Paracoccidioidomycosis in the state of Maranhão, Brazil: geographical and clinical aspects

Analysis and Interpretation of Automated Blood Count in the Treatment of Chronic Paracoccidioidomycosis

Blood count is crucial for assessing bone marrow's cell production and differentiation during infections, gaging disease severity, and monitoring therapeutic responses. The profile of blood count in chronic forms of paracoccidioidomycosis (PCM) has been insufficiently explored. To better understand the changes in hematological cells in different stages of the PCM chronic form, we evaluated the blood count, including immature blood cells in automated equipment, before and during the treatment follow-up of 62 chronic PCM patients. Predominantly male (96.8%) with an average age of 54.3 (standard deviation SD 6.9) years, participants exhibited pre-treatment conditions such as anemia (45.2%), monocytosis (38.7%), and leukocytosis (17.7%), which became less frequent after clinical cure. Anemia was more prevalent in severe cases. Notably, hemoglobin and reticulocyte hemoglobin content increased, while leukocytes, monocytes, neutrophils, immature granulocytes, and platelets decreased. Chronic PCM induced manageable hematological abnormalities, mainly in the red blood series. Monocytosis, indicating monocytes' role in PCM's immune response, was frequent. Post-treatment, especially after achieving clinical cure, significant improvements were observed in various hematological indices, including immature granulocytes and reticulocyte hemoglobin content, underscoring the impact of infection on these parameters.

Iron metabolism disorders of patients with chronic paracoccidioidomycosis

Paracoccidioidomycosis (PCM) is caused by Paracoccidioides spp.; during infection, some host mechanisms limit the availability of iron, thereby reducing its reproduction. However, Paracoccidioides spp. can evade the immune defense and, even under limited iron conditions, use this mineral for growth and dissemination. This study evaluated the iron metabolism of 39 patients who were diagnosed with chronic PCM from 2013 to 2021. The forms of iron before treatment and at the time of clinical cure were evaluated based on the following: serum ferritin levels (storage iron); total iron-binding capacity (TIBC) and transferrin saturation (TSAT) level (transport iron); red blood cell (RBC), hemoglobin (Hb), hematocrit (HCT), and soluble transferrin receptor (sTfR) levels; and sTfR/log ferritin ratio (functional iron). The mean age of the patients was 54.5 years (±6.7 years). Most patients were men (97.4%), rural workers (92.1%), and smokers (84.6%); furthermore, most had moderate disease severity (66.7%). After achieving clinical cure, we observed that serum ferritin levels decreased, and parameters of functional iron increased. The extent of alteration in these parameters were more pronounced in severe cases than in to mild or moderate cases. Furthermore, moderate correlations were observed between C-reactive protein and the Hb (r = -0.500; p = 0.002), RBC (r = -0.461; p = 0.005), HCT (r = -0.514; p = 0.001), and iron levels (r = -0.491; p = 0.002). However, it is possible to infer that PCM interferes with functional and storage iron because improvements in these parameters after treatment as well as associations with disease severity were observed. PCM can lead to anemia of inflammation, which can be differentiated from iron deficiency anemia by a careful investigation of the iron form parameters.

