Oral paracoccidioidomycosis. A study of 36 South American patients

Oral Paracoccidioidomycosis affecting women: A systematic review

Paracoccidioidomycosis (PCM) is an infection caused by fungi of the genus Paracoccidioides and is marked by a strong predilection for men; nevertheless, some women have had developed PCM and have presented oral involvement by the disease.

OBJECTIVES

To review all published cases until August 2020 of oral PCM in women, with emphasis on the presence of systemic changes, deleterious habits (tobacco and alcohol) and oral manifestation features through a systematic review.

METHODS

Observational studies (both prospective and retrospective) and case reports indexed in the Embase, PubMed, Scopus, Web of Science and LIVIVO databases were selected by two reviewers in a two-phase process following the pre-established PICOS criteria.

RESULTS

Twenty-five studies met the eligibility criteria and were selected for qualitative synthesis, of which 72 participants were enrolled. Brazilian White women between 40 and 50 years were the most affected and social history revealed them to be housewives or rural workers. Fifteen women (33.3% of the informed cases) presented any systemic change at the time of PCM diagnosis, namely pregnancy, HIV infection and/or depression. Moriform stomatitis was predominant and affected preferentially the gingivae and alveolar processes in the form of a single painful lesion. Most patients were treated with sulfamethoxazole + trimethoprim or itraconazole.

CONCLUSIONS

Oral PCM in women is rare; some cases showed systemic changes at the time of PCM diagnosis, namely HIV infection, pregnancy and depression. New studies should be conducted to elucidate the influence of systemic alterations on the development of oral PCM in women.

Oral paracoccidioidomycosis in a non-endemic region from Brazil: A short case series

Background

Although the paracoccidioidomycosis (PCM) is endemic in Brazil, the occurrence in most states from the North and Northeastern Brazil is very unusual. The aim of this study was to evaluate the clinicopathologic features of a case series of oral PCM in a non-endemic region from Brazil (Northeastern region), discussing the clinical and histopathological differential diagnoses of the oral manifestations of the disease.

Material and Methods

Between 2000 and 2017, all cases of oral PCM were retrieved from the Oral Pathology Laboratory, Universidade Federal de Pernambuco, located at Northeastern Brazil. Clinical data, such as age, gender, origin, occupation, site, symptoms, time of complaints, clinical presentation, number of lesions, and clinical hypotheses of diagnosis, were collected from the clinical charts. All cases were histologically reviewed in hematoxylin-eosin and Gomori-Grocott staining.

Results

Six cases were identified. All patients were male, with a mean age of 53.8 years (ranging from 40 to 73 years). Four cases appeared as multiple ulcers and two presented single lesions (buccal mucosa and hard palate). Clinically, in five cases, squamous cell carcinoma was considered in the differential diagnosis. The common histopathological features consisted of hyperplastic epithelium, intraepithelial microabscesses, and formation of granulomatous chronic inflammatory reaction in a fibrous connective tissue with severe chronic inflammatory reaction. Yeasts were observed either inside of multinucleated giant cells or extracellularly.

Conclusions

Although rare in non-endemic regions, oral PCM should be considered in the differential diagnosis of oral chronic ulcers, mainly those multiple.

Key words:Oral mucosa, mycology, paracoccidoidomycosis, ulcer.

Oral paracoccidioidomycosis in a single-center retrospective analysis from a Brazilian southeastern population

BACKGROUND

Paracoccidioidomycosis (PCM) is the most prevalent endemic systemic fungal infection in Latin America. In Brazil, it stands out as the eighth-highest cause of mortality among chronic or recurrent infections and has the highest mortality rate among systemic mycoses. Oral mucosal lesions may be the first visible physical manifestation of the disease. This study traced the epidemiological and clinical profiles of patients with oral lesions treated at the University Hospital Cassiano Antonio Moraes, Federal University of Espirito Santo.

METHODS

A retrospective cross-sectional analysis of patient medical records was performed.

