Pulmonary Paracoccidioidomycosis and AIDS

Endemic pulmonary fungal diseases in immunocompetent patients: an emphasis on thoracic imaging

INTRODUCTION

Systemic endemic mycoses are prevalent in specific geographical areas of the world and are responsible for high rates of morbidity and mortality in these populations, and in immigrants and travelers returning from endemic regions. The most common fungal infections that can affect the lungs of immunocompetent patients include histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis, sporotrichosis, aspergillosis, and cryptococcosis. Diagnosis and management of these diseases remain challenging, especially in non-endemic areas due to the lack of experience. Therefore, recognition of the various radiologic manifestations of pulmonary fungal infections associated with patients' clinical and epidemiologic history is imperative for narrowing the differential diagnosis. Areas covered: This review discusses the clinical and radiological findings of the main endemic fungal diseases affecting the lungs in immunocompetent patients. Specific topics discussed are their etiology, epidemiology, pathogenesis, clinical manifestations, methods of diagnosis, pathology and main imaging findings, especially in computed tomography. Expert commentary: Imaging plays an important role in the diagnosis and management of pulmonary fungal infection and may reveal useful signs. Although definitive diagnosis cannot be made based on imaging features alone, the use of a combination of epidemiologic, clinical and imaging findings may permit the formulation of an adequate differential diagnosis.

Imaging paracoccidioidomycosis: A pictorial review from head to toe

Paracoccidioidomycosis is an infectious disease characterized primarily by pulmonary involvement and potential dissemination to other organs, mainly mucosa and skin; however, it can affect any organ in the body. Although difficult to diagnose purely based on imaging, imaging is important for diagnosis, follow-up, and assessment of disease-related complications. We provide a comprehensive review of the most notable imaging findings of paracoccidioidomycosis.

Approach to Fungal Infections in Human Immunodeficiency Virus-Infected Individuals: Pneumocystis and Beyond

Many fungi cause pulmonary disease in patients with human immunodeficiency virus (HIV) infection. Pathogens include Pneumocystis jirovecii, Cryptococcus neoformans, Aspergillus spp, Histoplasma capsulatum, Coccidioides spp, Blastomyces dermatitidis, Paracoccidioides brasiliensis, Talaromyces marneffei, and Emmonsia spp. Because symptoms are frequently nonspecific, a high index of suspicion for fungal infection is required for diagnosis. Clinical manifestations of fungal infection in HIV-infected patients frequently depend on the degree of immunosuppression and the CD4⁺ helper T cell count. Establishing definitive diagnosis is important because treatments differ. Primary and secondary prophylaxes depend on CD4⁺ helper T cell counts, geographic location, and local prevalence of disease.

Paracoccidioidomycosis in Brazilian Patients With and Without Human Immunodeficiency Virus Infection

Paracoccidioidomycosis (PCM) is endemic to Latin America, where 10 million people may be infected with Paracoccidioides brasiliensis/Paracoccidioides lutzii and 1,600,000 individuals live with human immunodeficiency virus (HIV) infection. An epidemiological overlapping of these infections occurred early in acquired immunodeficiency syndrome era with nearly 180 published cases. This study presents epidemiological, clinical, and outcome profiles for 31 PCM patients with HIV infection diagnosed in a teaching hospital in Brazil, and includes an update of previously reported cases. Medical records were reviewed and data compared with 64 PCM patients without HIV infection. Of the 31 PCM patients with HIV infection, 23 (74.1%) were male, with a median age of 36.7 years, whereas of the 64 PCM, 45 (70.3%) were male, with a median age of 35.1 years. Both groups presented similar proportions for smoking and alcoholism. PCM patients with HIV infection presented more fever, weight loss, and the acute clinical form than the PCM patients who had more mucosal and respiratory involvement characterizing the chronic form. Most PCM patients with HIV infection exhibited overlapping symptoms from both clinical forms with median symptom duration of 4.5 months compared with 8.3 months for the PCM control. Patients received sulfonamides and/or itraconazole for a median of 15.7 and 16.7 months for PCM/HIV-infected and PCM, respectively. Relapses occurred more in PCM (12 [30%]) than PCM/HIV-infected (4 [14.8%]) patients, whose mortality rate was higher (10 [32.8%]) than PCM patients (8 [20%]). The cases of PCM/HIV infection confirm that HIV can interact with some endemic diseases without increasing their frequency, while changing their natural history, clinical presentation, and outcome. The data presented here are in agreement with those observed in other studies.

