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Hahn RC, Hagen F, Mendes RP, Burger E, Nery AF, Siqueira NP, Guevara A, Rodrigues AM, de Camargo ZP. Paracoccidioidomycosis: Current Status and Future Trends. Clin Microbiol Rev 2022; 35:e0023321. [PMID: 36074014 PMCID: PMC9769695 DOI: 10.1128/cmr.00233-21] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Rosane Christine Hahn
- Medical Mycology Laboratory/Investigation, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
- Júlio Muller Hospital, EBSERH, Cuiabá, Mato Grosso, Brazil
| | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Institute for Biodiversity and Ecosystem Dynamics (IBED), University of Amsterdam, Amsterdam, The Netherlands
| | - Rinaldo Poncio Mendes
- Faculdade de Medicina de Botucatu, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
- Faculdade de Medicina, Federal University of Mato Grosso do Sul (UFMS), Campo Grande, Mato Grosso do Sul, Brazil
| | - Eva Burger
- Department of Microbiology and Immunology, Federal University of Alfenasgrid.411180.d (UNIFAL), Alfenas, Minas Gerais, Brazil
| | - Andreia Ferreira Nery
- Medical Mycology Laboratory/Investigation, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
- Júlio Muller Hospital, EBSERH, Cuiabá, Mato Grosso, Brazil
| | - Nathan Pereira Siqueira
- Medical Mycology Laboratory/Investigation, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
| | - Armando Guevara
- Medical Mycology Laboratory/Investigation, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
| | - Anderson Messias Rodrigues
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology, and Parasitology, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
- Department of Medicine, Discipline of Infectious Diseases, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Zoilo Pires de Camargo
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology, and Parasitology, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
- Department of Medicine, Discipline of Infectious Diseases, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
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de Brito TGN, Taborda M, Provenci B, Costa AN, Benard G. A Case-Control Study of Paracoccidioidomycosis in Women: The Hormonal Protection Revisited. J Fungi (Basel) 2021; 7:jof7080655. [PMID: 34436194 PMCID: PMC8398402 DOI: 10.3390/jof7080655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
Clinical observations have long suggested that women are protected against paracoccidioidomycosis. 17β-estradiol, the main female estrogen, inhibits conidia-to-yeast transformation (C-to-Y), which is required for the infection establishment. However, experiments in murine models have yielded conflicting results, suggesting that C-to-Y inhibition, alone, fails to explain the female-associated protection and that sexual hormones may also act by modulating the host’s immune responses. Therefore, this issue remains unsolved. Strikingly, no studies have compared the severity of paracoccidioidomycosis between men and women. This retrospective case-control study compared 36 women with 72 age-matched men for clinical–demographic, laboratory, and chest imaging findings. Overall, paracoccidioidomycosis in women presented the main features described in the acute/subacute and chronic forms seen in men. Women also showed similar demographic features and clinical–laboratory and imaging severity scores as men. We additionally reviewed 58 paracoccidioidin skin test surveys undertaken by volunteers from endemic areas. Data accumulated from 10.873 tests showed that females and males are infected with similar magnitudes (21.9% vs. 25.2%) and that reactivity steadily increased with age, peaking after the age of 60. We discuss the paradox of similar infection rates but much lower disease prevalence in women, considering the current pathogenetic views of paracoccidioidomycosis, and we raise alternative hypotheses to account for this paradox.
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Affiliation(s)
- Tereza Graciano Nascimento de Brito
- Laboratorio de Investigacao em Imunologia e Dermatologia (LIM56), Departamento de Dermatologia and Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 470, São Paulo 05403-000, Brazil;
| | - Mariane Taborda
- Divisao de Doenças Infecciosas, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 255, São Paulo 05403-000, Brazil;
| | - Bruna Provenci
- Divisao de Pneumologia, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 44, São Paulo 05403-900, Brazil; (B.P.); (A.N.C.)
| | - André Nathan Costa
- Divisao de Pneumologia, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 44, São Paulo 05403-900, Brazil; (B.P.); (A.N.C.)
| | - Gil Benard
- Laboratorio de Investigacao em Imunologia e Dermatologia (LIM56), Departamento de Dermatologia and Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 470, São Paulo 05403-000, Brazil;
- Laboratorio de Micologia Medica (LIM53), Departamento de Dermatologia and Instituto de Medicina Tropical, Faculdade de Medicina, Universidade de Sao Paulo, SP, R. Dr. Enéas de Carvalho Aguiar 470, São Paulo 05403-000, Brazil
- Correspondence:
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Nery AF, de Camargo ZP, Rodrigues AM, Portela TF, Hoffmann-Santos HD, Pinheiro BG, Possa AP, Cavalcante LRDS, Hagen F, Hahn RC. Puzzling paracoccidioidomycosis: Factors associated with the severity of Paracoccidioides lutzii infections. Int J Infect Dis 2021; 107:284-290. [PMID: 33989777 DOI: 10.1016/j.ijid.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Historically, the Brazilian Central-West region has had high numbers of paracoccidioidomycosis (PCM) cases caused by the dimorphic fungus Paracoccidioides lutzii. METHODS This epidemiological, observational, analytical, cross-sectional study was performed to investigate the clinical and laboratory data of 44 PCM patients with a culture-proven P. lutzii infection. All patients were referred to the Systemic Mycosis Center, Júlio Muller University Hospital, Cuiabá, Brazil, during January 2017 to March 2020. The neutrophil to lymphocyte ratio (NLR) was calculated and dichotomized by its median value to include in the identification of factors associated with severity. RESULTS At admission, 13 (31.7%) patients showed the disseminated multifocal chronic form of PCM and 16 (36.4%) patients met the clinical severity criteria. Treatment prescribed on admission did not follow the recommendations of the Brazilian Guideline for the Clinical Management of Paracoccidioidomycosis in 26% of the severe PCM cases (prevalence ratio 0.26, 95% confidence interval 0.14-0.49; P < 0.0001). Patients with severe PCM had a higher NLR that was greater than the median (≥4.11). CONCLUSIONS The NLR biomarker complements the criteria for PCM severity. Applying the low-cost NLR test can greatly increase the diagnostic sensitivity when screening patients for PCM and contribute to better control of the disease, management of complications, and therapeutic strategies.