RESULTS

Among the 161 patients identified with a confirmed diagnosis of PCM, 97 (60.24%) presented with oral lesions. The male:female ratio was 15:1, the mean age was 50.5 years, and the chronic form of paracoccidioidomycosis was predominant. Most of the patients had smoking habits and were rural workers. The most common oral lesions present in various anatomical sites were mulberry-like ulcers, more frequently observed in the gingiva, with regression within one to three months. Patients completed the treatment in one to two years (32.99%), and 47.42% of cases discontinued treatment.

CONCLUSIONS

In addition to the characteristics of the oral lesions, information from the clinical profiles of patients with oral PCM is a central tool for dentists for early diagnosis. Earlier diagnosis may result in fewer consequences, especially respiratory ones that may cause an inability to work and poor quality of life.

Oral paracoccidioidomycosis: Retrospective analysis of 55 Brazilian patients

Paracoccidioidomycosis (PCM) is a rare fungal infection in the world, but endemic and acquired exclusively in Latin America, with the highest prevalence in South America and Brazil, particularly. Changes in oral cavity are common and constitute the first clinical manifestation in many patients. The aim of this study was to describe the prevalence of oral PCM and analyse the profile of the disease and patients. Retrospective research, consisting of information present in the medical records in the period 1998-2015, whose histopathological diagnosis was oral PCM. Fifty-five oral PCM cases were confirmed. Of these patients, 90.9% were males and 9.1% were females. The average age was 49.66 years and the most reported occupation was rural workers. The painful symptomatology was present in 61.82% of patients. Erythematous lesions were predominant in 73% of them. In single lesions (22 cases), the most common locations were jugal mucosa and tongue. In multiple involvement (30 cases), the most affected regions were lips, jugal mucosa and alveolar ridge. Epidemiology of PCM, was similar to several other studies, especially in Brazil. This is the most important fungal infection in Latin America and the recognition of oral lesions is extremely important, as is often the first and in many cases the only manifestation of the disease.

Sore or Swollen Lips Part 2: Systemic Causes

This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips. Clinical relevance: Sore and/or swollen lips are not uncommon, often have a local cause, but may reflect a systemic disease. The previous article reviewed important causes, from actinic to contact cheilitis, while this paper starts with drug-induced cheilitis and completes that alphabetical list.

Erratum: Paracoccidioidomycosis of the Mouth: an Emerging Deep Mycosis

Oral fungal infections (mycoses) have come into particular prominence since the advent of infection with Human Immunodeficiency Virus (HIV), and recognition of the Acquired Immune Deficiency Syndrome (AIDS), as well as the phenomenal increase in world travel with increased exposure to infections endemic in the tropics. Paracoccidioidomycosis is a rare mycosis worldwide but common in Brazil and some other areas in Latin America. It can be life-threatening and can manifest with a spectrum of clinical presentations, including frequent oral lesions. This paper reviews the more recent information on Paracoccidioidomycosis, emphasizing those areas most relevant in dental science.

Disseminated paracoccidioidomycosis diagnosis based on oral lesions

Paracoccidioidomycosis (PCM) is a deep mycosis with primary lung manifestations that may present cutaneous and oral lesions. Oral lesions mimic other infectious diseases or even squamous cell carcinoma, clinically and microscopically. Sometimes, the dentist is the first to detect the disease, because lung lesions are asymptomatic, or even misdiagnosed. An unusual case of PCM with 5 months of evolution presenting pulmonary, oral, and cutaneous lesions that was diagnosed by the dentist based on oral lesions is presented and discussed.

Unexpected Blastomyces dermatitidis etiology of fungal sinusitis and erosive palatal infection in a diabetic patient

We present what is believed to be the initial report of hard-palate infection caused by Blastomyces dermatitidis. The organism was cultivated from biopsy material obtained from a diabetic patient presenting with complaints of headache and malaise. Radiologic findings revealed a malignant-appearing soft-tissue mass with paranasal sinus base destruction.