Computed tomography findings of paracoccidiodomycosis in musculoskeletal system

Objective

To evaluate musculoskeletal involvement in paracoccidioidomycosis at computed tomography.

Materials and Methods

Development of a retrospective study based on a review of radiologic and pathologic reports in the institution database. Patients with histopathologically confirmed musculoskeletal paracoccidioidomycosis and submitted to computed tomography were included in the present study. The imaging findings were consensually described by two radiologists. In order to avoid bias in the analysis, one patient with uncountable bone lesions was excluded from the study.

Results

A total of seven patients were included in the present study. A total of 18 bone lesions were counted. The study group consisted of 7 patients. A total number of 18 bone lesions were counted. Osteoarticular lesions were the first manifestation of the disease in four patients (57.14%). Bone lesions were multiple in 42.85% of patients. Appendicular and axial skeleton were affected in 85.71% and 42.85% of cases, respectively. Bone involvement was characterized by well-demarcated osteolytic lesions. Marginal osteosclerosis was identified in 72.22% of the lesions, while lamellar periosteal reaction and soft tissue component were present in 5.55% of them. One patient showed multiple small lesions with bone sequestra.

Conclusion

Paracoccidioidomycosis can be included in the differential diagnosis of either single or multiple osteolytic lesions in young patients even in the absence of a previous diagnosis of pulmonary or visceral paracoccidioidomycosis

Other HIV-associated pneumonias

The incidence, mortality, and epidemiology of human immunodeficiency virus (HIV)-associated pulmonary infections have changed as a result of effective antiretroviral and prophylaxis antimicrobial therapy. The clinical presentation, radiographic abnormalities, and treatment of pneumonia from various uncommon pathogens in patients with AIDS can be different from those in immunocompetent patients. Advances in invasive and noninvasive testing and molecular biological techniques have improved the diagnosis and prognosis of pulmonary infections in patients infected with HIV. This review focuses on pulmonary infections from nontuberculosis mycobacteria, cytomegalovirus, fungi (aspergillosis, cryptococcosis, endemic fungi), and parasites (toxoplasmosis), and uncommon bacterial pneumonia (nocardiosis, rhodococcosis) in these patients.

Thoracic paracoccidioidomycosis: radiographic and CT findings

Paracoccidioidomycosis (PCM) is the most common systemic mycosis in Latin America. Although most cases occur in developing countries, recent immigration patterns and an increase in travel have led to a growing number of PCM cases in the United States and Europe. PCM is caused by the dimorphic fungus Paracoccidioides brasiliensis, and the chronic form may progress to severe pulmonary involvement. Several radiologic patterns have been described for pulmonary PCM, including linear and reticular opacities, variable-sized nodules, patchy ill-defined opacities, airspace consolidation, and cavitary lesions. Fibrosis and paracicatricial emphysema are common associated findings. Chest computed tomography (CT) is the method of choice for evaluating pulmonary PCM, with the most common CT findings being ground-glass attenuation, consolidation, small or large nodules, masses, cavitations, interlobular septal thickening, emphysema, and fibrotic lesions. PCM is also an important cause of the "reversed halo" sign at high-resolution CT and should be considered in the differential diagnosis. Awareness of the multiple radiologic manifestations of PCM as well as its epidemiologic and clinical characteristics may permit early diagnosis and initiation of specific treatment, thereby reducing associated morbidity and mortality.