Paracoccidioides brasiliensis PS2: First Autochthonous Paracoccidioidomycosis Case Report in Rio de Janeiro, Brazil, and Literature Review

First case report of long-term latent infection paracoccidioidomycosis in China

RATIONALE

Although paracoccidioidomycosis is one of the most prevalent endemic mycoses in Latin American countries, where at least 10 million people are infected, the prevalence of paracoccidioidomycosis in China remains unknown because no related case has been reported, and its diagnosis is extremely challenging for local clinicians because of the complexity of disease progression and lack of specific evidence.

PATIENT CONCERNS

Here, we report the first case of PCM in a male patient with a long-term latent infection in China.

DIAGNOSIS

The results of special staining, immunohistochemistry, lymph node biopsy pathology, and metagenomic second-generation sequencing indicated that the patient was infected with Paracoccidioides brasiliensis.

INTERVENTIONS

In this case, the patient was administered voriconazole 200 mg twice daily.

OUTCOMES

After continuous treatment for 6 months, the patient's symptoms improved significantly, and the medication was discontinued. The outpatient follow-up revealed no discomfort.

LESSONS

This case is of great value for the early diagnosis, treatment, and prevention of the spread of this emerging infectious disease in China.

Paracoccidioides Species Circulating in the Endemic Area of Rio de Janeiro, Brazil: Updates into Their Genetic Diversity

Paracoccidiodomycosis (PCM) is the most important systemic mycosis in Brazil, and is usually associated with rural work. PCM is caused by inhalation of infective propagules of thermodimorphic fungi from the genus Paracoccidioides. In the past, it was believed that Paracoccidioides brasiliensis was the single species responsible for PCM cases. However, recent advances in molecular methods allowed the description of several new species, using phylogenetic concordance as the gold standard. Aside from P. brasiliensis sensu stricto, Paracoccidioides americana is also endemic in Rio de Janeiro state, Brazil. This study aimed to evaluate intraspecific genetic variability of Paracoccidioides isolates from patients diagnosed with PCM at a reference center for endemic mycoses in Rio de Janeiro state, from 2015 to 2021. Among the sixteen retrieved isolates, three (18.75%) were identified as P. americana and thirteen (81.25%) as P. brasiliensis sensu stricto. No intraspecific genetic variation was observed by the M-13 primer in P. americana isolates from this geographic region. However, P. brasiliensis sensu stricto isolates were clustered into two distinct molecular profiles, despite being grouped in a single clade in the phylogenetic tree after partial sequencing of arf and gp43 genes. The results suggest a single P. americana lineage and two P. brasiliensis populations causing PCM in Rio de Janeiro, Brazil.

Predicting of novel homoserine dehydrogenase inhibitors against Paracoccidioides brasiliensis: integrating in silico and in vitro approaches

Aim: To search for potential inhibitors to homoserine dehydrogenase (HSD) in Paracoccidioides brasiliensis the causative agent of paracoccidioidomycosis, an infection with a high mortality rate in Brazil.Materials & methods: The enzyme was modeled and used in the virtual screening of the compounds. The library was first screened by the Autodock, in which 66 molecules were better ranked than substrate, and then, also evaluated by the Molegro and Gold programs.Results: The HS23 and HS87 molecules were selected in common by the three programs, and ADME/Tox evaluation indicates they are not toxic. The molecular dynamics of PbHSD bonded to ligands showed stable complexes until 50 ns. To validate the results, compounds were purchased for assays of minimum inhibitory concentration (MIC), minimum fungicidal concentration (MFC), synergic profile with Amphotericin B (AmB) and cytotoxicity. The two molecules presented MIC of 32 μg/ml and MFC of 64 μg/ml against the P. brasiliensis (strain Pb18). They also showed synergistic activity with AmB and a lack of toxicity against Hela and Vero cell lines.Conclusion: These results suggest that the HS23 and HS87 are promising candidates as PbHSD inhibitors and may be used as hits for the development of new drugs against paracoccidioidomycosis.

