Single Oral Paracoccidioidomycosis Mimicking Other Lesions: Report of Eight Cases

Pseudoepitheliomatous hyperplasia: Squamous cell carcinoma versus oral paracoccidioidomycosis, a case from a dermatological perspective

Paracoccidioidomycosis is a systemic mycosis endemic in Latin America. The most frequent form involves a chronic compromise of the lungs, skin, and mucosa. The patient started with a single oral lesion that lasted for several years. The absence of other symptoms pointed out a possible malignant neoplasm, specifically a squamous cell carcinoma. Differentiation between both diagnoses –fungal infection and carcinoma– depends on the results of the direct examination, the histopathological study, and the initial and subsequent cultures. However, in this case, those findings were not conclusive. The coexistence of both diagnoses is frequent and increases the diagnostic challenge. After several consultations and tests, direct examination, immunodiffusion and real-time PCR findings the multifocal chronic paracoccidioidomycosis diagnosis was confirmed. This case warns about a systematical absence of clinical suspicion of endemic mycoses before the appereance of mucocutaneous lesions, which can be produced by fungi like Paracoccidioides spp, and the importance of considering those mycoses among the differential diagnoses.

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.

Diagnosis at different stages of paracoccidioidomycosis with oral manifestation: Report of two cases

Paracocciodiomycosis (PCDM) is a chronic systemic fungal infection, mainly affecting residents and rural workers, being characterized by a long incubation period, which it can take months or years without clinical manifestations, making diagnosis late and difficult. Depending on the stage of the disease, it can cause sequelae and low quality of life, so its correct diagnosis is of great importance for the accurate treatment. Therefore, the aim of this report is to present two cases of diagnosis of patients with PCDM at different stages, who developed chronic manifestations, pain, clinical involvement of the oral cavity and in one case also presented lung injury with fibrosis, as well as to weight loss, dysphagia and cachexia. Both of patients were treated with antifungal therapy and it was observed total remission of the lesions and no recurrences were detected.

A multicentre study of oral paracoccidioidomycosis: Analysis of 320 cases and literature review

OBJECTIVES

To investigate the frequency of oral paracoccidioidomycosis from representative geographical regions of Brazil and to compare the data with a literature review.

MATERIALS AND METHODS

A retrospective study was conducted on 108,304 biopsies obtained from 1953 to 2016 at six Brazilian oral and maxillofacial pathology services. Demographic data and clinical and histopathological diagnosis of oral paracoccidioidomycosis were evaluated. A literature review of oral paracoccidioidomycosis studies published in three electronic databases was carried out. Data were analysed descriptively.

RESULTS

A total of 320 cases of oral paracoccidioidomycosis were surveyed (0.3% of the oral lesions at the centres studied). The lesions were more frequent among male patients. The gingiva/alveolar ridge was the most affected site. Mean age of affected individuals was 51.3 years (±11.7). The literature review showed a higher incidence of oral paracoccidioidomycosis in the south-east and south regions of Brazil. Male individuals and individuals between 50 and 59 years were most affected.

CONCLUSIONS

Oral paracoccidioidomycosis is an uncommon lesion observed in oral biopsy samples. The differences in the relative frequency of oral paracoccidioidomycosis are related to geographical variations. Men between 50 and 59 years are more affected. This study provides helpful information for clinicians in the diagnosis of oral paracoccidioidomycosis.

Diagnosis of HIV infection on the basis of histoplasmosis-related oral ulceration

Histoplasmosis is an endemic systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum. In immunocompromised patients, histoplasmosis generally occurs as an opportunistic disease, with dissemination to various organs. Cutaneous involvement is observed in 38% to 85% of cases, with oral mucosal involvement in 30% to 60% of cases. This article describes the case study of a 32-year-old woman who presented an extensive tongue ulcer due to histoplasmosis and had the HIV infection diagnosis based on laboratory tests requested by the dentist.

M2 macrophages and inflammatory cells in oral lesions of chronic paracoccidioidomycosis

BACKGROUND

Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by Paracoccidioides brasiliensis (Pb) and associated with deficient cellular immune response, which is modulated by inflammatory cells, mainly macrophages, and cytokines. Recently, the comprehension of the macrophage polarization mediated by Th1 and Th2 cytokines has contributed to elucidate the immune response that takes part in some diseases. Thus, the aim of this study was to assess the presence of Th1- and Th2-immune response and also Pb counting in oral lesions of chronic PCM.

METHODS

Forty-eight cases of chronic PCM oral lesions were included. All cases were classified as loose or dense granulomas. S100 protein, IL-1β, IL-6, TNF-α, CD163 and CD68 immunoexpressions, and Pb localization were evaluated. The fungi present in the tissue were quantified by anti-Pb antibody.

RESULTS

Most patients were white men with mean age of 47 years old and showed higher incidence of multiple lesions. Loose granulomas were predominant and exhibited a great amount of M2 macrophages, which were visualized with anti-CD163 antibody. The expression for CD163 and CD68 was similar (P = 0.05), highlighting the predominance of M2 macrophages in PCM. IL-1β, IL-6, and TNF-α immunoexpression did not significantly change with CD163, CD68, and S100 protein. The number of fungi was significantly higher in cases with intense IL-1β immunoexpression (P = 0.003).

CONCLUSIONS

M2-activated macrophages were the majority among inflammatory cells in chronic PCM, characterizing the action of a Th2-immune response. Nevertheless, Th1 cytokines were also found; mainly IL-1β, which was associated with fungi counting in oral lesions.

Synchronous oral paracoccidioidomycosis and pulmonary tuberculosis in an immunocompetent patient

Paracoccidioidomycosis (PCM) and tuberculosis (TB) are chronic granulomatous infectious diseases, in which the main form of contraction is through inhalation of the microorganism-Paracoccidioides brasiliensis and Mycobacterium tuberculosis. Oral involvement of PCM is observed in up to 70 % of the cases and usually presents clinically as ulcerations with granular surface showing tiny hemorrhagic areas. Oral presentation of TB is rare with prevalence smaller than 0.5 % of all cases. Clinical presentation of oral TB mainly consists of single ulcers with irregular limits and necrotic base. A 70-year-old immunocompetent man presented simultaneously oral PCM and pulmonary TB. Medical history revealed a previous diagnosis of pulmonary TB; however, even under treatment for TB, the patient remained with oral lesions and intense pulmonary fibrosis. The physician requested P. brasiliensis serological analysis, which resulted positive. Although the combination of PCM and TB has been reported in the literature, it is still considered an uncommon condition and their diagnosis may represent a challenge to healthcare professionals because of the similarity between their clinical and radiological presentations.

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.

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.

Synchronous oral paracoccidioidomycosis and esophageal carcinoma

Paracoccidioidomycosis is the most common deep mycosis in South America and is caused by Paracoccidioides brasiliensis (P. brasiliensis), a thermally dimorphic fungus. Infections usually occur by inhalation of conidia, which more often cause respiratory, mucocutaneous, and lymph nodal changes. Chronic features of this mycosis can mimic diverse infections and malignancies and constitute diagnosis challenges. Squamous cell carcinoma deserves special attention in this setting. We describe the case of a patient with synchronous diagnosis of oral paracoccidioidomycosis and esophageal squamous cell carcinoma. Concomitance of these conditions may be a casual event, but a not fully understood causal relationship can be involved.