Cláudia Yrlanda SimonI; Cleudson Nery de CastroI,II; Gustavo Adolfo Sierra RomeroI,II
IServiço de Doenças Infecciosas e Parasitárias da Área de Clínica Médica do Hospital Universitário de Brasília, Brasília, DF IINúcleo de Medicina Tropical da Universidade de Brasília, Brasília, DF
A 23 years old woman, from the State of Minas Gerais, Brazil, came to hospital complaining of cervical, axillary and inguinal lymph nodes for the last two months. She also complained of productive cough with white sputum and nocturne fever with weight loss during the last month. She denied dyspnea, urinary or gastrointestinal symptoms. On physical examination she appeared in regular condition, pale, febrile and with rude lung rales. Abnormal painful and hard lymph nodes were detected in cervical, supraclavicular, popliteal, axillary and inguinal chains (1 to 4cm diameter). One cervical lymph node had been submitted to biopsy and diagnosed as lymphatic cryptococcosis at the health unit that referred the patient. Abdominal examination was normal. During hospital stay the following laboratory and imaging findings were described: high blood leukocytes, 9.6/g/dl hemoglobin, negative acid-fast bacilli in sputum smears, negative PPD, normal abdominal ultrasound and chest x-rays with hilar dense images (Figure 1). Once paracoccidioidomycosis was suspected, the biopsy was revised confirming Paracoccidioides brasiliensis infection. Serology with immune diffusion technique (ID) revealed positive result for paracoccidioidomycosis and negative for histoplasmosis. She was treated with itraconazol and followed with regularly monthly evaluations. She had satisfactory evolution becoming asymptomatic one month after the introduction of itraconazole therapy, remaining with thoracic adenomegaly until the third month of treatment (Figure 2). Clinical evaluation of respiratory sounds was normal six months later, and peripheral adenomegaly disappeared at the eighth month. After one year of follow-up, treatment was suspended because the patient showed complete remission of signs and symptoms, lowering antibody levels detected by the ID test and remarkable thoracic radiologic improvement (Figure 3). She had the first negative ID test 33 months after treatment interruption. One year later, she stopped the hospital follow-up.
The peculiarities of the reported case are related to the predominant and remarkable involvement of thoracic lymph nodes compared to the less relevant involvement of other lymphatic chains, and the absence of other signs of severe disease and apparently normal lung parenchyma in a post-pubertal woman with excellent response to treatment, all differing from the classical juvenile form of the disease.
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2. Paniago AMM, Aguiar JIA, Aguiar ES, Cunha RV, Pereira GROL, Londero AT, Wanke B. Paracoccidiodomicose: estudo clínico e epidemiológico de 422 casos observados no Estado do Mato Grosso do Sul. Revista da Sociedade Brasileira de Medicina Tropical 36: 455-459, 2003.
3. Pereira RM, Bucaretchi F, Barison EM, Hessel G, Tresoldi AT. Paracoccidioidomycosis in children: clinical presentation, follow-up and outcome. Revista do Instituto de Medicina Tropical de São Paulo 46: 127-131, 2004.
Prof. Gustavo Romero
Núvleo de Medicina Tropical/UnB
Campus Universitário Darcy Ribeiro
Caixa Postal 04-517
70919-970 Brasília, DF, Brasil
Tel: 55 61 3273-5008
Fax: 55 61 3273-2811
Recebido para publicação em 9/5/2005
Aceito em 15/6/2005