Adjunctive methylene blue antimicrobial photodynamic therapy for mucocutaneous lesions of mycoses: three case reports

Dermatophytosis, paracoccidioidomycosis and sporotrichosis are mycoses caused by different fungal species with significant prevalence in Brazil and other countries. In some situations, they affect quality of life, especially in the most vulnerable populations. Antifungal drug therapy is the conventional treatment for these diseases, although some difficulties may occur. Adjunctive use of antimicrobial photodynamic therapy (aPDT) may reduce these challenges. Three patients were treated with aPDT and conventional antifungals. In all cases, the patients did not report pain, discomfort or side effects during or after the aPDT intervention. The adjunctive use of aPDT in the cases presented proved to be a safe, low-cost tool that may be promising for the treatment of different mycoses.

Fantastic yeasts and where to find them: the hidden diversity of dimorphic fungal pathogens

Dimorphic fungal pathogens are a significant cause of human disease worldwide. Notably, the dimorphic fungal pathogens within the order Onygenales are considered primary pathogens, causing disease in healthy hosts. Current changes in taxonomy are underway due to advances in molecular phylogenetics, population genetics, and new emerging dimorphic fungal pathogens causing human disease. In this review, we highlight evolutionary relationships of dimorphic fungal pathogens that cause human disease within the order Onygenales and provide rationale to support increased investment in studies understanding the evolutionary relationships of these pathogens to improve rapid diagnostics, help identify mechanisms of antifungal resistance, understand adaptation to human host, and factors associated with virulence.

Clinical and epidemiological features of paracoccidioidomycosis due to Paracoccidioides lutzii

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.

Clinical features and genetic background of the sympatric species Paracoccidioides brasiliensis and Paracoccidioides americana

Introduction

The agents of paracoccidioidomycosis, historically identified as Paracoccidioides brasiliensis, are in fact different phylogenetic species. This study aims to evaluate associations between Paracoccidioides phylogenetic species and corresponding clinical data.

Methods

Paracoccidioides strains from INI/Fiocruz patients (1998–2016) were recovered. Socio-demographic, epidemiological, clinical, serological, therapeutic and prognostic data of the patients were collected to evaluate possible associations of these variables with the fungal species identified through partial sequencing of the ADP-ribosylation factor (arf) and the 43-kDa-glycoprotein (gp43) genes.

Results

Fifty-four fungal strains were recovered from 47 patients, most (72.3%) infected in Rio de Janeiro state, Brazil. Forty-one cases were caused by Paracoccidioides brasiliensis and six by Paracoccidioides americana (former PS2). P. brasiliensis was responsible for severe lymph abdominal forms, whereas patients infected with P. americana presented a high rate of adrenal involvement. However, no statistically significant associations were found for all variables studied. P. americana presented 100% reactivity to immunodiffusion, even when tested against antigens from other species, while negative results were observed in 9 (20%) cases caused by P. brasiliensis, despite being tested against a homologous antigen.

Conclusions

P. brasiliensis and P. americana are sympatric and share similar clinical features and habitat, where they may compete for similar hosts.

Paracoccidioidomycosis (PCM) is a severe systemic mycosis caused by different phylogenetic species. According to previous studies, these species could have an impact in PCM clinical features. This study aims to investigate possible associations between Paracoccidioides species and corresponding clinical data. The fungal strains from the patients were recovered, whereas their clinical data were collected to evaluate possible associations of these variables with the fungal species identified through DNA sequencing. Fifty-four fungal strains were recovered from 47 patients, most infected in Rio de Janeiro state, Brazil. Forty-one cases were caused by Paracoccidioides brasiliensis and six by Paracoccidioides americana. P. brasiliensis was responsible for severe clinical forms, and patients infected with P. americana presented a high rate of adrenal involvement. However, no statistically significant associations were found for all variables studied. P. brasiliensis and P. americana share similar clinical features.