Paracoccidioidomycosis mimicking squamous cell carcinoma on the dorsum of the tongue and review of published literature

INTRODUCTION

Paracoccidioidomycosis is a disease that is endemic to southern and southeastern Brazil, caused by the fungus Paracoccidioides brasiliensis. The most common clinical oral manifestation is the presence of multiple granulomatous ulcers with hemorrhagic dots, located mainly on the lips, palate, and buccal mucosa. However, the disease can manifest atypically as a single ulcer, mimicking oral squamous cell carcinoma (SCC) or tuberculosis.

CASE REPORT

A 65-year-old male patient presented with a complaint of a single ulcerated lesion on the dorsum of the tongue; the lesion had evolved over 6 months. The diagnostic hypotheses were SCC and oral manifestation of tuberculosis. An incisional biopsy was performed, and histopathological analysis of the specimen revealed pseudoepitheliomatous hyperplasia, a granulomatous structure of epithelioid histiocytes, multinucleated giant cells, and lymphocytes in the connective tissue. Grocott staining confirmed the presence of the fungus in the lesion, and a diagnosis was made of paracoccidioidomycosis. The patient was treated with 200 mg/day of itraconazole for 12 months and now shows no signs or symptoms of recurrence of the disease.

CONCLUSION

Correct diagnosis is essential for a successful therapeutic approach and resolution of the lesion.

Head and neck manifestations of paracoccidioidomycosis: an epidemiological study of 36 cases in Brazil

BACKGROUND

Paracoccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis. It is the principal systemic mycosis in Brazil, with higher incidence rates in the southern, southeastern, and midwestern regions. It primarily involves the lungs, but head and neck manifestations are common, and differential diagnosis with granulomatous and neoplastic diseases should therefore be considered.

METHODS

We conducted a retrospective analysis of medical records of paracoccidioidomycosis cases with head and neck manifestations in southern Brazil over a 10-year period, from 1998 to 2008.

RESULTS

A total of 36 cases of paracoccidioidomycosis were confirmed by histopathological examination, fungal investigation, or culture. Most cases consisted of men with smoking and/or chronic drinking habits and with poor hygiene and nutrition.

CONCLUSIONS

Paracoccidioidomycosis is endemic to southern Brazil. Most cases with mucocutaneous manifestations affect the head and neck region. Given that risk factors and clinical manifestations are similar to those of head and neck carcinomas, a differential diagnosis has to be done.

Primary blastomycosis of oral cavity

BACKGROUND

Blastomycosis is an uncommon male-predominant disease caused by the fungus Blastomyces dermatitidis. The lungs are most commonly affected, and other organs are usually involved by dissemination. Clinical feature and pathohistologic findings are similar to the appearance of squamous cell carcinoma.

METHODS AND RESULTS

A 52-year-old male patient who has lived as a farmer on the countryside in Argentina for 35 years presented with an initial histopathologic diagnosis of a squamous cell carcinoma of the right lower jaw. There was no history of pulmonary disease, in particular fever, coughing, or hemoptysis. Final pathohistologic evaluation after resection revealed B. dermatitidis infection. This article presents the first described case of oral manifestation of B. dermatitidis infection in Switzerland.

CONCLUSIONS

Manifestation of blastomycosis in oral tissue can mimic the feature of a squamous cell carcinoma and can therefore be a diagnostic pitfall that head and neck surgeons and a pathologist should be aware of.

Characterization of inflammatory cells in oral paracoccidioidomycosis

Paracoccidioidomycosis (Pmycosis) is one of the most common deep mycoses in many regions of Latin America, particularly in Brazil. Microscopically, it shows granulomatous inflammatory reaction with giant cells, macrophages, lymphocytes, plasma cells, polymorphonuclear neutrophilic leukocytes, and eosinophils. The purpose of this study was to assess the distribution of inflammatory cells in oral Pmycosis. Fifteen cases of oral Pmycosis were studied by immunohistochemistry for the presence of macrophages, CD4(+) and CD8(+) lymphocytes, CD20(+), CD15(+), and S100(+) cells. Macrophages were the main cells in well-organized granulomas and non-granulomatous areas. The CD4 phenotype was predominant in well-organized granulomas and a balance between CD4(+) and CD8(+) cells was observed in non-granulomatous areas. Dendritic, S100(+) cells were found mainly in the epithelium, in subepithelial connective tissue, and at the periphery of organized granulomas. CD15(+) cells were concentrated mainly in areas of intraepithelial microabscess and ulceration. Macrophages and T cells are the predominant cells in oral Pmycosis. Well-organized granulomas contain fewer yeast particles, indicating a more effective host immune response. Better understanding of the histopathological changes in oral Pmycosis might help determine treatment, severity and systemic involvement of the disease.

