paracoccidioides
brasiliensis is geographically restricted to areas of
South and Central America.
Also known as
Brazilian blastomycosis,
South American blastomycosis,
Lutz-Splendore-de Almeida disease
3. Lutz-Splendore-de Almeida disease is named for the
physicians Adolfo Lutz, Alfonso
Splendore,and Floriano Paulo de Almeida,who first
characterized the disease in Brazil in the early 20th
century.
Paracoccidioidomycosis (PCM), formerly known as
South American blastomycosis and Lutz-Splendore-
Almeida disease, is a fungal infection endemic to
South and Central America.
Paracoccidioidomycosis most commonly manifests as
a chronic progressive systemic mycosis in men from
the forested tropical and subtropical regions of Latin
America.
Pulmonary infection is the most common
manifestation; however, following dissemination,
paracoccidioidomycosis frequently involves the
4. Etiology
P. brasiliensis is a thermally-dimorphic fungus
The habitat of the infectious agent is not known but
appears to be aquatic.
In biopsies the fungus appears as a polygemulating
yeast with a pilot's wheel-like appearance.
5. Epidemiology
Rare cases of paracoccidioidomycosis are reported
from outside the endemic area, including in North
America..
Restricted geographically to South and Central
America, from Mexico to Argentina, with exception of
Chile, Surinam, the Guyana, Nicaragua, Belize, and
most of the Caribbean Islands.
Paracoccidioidomycosis is most common in the
southeast provinces of Brazil, with an estimated
annual incidence of 1-3 cases per 10,000 inhabitants,
followed by Colombia, Venezuela, Ecuador, and
Argentina.
Within endemic regions, paracoccidioidomycosis is
restricted ecologically to coffee- or tobacco-
growing areas, areas with acidic soils, and areas
with temperatures between 12°C and 30°C, altitudes
between 150 and 2000 m, and rainfall between 100
6.
7. Mortality/Morbidity
Untreated paracoccidioidomycosis carries a high
mortality rate (16-25%). The mortality rate in Brazil,
where it has been reported as the 8th leading cause of
death, is estimated at 1.4 deaths per 1 million
inhabitants.
Sex: More common in men, especially farmers and
hunters, with a mean male-to-female ratio of 15:1.
Some have attributed this unequal distribution to
exposure; however, skin-testing studies have
revealed nearly equal rates of subclinical infection.
That a higher proportion of men progress on to clinical
disease has been attributed to differences in
steroidal hormones. β-stradiol has been shown in
vitro to block or delay the transformation of P.
brasiliensis from mycelial to yeast form
Age: Rare in children and teenagers. Most common
8. Pathogenisis
Naturally acquired P. brasiliensis infection in
animals has been reported only in armadillos.
However, bats may serve as reservoirs
The lungs are the primary site of infection,
likely secondary to inhalation of conidia or
mycelial fragments.
Afterward, P brasiliensis yeast disseminate to
other organs through the venous and lymphatic
systems.
The intestinal mucosa may serve as a site
of direct inoculation if P. brasiliensis is
ingested.
9. Clinical features
• Ranges from an asymptomatic infection to
disease process with either acute or chronic form
• Clinical forms:
A. Paracoccidioidomycosis- Infection
Subclinical and is detected only by skin test
B. Paracoccidioidomycosis- Disease
1. Acute or Sub acute Forms ( Juvenille Type)
Severe- Mucosal involvement
2. Chronic Form (Adult type)
Unifocal- one organ
Multifocal- multi organ
3. Quiescent or Sequele (Latent form): old active
lesions with scars
Mucocutaneous
Lymphatic
Visceral
10.
11. Laboratory diagnosis
• Specimen:
• Skin scrapings,
• Sputum and bronchial washings,
• Cerebrospinal fluid,
• Pleural fluid
• Blood , bone marrow,
• Tissue biopsies from various visceral
organs.
12. Direct Microscopy
(a) Skin scrapings should be examined using 10%
KOH and Parker ink or calcofluor white
mounts;
(b) Exudates and body fluids should be centrifuged
and the sediment examined using either 10%
KOH and Parker ink or calcofluor white mounts,
(c) Tissue sections should be stained using PAS
digest, Grocott's methenamine silver (GMS) or
Gram stain.
• Histopathology is especially useful and is one
of the most important ways of alerting the
laboratory that they may be dealing with a
potential pathogen.
15. Culture
• Clinical specimens should be inoculated onto
primary isolation media, like Sabouraud's
dextrose agar and BHI agar supplemented
with 5% sheep blood.
• Colony:
• At 250C: Flat to wrinkled, leathery first and later
on developing tufts of aerial mycelia, which
eventually cover colonies.
• White to tan with yellowish
brown reverse
16. Immunodiagnosis
Skin test
Intradermal injection of
Paracoccidioidin
Serological tests
Gp43 is used as antigen against
patient sera
Immunodiffusion
ELISA
CIEP
17. Treatment
Sulfonamides are the traditional remedies
The most used sulfa drugs in this infection are
sulfadimethoxime, sulfadiazine and co-
trimoxazole. This treatment is generally safe
but several adverse effects can appear.
Amphotericin-B or ketoconazole are also
effective in clearing the infection but they are
very expensive compared with sulfonamides.
During therapy fibrosis can appear and a
surgery be needed to correct this.