The Curious Case of "Case Report" of Infections Caused by Human and Animal Fungal Pathogens: An Educational Tool, an Online Archive, or a Format in Need of Retooling

Case reports describe the unusual occurrence and complications of diseases, diagnostic challenges, and notable therapeutic successes. Some journals have discontinued the case reports, while new case report journals have appeared in recent years. During the eightieth anniversary of Mycopathologia, it is fitting to examine the relevance of the case report since the journal continues to traverse the boundaries of basic and clinical sciences. A random sample of recent case reports and other articles were selected from Mycopathologia. Springer Nature individual article download statistics, and Google Scholar and Scopus citations numbers were compared to assess the reader access and bibliometric impact of case reports. Our analysis indicated that the case report format continues to be a vital element of publication in a cross-disciplinary journal such as Mycopathologia. Medical and veterinary case reports covering fungal pathogens are widely read as evident from their download numbers. The download numbers have a positive correlation with the completeness of the report, the topics and geographic origin of reports have a neutral influence, and the recency leads to lower downloads. There is no discernible trend between the download numbers and the citations of case reports as measured by Google Scholar and Scopus. A specially designed checklist for Mycopathologia case reports and new format MycopathologiaIMAGES are being introduced to improve the quality and relevance of case reports further.

Paracoccidioidomycosis due to Paracoccidioides brasiliensis S1 plus HIV co-infection

BACKGROUND

Paracoccidioidomycosis (PCM) is one of the most important systemic mycoses in Latin America and the leading fungal cause of mortality in non-immunosuppressed individuals in Brazil. However, HIV/PCM co-infection can increase the clinical severity in these co-infected patients. This co-infection is rarely reported in the literature mainly because of the different epidemiological profiles of these infections. Furthermore, PCM is a neglected and non-notifiable disease, which may underestimate the real importance of this disease. The advent of molecular studies on the species of the genus Paracoccidioides has expanded the knowledge regarding the severity and the clinical spectrum in PCM. In this context, the development of studies to describe the association of the Paracoccidioides phylogenetic cryptic species in vulnerable populations, such as HIV-infected patients, appears relevant.

OBJECTIVE

To describe the clinical, epidemiological, therapeutic and prognostic aspects in HIV/PCM co-infected patients, along with the molecular identification of the Paracoccidioides species involved in these cases.

METHODS

The investigators performed a molecular and clinical retrospective study involving HIV/PCM co-infected patients, from a reference centre for PCM care in the endemic area of Rio de Janeiro, Brazil, from 1998 to 2015. Molecular identification of the fungal strains was done by amplification of partial sequences of arf and gp43 genes.

FINDINGS

Of 89 patients diagnosed with PCM by fungal isolation in the culture, a viable isolate was recovered for molecular analysis from 44 patients. Of these 44 patients, 28 (63.6%) had their serum samples submitted for enzyme immunoassay tests for screening of HIV antibodies, and 5 (17.9%) had a positive result. All cases were considered severe, with a variable clinical presentation, including mixed, acute/subacute clinical forms and a high rate of complications, requiring combination therapy. Paracoccidioides brasiliensis S1 was the species identified in all cases.

CONCLUSIONS

HIV/PCM co-infection can change the natural history of this fungal disease. The authors reinforce the need to include HIV screening diagnostic tests routinely for patients with PCM.

Targeting the Immune System with Plant Lectins to Combat Microbial Infections

The arsenal of drugs available to treat infections caused by eukaryotic and prokaryotic microbes has been declining exponentially due to antimicrobial resistance phenomenon, leading to an urgent need to develop new therapeutic strategies. Host-directed immunotherapy has been reported as an attractive option to treat microbial infections. It consists in the improvement of host defenses by increasing the expression of inflammatory mediators and/or controlling of inflammation-induced tissue injury. Although the in vitro antimicrobial and immunomodulatory activities of lectins have been extensively demonstrated, few studies have evaluated their in vivo effects on experimental models of infections. This review aims to highlight the experimental use of immunomodulatory plant lectins to improve the host immune response against microbial infections. Lectins have been used in vivo both prophylactically and therapeutically resulting in the increased survival of mice under microbial challenge. Other studies successfully demonstrated that lectins could be used in combination with parasite antigens in order to induce a more efficient immunization. Therefore, these plant lectins represent new candidates for management of microbial infections. Furthermore, immunotherapeutic studies have improved our knowledge about the mechanisms involved in host–pathogen interactions, and may also help in the discovery of new drug targets.