Gingival Involvement in Oral Paracoccidioidomycosis

BACKGROUND

Paracoccidioidomycosis, a deep mycosis endemic in parts of Latin America, often presents with oral lesions involving the gingiva. Nevertheless, the periodontal literature is devoid of references to oral paracoccidioidomycosis. The purpose of this study was to characterize the gingival involvement in oral paracoccidioidomycosis and to contrast clinical and histopathologic diagnosis of the disease. Differential diagnosis and management of oral paracoccidioidomycosis were reviewed.

METHODS

From January 1995 to October 2006, the files of the Oral Pathology Laboratory, School of Dentistry, Alfenas Federal University, were reviewed to identify cases referred because of a clinical diagnosis of oral paracoccidioidomycosis. Data collected included patient demographics (age, gender, race, and occupation), clinical information (oral lesion location), and histopathologic diagnosis.

RESULTS

Forty-six cases were identified, and 34 were histopathologically confirmed as paracoccidioidomycosis. Of the remaining 12 cases, one-half were diagnosed as either carcinoma or dysplastic leukoplakia. Of the 34 confirmed paracoccidioidomycosis cases, 45% presented with multiple site involvement, whereas the gingiva/alveolar process was the most prevalent site overall (52%). The gingiva/alveolar process was the most prevalent site in both multiple and single site cases. The majority of patients were men (88%), white (75%), and in their fourth decade of life (47%). Statistical analysis revealed that patients with gingival/alveolar process involvement were demographically indistinguishable from those without.

CONCLUSIONS

Oral paracoccidioidomycosis has a strong predilection for the gingiva, whereas patients with gingival lesions do not differ from patients lacking such involvement. Early diagnosis of gingival/oral lesions may prevent life-threatening complications of this mycosis.

(B1) Candida and mycotic infections

Oral candidiasis (OC) is the most common mucosal manifestation of HIV infection. This workshop examined OC and other mycoses associated with HIV infection. Historically, blood CD4 cell numbers were the primary prognosticator for the development of OC. However, a study that statistically evaluated the predictive role of HIV viral load vs. CD4 cell counts revealed viral load to be a stronger predictor for OC. The role of biofilms and antifungal resistance in recalcitrant OC is unclear at present. In general, micro-organisms including yeasts in biofilms are more resistant to antifungals than their planktonic counterparts. When the remaining organisms are eliminated, the few resistant organisms may not be problematic, because they are present in low numbers. Unusual exotic mycoses in HIV-infected patients are more common in patients from the developing than the developed world. These infections may be recurrent and recalcitrant to therapy, be present in multiple and uncommon sites, increase with the progression of HIV disease, and may play a role similar to that of the more common mycoses. Typing and subtyping of yeasts are probably not critical to the clinical management of candidiasis caused by Candida albicans and non-albicans strains, including C. dubliniensis, because it is responsive to antifungal therapy. C. glabrata is probably the only exception. The presence of oral thrush in infants younger than 6 months of age is associated with an increased post-natal transmission risk of HIV infection. Thus, perinatal retroviral therapy should be combined with the treatment of oral thrush to prevent the post-natal acquisition of HIV.

Current trends of HIV disease of the mouth

HIV infection affects residents of all countries of the world, but the greater majority of affected individuals reside in the developing world. In the past decade there have been substantial changes in the management of HIV disease, particularly the introduction of highly active antiretroviral therapy (HAART). Such agents have reduced significantly the morbidity and mortality associated with HIV disease, however, they are not available for most HIV-infected individuals in the developing world. There is now considerable understanding of the molecular epidemiology, transmission and therapy of the common opportunistic oral infections of HIV disease, and as a consequence of improved anti-HIV strategies, the frequency and severity of oral disease associated with HIV infection have reduced considerably, although HAART may predispose to human papilloma virus infection of the mouth and potentially increase the risk of later oral squamous cell carcinoma. Despite advances in clinical care the majority of individuals with HIV disease worldwide will continue to develop oral disease, as they are resident in the developing world and do not have ready access to even simple therapies.