Paracoccidioidomycosis: Current Status and Future Trends

Paracoccidioidomycosis (PCM), initially reported in 1908 in the city of São Paulo, Brazil, by Adolpho Lutz, is primarily a systemic and neglected tropical mycosis that may affect individuals with certain risk factors around Latin America, especially Brazil. Paracoccidioides brasiliensis sensu stricto, a classical thermodimorphic fungus associated with PCM, was long considered to represent a monotypic taxon. However, advances in molecular taxonomy revealed several cryptic species, including Paracoccidioides americana, P. restrepiensis, P. venezuelensis, and P. lutzii, that show a preference for skin and mucous membranes, lymph nodes, and respiratory organs but can also affect many other organs. The classical diagnosis of PCM benefits from direct microscopy culture-based, biochemical, and immunological assays in a general microbiology laboratory practice providing a generic identification of the agents. However, molecular assays should be employed to identify Paracoccidioides isolates to the species level, data that would be complemented by epidemiological investigations. From a clinical perspective, all probable and confirmed cases should be treated. The choice of treatment and its duration must be considered, along with the affected organs, process severity, history of previous treatment failure, possibility of administering oral medication, associated diseases, pregnancy, and patient compliance with the proposed treatment regimen. Nevertheless, even after appropriate treatment, there may be relapses, which generally occur 5 years after the apparent cure following treatment, and also, the mycosis may be confused with other diseases. This review provides a comprehensive and critical overview of the immunopathology, laboratory diagnosis, clinical aspects, and current treatment of PCM, highlighting current issues in the identification, treatment, and patient follow-up in light of recent Paracoccidioides species taxonomic developments.

Clinical and Eco-Epidemiological Aspects of a Novel Hyperendemic Area of Paracoccidioidomycosis in the Tocantins-Araguaia Basin (Northern Brazil), Caused by Paracoccidioides sp

Paracoccidioidomycosis (PCM) is the most prevalent systemic mycosis in Brazil. The disease is caused by dimorphic fungi nested within the Paracoccidioides genus. We described 106 PCM cases (47.1 cases/year) at the Tropical Diseases Public Hospital of Tocantins State. PCM was prevalent in males and rural workers over 50 years; the chronic pulmonary form predominated in 67% of cases. The male-to-female ratio was 2.65:1, with more women affected than other endemic regions of Brazil. Urban or indoor activities were reported in women and are ascribed to disease urbanization. qPCR-based assays confirmed the identification of Paracoccidioides DNA in 37 biological specimens. Paracoccidioides sp. DNA was found in 53% of the environmental samples, suggesting autochthonous infections. Therefore, the Tocantins-Araguaia basin must be considered a novel hyperendemic area of PCM in Brazil, reinforcing the importance of including PCM as a notifiable disease, requiring specific diagnosis and health measures.

Re-drawing the Maps for Endemic Mycoses

Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within specific geographic areas of known endemicity. However, over the past few decades, there have been increasingly frequent reports of infections due to endemic fungi in areas previously thought to be “non-endemic.” There are numerous potential reasons for this shift such as increased use of immune suppressive medications, improved diagnostic tests, increased disease recognition, and global factors such as migration, increased travel, and climate change. Regardless of the causes, it has become evident that our previous understanding of endemic regions for these fungal diseases needs to evolve. The epidemiology of the newly described Emergomyces is incomplete; our understanding of it continues to evolve. This review will focus on the evidence underlying the established areas of endemicity for these mycoses as well as new data and reports from medical literature that support the re-thinking these geographic boundaries. Updating the endemic fungi maps would inform clinical practice and global surveillance of these diseases.

Hospitalisations for mycoses as an indicator of socio-environmental vulnerability in the Brazilian Amazon-Savanna transition region

BACKGROUND

The infections caused by fungi represent a global concern and an important cause of hospital admissions in endemic areas. The influence of socio-environmental factors in infectious diseases has been documented; however, this phenomenon remains unclear regarding mycoses.

OBJECTIVES

This study aimed to analyse the spatio-temporal dynamics of hospitalisations for mycoses (HM) and the association with socio-economic and climate data in the Amazon-Savanna Transition Region in the state of Maranhão, Brazil.

METHODS

In this study, Spearman's correlation was applied to determine the correlation between HM, socio-economic and climatic data obtained from national databases in the period from 1998 to 2016. Hospitalisations for mycoses data were spatialised and analysed using the local Moran's index.

RESULTS

Our data revealed a negative and significant correlation between HM and socio-economic data regarding population, demographic density, human development index, health facilities and sanitary sewage. Significant correlations were observed between HM and precipitation, maximum temperature and minimum temperature. The main modulating climatic variable was the minimum temperature. The spatial autocorrelation analysis showed the dynamics of HM in municipalities belonging to the different regions of the state influenced by socio-economic conditions. We observed the presence of municipalities with high incidence of HM surrounded by others with low HM cases and vice versa.