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Affiliation(s)
- Andreia Ferreira Nery
- Internal Medicine Department, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil; Júlio Muller University Hospital, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
| | - Zoilo Pires de Camargo
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil; Discipline of Infectious Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Anderson Messias Rodrigues
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil; Discipline of Infectious Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Tiago Ferreira Portela
- Júlio Muller University Hospital, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil
| | | | - Breno Gonçalves Pinheiro
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil
| | - Ana Paula Possa
- Laboratory of Emerging Fungal Pathogens, Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Rosane Christine Hahn
- Júlio Muller University Hospital, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil; Laboratory of Mycology/Research, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, Mato Grosso, Brazil.
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Hahn RC, Rodrigues AM, Della Terra PP, Nery AF, Hoffmann-Santos HD, Góis HM, Fontes CJF, de Camargo ZP. Clinical and epidemiological features of paracoccidioidomycosis due to Paracoccidioides lutzii. PLoS Negl Trop Dis 2019; 13:e0007437. [PMID: 31163028 PMCID: PMC6548353 DOI: 10.1371/journal.pntd.0007437] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The fungus Paracoccidioides lutzii was recently included as a new causative species of paracoccidioidomycosis (PCM) and most cases have been reported from Brazil. According to available epidemiological information, P. lutzii is concentrated in the Middle-West region in Brazil, mainly in the state of Mato Grosso. However, clinical and laboratorial data available on patients infected with P. lutzii remain extremely limited. METHODOLOGY/MAIN FINDINGS This work describes the clinical manifestations of 34 patients suffering from PCM caused by P. lutzii, treated along 5 years (2011-2017) at a reference service center for systemic mycoses in Mato Grosso, Brazil. Adult rural workers (men), aged between 28 and 67 predominated. All patients had the chronic form of the disease, and the oral mucosa (n = 19; 55.9%), lymph nodes (n = 23; 67.7%), skin (n = 16; 47.1%) and lung (n = 28; 82.4%) were the most affected sites. Alcohol intake (n = 19; 55.9%) and smoking (n = 29; 85.3%) were frequent habits among the patients. No patient suffered from any other life-threatening disease, such as tuberculosis, cancer or other inflammatory or infectious parasitic diseases. The positivity in culture examination (97.1%) was higher than that found for the direct mycological examination (88.2%). Particularly, one patient presented fungemia at diagnosis, which lead to his death. The time elapsed between the initial symptoms and the initiation of treatment of PCM caused by P. lutzii was 19.7 (31.5) months, with most patients diagnosed 7 months after the symptoms' onset. CONCLUSIONS/SIGNIFICANCE Compared with the classical clinical-epidemiological profile of PCM caused by P. brasiliensis, the results of this descriptive study did not show significant clinical or epidemiological differences that could be attributed to the species P. lutzii. Future studies may confirm or refute the existence of clinical differences between the two fungal species.
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Affiliation(s)
- Rosane Christine Hahn
- Federal University of Mato Grosso, Faculty of Medicine, Laboratory of Mycology/Research, Cuiabá, Mato Grosso, Brazil
- Federal University of Mato Grosso, Júlio Muller University Hospital, Mato Grosso, Brazil
- Federal University of São Paulo, Paulista School of Medicine, Department of Microbiology, Immunology and Parasitology, Cellular Biology Division, São Paulo, São Paulo, Brazil
| | - Anderson Messias Rodrigues
- Federal University of São Paulo, Paulista School of Medicine, Department of Microbiology, Immunology and Parasitology, Cellular Biology Division, São Paulo, São Paulo, Brazil
| | - Paula Portella Della Terra
- Federal University of São Paulo, Paulista School of Medicine, Department of Microbiology, Immunology and Parasitology, Cellular Biology Division, São Paulo, São Paulo, Brazil
| | - Andréia Ferreira Nery
- Federal University of Mato Grosso, Júlio Muller University Hospital, Mato Grosso, Brazil
| | - Hugo Dias Hoffmann-Santos
- Federal University of Mato Grosso, Faculty of Medicine, Laboratory of Mycology/Research, Cuiabá, Mato Grosso, Brazil
| | - Hellen Meira Góis
- Federal University of Mato Grosso, Júlio Muller University Hospital, Mato Grosso, Brazil
| | | | - Zoilo Pires de Camargo
- Federal University of São Paulo, Paulista School of Medicine, Department of Microbiology, Immunology and Parasitology, Cellular Biology Division, São Paulo, São Paulo, Brazil
- * E-mail:
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