[Clinical-epidemiologic profile of paracoccidioidomycosis at the Stomatology Department of São Lucas Hospital, Pontificia Universidade Católica of Rio Grande do Sul]

The aim of the article was to describe clinical and epidemiological features of 61 oral paracoccidioidomycosis cases from the Stomatology Department of São Lucas Hospital, analyzed from July 1976 to June 2004. The State of Rio Grande do Sul is an endemic region due to ecoepidemiologic conditions, that are favorable for the development of the yeast. Men are the most affected gender, with 58 (95%) affected compared to 3 (5%) women. Ii is most prevalent (70.5%) between 40 and 59 years of age. Agricultural labor was the most common occupation with 27/61 (44.3%) patients. Tobacco smoking was prevalent in 52 (85.3%) of the sample, and alcoholism was a frequent finding. All the patients showed stomatologic manifestations, with ulcers and mulberry-like stomatitis the most prevalent, these oral lesions were also observed in many anatomical sites. Alterations were present in 32 (65.3%) of the pulmonary radiographs.

Diagnosis of periodontal manifestations of systemic diseases

Many systemic diseases can mimic periodontitis or gingivitis. These include many immunologic, infectious, neoplastic and metabolic disorders. In comparison with periodontitis and gingivitis, these disorders are considerable less common. However, since their diagnosis and management differ, a high index of suspicion is frequently needed when confronted a patient presenting with gingival or periodontal disease. This chapter has reviewed a number of systemic conditions that may mimic clinically both gingivitis and chronic periodontitis and has focused on the features that may assist the clinician in making the diagnosis and providing specific therapies.

Oral manifestations of paracoccidioidomycosis. Report of 21 cases from Argentina

The present study describes 21 Argentinian patients living in the province of Corrientes, who had developed oral manifestations due to Paracoccidioides brasiliensis infection. Of these, 20 patients were men and one a woman. Patients were of an average age of 39 years (range 25 to 72 years). Approximately, 76.2% of the patients were farmers. Gingival lesions were observed in 76%. Also, the tongue (71%) and the lips (62%) were frequently affected. Cytological smears and histopathology showed the characteristic fungal cells with the characteristic granulomatous inflammatory reaction consisting of lymphocytes, epithelioid cells and giant cells of the Langhans type. All patients except one had detectable pulmonary involvement. Therapy consists of long-term administration of itraconazole. Oral manifestations of paracoccidioidomycosis are characteristic in their clinical presentation. Early diagnosis and adequate therapy may prevent extensive tissue destructions. Long-term follow-up is mandatory.

Paracoccidioidomycosis of the mouth: an emerging deep mycosis

Oral fungal infections (mycoses) have come into particular prominence since the advent of infection with Human Immunodeficiency Virus (HIV), and recognition of the Acquired Immune Deficiency Syndrome (AIDS), as well as the phenomenal increase in world travel with increased exposure to infections endemic in the tropics. Paracoccidioidomycosis is a rare mycosis worldwide but common in Brazil and some other areas in Latin America. It can be life-threatening and can manifest with a spectrum of clinical presentations, including frequent oral lesions. This paper reviews the more recent information on Paracoccidioidomycosis, emphasizing those areas most relevant in dental science.

Paracoccidioidomycosis: report of 2 cases mimicking squamous cell carcinoma

Paracoccidioidomycosis is an endemic fungal infection in Latin America. This mucocutaneous disease often involves the oral mucosa and may clinically resemble other infectious and neoplastic processes. Paracoccidioidomycosis that clinically suggested squamous cell carcinoma was diagnosed in 2 patients with a history of heavy alcohol and tobacco use. Antifungal therapy with ketoconazole and itraconazole resulted in resolution of the oral lesions. Interestingly, 1 patient had a pulmonary lesion that persisted after antifungal therapy, and biopsy proved this to be a squamous cell carcinoma of the lung.