CONCLUSIONS

Our results indicate that hospitalisations for mycoses represent an important indicator of socio-environmental vulnerability in the Amazon-Savanna transition region in Brazil. We encourage the adoption of measures to mitigate social and environmental impact on these diseases, especially in municipalities with low socio-economic status.

An autochthonous case of paracoccidioidomycosis in a new area of Ceara State, Northeastern Brazil

The largest endemic areas of paracoccidioidomycosis (PCM) in Brazil comprise the humid agricultural regions of the Southeast, South, and, recently, the Midwest and North regions. The Ceara State, located in the Brazilian Northeast region, presents semi-arid climate in most of its territory, characterized by high temperatures, scarce vegetation and low humidity. The objective of the present study was to describe a new autochthonous case of paracoccidioidomycosis from a distinct area of Ceara and review the characteristics of PCM occurrence in Northeastern Brazil. The patient was a 65-year-old male farmer who denied traveling outside the Ceara State or living in other locations. He was born and lived in the rural area known as Camara, bordering the municipalities of Itapaje and Itapipoca. Camara is one of the highest areas (around 720 m of altitude) of the Uruburetama mountains that exhibits tropical forests and is located in Northern Ceara, distant 139 km from the capital, Fortaleza. The patient sought for care, complaining of an oral lesion that appeared over the past three years. The hard palate lesion biopsy revealed multinucleated cells with cytoplasmic inclusions, compatible with PCM. After culture, P. brasiliensis was identified by polymerase chain reaction. Serological testing for PCM was reagent. The patient was treated with itraconazole for approximately 17 months, persisting free of symptoms after 15 months of follow-up. Regarding this new autochthonous case in the Ceara State, PCM should be considered in the differential diagnosis of patients with suggestive clinical manifestations, proceeding from the mountainous areas of Ceara.

Climate drivers of hospitalizations for mycoses in Brazil

Climate can modulate human health at large spatial scales, but the influence of global, regional, and local environments remains poorly understood, especially for neglected diseases, such as mycoses. In this work, we present the correlation between climatic variables and hospitalizations for mycoses in Brazilian state capitals, evaluating the period of 2008 to 2016 at different time scales. The results indicate that climate modulates the hospitalizations for mycoses differently at annual and monthly time scales, with minimum temperature as a key climatic variable during periods of high prevalence in the 10 Brazilian capitals with the highest hospitalizations for mycoses rates. The greatest number of hospitalizations coincided with La Niña events, while a reduction was observed during El Niño events, thereby demonstrating the influence of the Pacific Interdecadal Climate Oscillation on the prevalence of mycoses in Brazil. At a regional scale, the mycoses burden in Brazil appears to respond differently to local and global climatic drivers.

Treatment compliance of patients with paracoccidioidomycosis in Central-West Brazil

Objective:

To evaluate the treatment compliance of patients with paracoccidioidomycosis.

Methods:

We studied 188 patients with paracoccidioidomycosis admitted to a tertiary referral hospital in the Central-West Region of Brazil from 2000 to 2010, to assess their compliance to treatment. In order to be considered compliant, patients needed to present two established criteria: (1) receive medicines from the pharmacy, and (2) achieve a self-reported utilization of at least 80% of the dispensed antifungal compounds prescribed since their previous appointment.

Results:

Most patients were male (95.7%), had the chronic form of the disease (94.2%), and were treated with cotrimoxazole (86.2%). Only 44.6% of patients were treatment compliant. The highest loss to follow-up was observed in the first 4 months of treatment (p < 0.02). Treatment compliance was higher for patients with than for those without pulmonary involvement (OR: 2.986; 95%CI 1.351-6.599), and higher for patients with than without tuberculosis as co-morbidity (OR: 2.763; 95%CI 1.004-7.604).