Brazilian guidelines for the clinical management of paracoccidioidomycosis

Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis ( P. brasiliensis ) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii ( P. lutzii ), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

Pulmonary paracoccidioidomycosis associated with septic shock in an immunocompetent patient. Case report

Introducción. La paracoccidioidomicosis (PCM) es una enfermedad crónica granulomatosa causada por el hongo dimórfico Paracoccidioides brasiliensis. Esta entidad compromete de manera preferencial a los pulmones, pero puede diseminarse a otros órganos, con particular trofismo por mucosa oral, glándulas suprarrenales, nódulos linfáticos, entre otros.Presentación del caso. Se presenta el caso de un hombre con PCM pulmonar manejada en el Hospital Universitario de Santander. El paciente ingresó con sospecha inicial de tuberculosis pulmonar activa por presencia en la tomografía de tórax de múltiples cavitaciones y nódulos de distribución aleatoria en el parénquima pulmonar y posterior aislamiento de levaduras compatibles con Paracoccidioides; se le suministró anfotericina B deoxicolato sin respuesta favorable y con posterior desarrollo de choque séptico por Klebsiella pneumoniae de espectro extendido. A pesar del manejo antibiótico multiconjugado, el sujeto presenta síndrome de falla multiorgánica con desenlace fatal a los 21 días de hospitalización.Conclusión. La PCM pulmonar es una enfermedad endémica que conlleva una respuesta inmunológica inadecuada del huésped que —en conjunto con factores de riesgo como tabaquismo, enolismo, desnutrición y bajo nivel socioeconómico— facilita la aparición de infecciones o enfermedades coexistentes potencialmente mortales, por lo cual su diagnóstico oportuno a partir de una sospecha clínica temprana influye potencialmente en la sobrevida del paciente.

Acute juvenile Paracoccidioidomycosis: A 9-year cohort study in the endemic area of Rio de Janeiro, Brazil

BACKGROUND

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by pathogenic dimorphic fungi of the genus Paracoccidioides. It is the most important systemic mycosis in Latin America and the leading cause of hospitalizations and death among them in Brazil. Acute PCM is less frequent but relevant because vulnerable young patients are affected and the severity is usually higher than that of the chronic type.

METHODS

The authors performed a retrospective cohort study from 2001 to 2009 including acute juvenile PCM patients from a reference center in Rio de Janeiro, Brazil. Clinical, epidemiological, diagnostic, therapeutic, and prognostic data were reported.

RESULTS

Twenty-nine patients were included. The average age was 23 years old and the male to female ratio was 1:1.07. All cases were referred from 3 of 9 existing health areas in the state of Rio de Janeiro, predominantly from urban areas (96.5%). Lymph nodes were the most affected organs (100%), followed by the skin and the spleen (31% each). Twenty-eight patients completed treatment (median 25 months) and progressed to clinical and serological cure; 1 death occurred. Twenty-four patients completed 48-month median follow-up. Four patients abandoned follow-up after the end of treatment. The most frequent sequela was low adrenal reserve. Paracoccidioides brasiliensis S1 was identified by partial sequencing of the arf and gp43 genes from 4 patients who presented a viable fungal culture.

CONCLUSION

Acute juvenile PCM is a severe disease with a high rate of complications. There are few cohort clinical studies of acute PCM in the literature. More studies should be developed to promote improvement in patients' healthcare.