The oral route in the pathogenesis of paracoccidioidomycosis: an experimental study in BALB/c mice infected with P. brasiliensis conidia

Due to the high frequency of oral mucosal lesions observed in paracoccidioidomycosis patients, it was advocated that the infection was acquired by the traumatic implantation of the etiologic agent Paracoccidioides brasiliensis. Although at present this theory is considered invalid, it has not yet been excluded in experimental studies. In order to determine if intra-oral inoculation could explain the pathogenesis of paracoccidioidomycosis, 64 BALB/c mice were inoculated intra-orally with 850.000 viable P. brasiliensis conidia into the mandibular body. Animals were sacrificed at various time intervals up to 20 weeks and cultures were made from gingiva, lungs, spleen, and liver. Additionally, histopathological studies of the mandibular body were also performed. P. brasiliensis was isolated from all gingival tissues during the interval 24-72 h, indicating that the infection was active. During the 5-10 week period, the infection appeared to have been controlled at the inoculation site as cultures showed a significant reduction in colony forming units (CFU); however, at the 15-20 week period such control was lost and the fungus was recovered once more. Dissemination to other body sites was rare; thus, the lungs were involved in just one animal (2%), the liver in two (3%) and the spleen in seven (11%). The infection became established as proven by positive organ cultures, but the dissemination pattern did not correspond to the one observed in humans. Based on these findings, the intra-oral traumatic route does not appear to mimic the natural history of paracoccidioidomycosis.

Cutaneous primary paracoccidioidomycosis

Paracoccidioidomycosis is a common fungal infection in Latin America. Few cases have been described in non-endemic countries and their diagnosis without the correct suspicion, bearing in mind that the latency period might be up to 60 years, may not be easy. We report the case of a 59-year-old man who worked as a taxi driver for 25 years in Venezuela. Cutaneous paracoccidioidomycosis was diagnosed one year after he returned to Spain. No internal signs or symptoms of the disease were found and cell-mediated immunity showed no depression. Our case suggested us to consider direct cutaneous infection, although respiratory tract is believed to be the most frequent portal of entry for this infection.

The deep mycoses in HIV infection

The deep mycoses are uncommon infections, usually acquired from the inhalation or ingestion of fungal spores, sometimes from the soil in areas of endemicity, such as in the Americas and south-east Asia, or from decaying vegetable matter. They are also seen in immunocompromised persons and, increasingly, in HIV-infected persons. Respiratory involvement is frequent, with granuloma formation, and mucocutaneous involvement may be seen. Oral lesions of the deep mycoses are typically chronic but non-specific, though nodular or ulcerative appearances are common. Person-to-person transmission is rare. In HIV disease, the most common orofacial involvement of deep mycoses has been in histoplasmosis, cryptococcosis, aspergillosis and zygomycosis. Diagnosis is usually confirmed by lesional biopsy although culture may also be valuable. Treatment is with amphotericin or an azole.

Oral secondary syphilis in a patient with human immunodeficiency virus infection

This report describes a case of secondary syphilis in a patient with the human immunodeficiency virus (HIV) in whom the main clinical presentation of the disease was an extensive oral lesion. Few reports in the literature have focused on oral manifestations of syphilis in HIV-infected patients; most of these reports have dealt with a rare manifestation of secondary syphilis, the ulceronodular variety or lues maligna. However, in the case reported here the lesions were painless, smooth, white, oral plaques and papules on an erythematous base with a serpentine and reddish outline corresponding to the description of mucous patches. The differential diagnosis of this lesion may include oral squamous carcinoma, leukoplakia, erythroleukoplakia, candidosis, lichen planus, and granulomatous diseases. This case report emphasizes the importance of considering secondary syphilis in the differential diagnosis of oral lesions in HIV-infected patients, reinforces the importance of follow-up on the patient, and highlights the consideration for routine serologic testing for syphilis in all HIV-infected patients.