Conclusions:

Compliance to paracoccidioidomycosis treatment was low, and the period with the highest loss to follow-up corresponds to the first four months. Pulmonary paracoccidioidal involvement or tuberculosis comorbidity predicts a higher compliance to paracoccidioidomycosis therapy.

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.

New Trends in Paracoccidioidomycosis Epidemiology

Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America and more prevalent in South America. The disease is caused by the dimorphic fungus Paracoccidioides spp. whose major hosts are humans and armadillos. The fungus grows in soil and its infection is associated with exposure to the rural environment and to agricultural activities, with a higher risk in coffee and tobacco plantations. Population studies assessing the reactivity to Paracoccidioides spp. antigens by intradermal reaction or serological tests have detected previous subclinical infections in a significant proportion of healthy individuals living in various endemic countries. Paracoccidioidomycosis-disease is manifested by a small minority of infected individuals. The risk of developing the disease and its type of clinical form are related to the personal and life style characteristics of infected individuals, including genetic background, age, sex, ethnicity, smoking habit, alcohol drinking, and eventual cellular immunosuppression. Brazil, Colombia, Venezuela, Argentina, and Ecuador have endemic areas that had already been defined in the 20th century. The incidence of paracoccidioidomycosis can be altered by climate phenomena and mainly by human migration and occupation of poorly explored territories. In Brazil, the endemy tends to expand towards the North and Center-West around the Amazon Region.

Tropical Skin Diseases in Children: A Review- Part I

Because of travel and migration patterns, tropical skin diseases are now seen all around the world, not just in tropical or developing countries. Nutrition, housing, and environmental factors play an important role in these infectious diseases, so when they appear out of their normal environments, their classic presentation may vary. Tropical diseases can also present differently in childhood, making their recognition, diagnosis, and management a clinical challenge. Health care providers in developed countries need to be familiar with tropical skin diseases and be able to diagnose them in returning travelers or immigrants in order to optimize care. This article aims to review the epidemiologic, clinical, diagnostic, and therapeutic aspects of some of the most common tropical dermatologic conditions in children.

EPIDEMIOLOGY OF PARACOCCIDIOIDOMYCOSIS

The epidemiological characteristics of paracoccidioidomycosis were reviewed and updated. The new endemic areas in Brazil were discussed in the section regarding the geographic distribution of the mycosis. Subclinical infection with Paracoccidioides brasiliensis was discussed on the basis of skin test surveys with antigens of the fungus, seroepidemiological studies, and disease cases outside Latin America. Large case series permitted a comparison of the prevalence of the mycosis in different regions, its estimated incidence and risk factors for the development of the disease. Aspects modulating the expression of the clinical forms of paracoccidioidomycosis are also presented. This review also deals with diseases associated with the mycosis, opportunistic paracoccidioidomycosis, lethality, mortality and infection and disease in animals.

Advances and challenges in paracoccidioidomycosis serology caused by Paracoccidioides species complex: an update

Understanding the possible methodologies for the rapid and inexpensive identification of fungal infections is essential for disease diagnosis, but there are some limitations. To help with this problem, serological methods that detect antigens or antibodies are widely used and are useful for the diagnosis of paracoccidioidomycosis (PCM) through the detection of gp43, which is the main antigen employed for the immunodiagnosis of this disease caused by Paracoccidioides brasiliensis. However, the use of gp43 has become restricted because it was recently found that this marker is not identified in the infections caused by Paracoccidioides lutzii. Therefore, it is necessary to identify new antigens in both species or antigens specific for P. lutzii to decrease the morbidity and/or mortality associated with PCM. This review provides a discussion of new diagnostic challenges after the recent discoveries regarding the taxonomy of the Paracoccidioides genus.

Correlation between histopathological and FT-Raman spectroscopy analysis of the liver of Swiss mice infected with Paracoccidioides brasiliensis

Paracoccidioidomycosis is the most important systemic mycosis in Latin America. The main entrance of the fungus is the airway. It primarily occurs in the lung, but in its disseminated form may affect any organ. The liver is one of the organs afflicted by this disease and its homeostasis may be impaired. The aim of the present study was to evaluate the evolution of paracoccidioidomycosis in the liver of Swiss mice and correlate morphological factors with the expression of gp43 and with physicochemical analysis via FT-Raman of the infected organ. According to colony forming unit (CFU) and granuloma counting, the first and second weeks were the periods when infection was most severe. Tissue response was characterized by the development of organized granulomas and widespread infection, with yeasts located within the macrophages and isolated hepatocytes. The gp43 molecule was distributed throughout the hepatic parenchyma, and immunostaining was constant in all observed periods. The main physicochemical changes of the infected liver were observed in the spectral ranges between 1700-1530 cm(-1) and 1370-1290 cm(-1), a peak shifting center attributed to phenylalanine and area variation of -CH2 and -CH3 compounds associated to collagen, respectively. Over time, there was a direct proportional relationship between the number of CFUs, the number of granulomas and the physicochemical changes in the liver of mice infected with Paracoccidioides brasiliensis. The expression of gp43 was similar in all observed periods.

Decreasing prevalence of the acute/subacute clinical form of paracoccidioidomycosis in Mato Grosso do Sul State, Brazil

With the objective to evaluate the behavior of paracoccidioidomycosis in the last three decades, clinical and epidemiological data of 595 patients admitted to clinical services of the Federal University of Mato Grosso do Sul from 1980 to 2009 were investigated. Gender, age distribution, clinical form, comorbidity with tuberculosis or AIDS, and mortality were compared by decades of clinical admission. It was shown that during the three decades there was a decrease in women percentage, and the same manner occurred a reduction in participants in the age group of 20 to 39 years. Moreover, the acute/subacute forms have been diminished in the period. These fluctuations are closely related and can be simultaneously analyzed. Increased AIDS co-infection prevalence from the first to the second decade was also revealed, coinciding with the appearance of the retroviral epidemic and stabilizing during the third decade. No change in the tuberculosis co-infection rate was observed (overall = 6.9%). It reinforces the importance of this co-morbidity. The overall mortality rate remained steady at 6.7%, not varying significantly from one decade to another. The persistent mortality rate calls attention to the importance of this neglected disease.

Paracoccidioidomycosis: epidemiological, clinical, diagnostic and treatment up-dating

Paracoccidioidomycosis is an acute - to chronic systemic mycosis caused by fungi of the genus Paracoccidioides. Due to its frequent tegument clinical expression, paracoccidioidomycosis is an important disease for dermatologists, who must be up-to-date about it. This article focuses on recent epidemiological data and discusses the new insights coming from molecular studies, as well as those related to clinical, diagnostic and therapeutic aspects. In the latter section, we give particular attention to the guideline on paracoccidioidomycosis organized by specialists in this subject.

Ribosomal DNA nanoprobes studied by Fourier transform infrared spectroscopy

Paracoccidioides brasiliensis (P. brasiliensis) is a thermo-dimorphic fungus that causes paracoccidioidomycosis. Brazil epidemiological data shows that endemic areas are the subtropical regions, especially where agricultural activities predominate such as the Southeast, South, and Midwest. There are several tests to diagnose paracoccidioidomycosis, but they have many limitations such as low sensitivity, high cost, and a cross-reacting problem. In this work, gold nanoprobes were used to identify P. brasiliensis as an alternative diagnostic technique, which is easier to apply, costs less, and has great potential for application. The specific Ribosomal sequence of P. brasiliensis DNA was amplified and used to design the nanoprobes using a thiol-modified oligonucleotide. The results of positive and negative tests were done by UV-visible and Fourier Transform Infrared (FT-IR) measurements. The deconvolution of FT-IR sample spectra showed differences in the vibrational modes from the hydrogen bridge NHN and NHO bands that form the double helix DNA for samples matching the DNA sequence of nanoprobes that could be used to classify the samples.