Paracoccidioidomycosis Research Articles

Characterization of Aspartic Proteases from Paracoccidioides brasiliensis and Their Role in Fungal Thermo-Dimorphism

Paracoccidioidomycosis (PCM) is the most prevalent systemic mycosis in Latin America and is caused by fungi from the Paracoccidioides genus. The infection begins after inhalation of the fungal propagules and their thermo-dimorphic shift to yeast form. Proteases play an important role in the host invasion process and immune modulation in many pathogenic microorganisms. Aspartyl proteases are virulence factors in many human fungal pathogens that play an important role in the host invasion process morphogenesis, cellular function, immunity, and nutrition. In the present study, we characterized the modulation of acid proteases from Paracoccidioides brasiliensis. We detected four aspartyl proteases in P. brasiliensis with high homology to aspartic protease from Saccharomyces cerevisiae Pep4. Furthermore, we demonstrated that Pepstatin A can inhibit dimorphic switching (mycelium→yeast) in P. brasiliensis. In addition, these genes were modulated during thermo-dimorphism (M→Y transition) in the presence or absence of carbon and nitrogen sources and during growth at pH 4 during 24 and 48 h. We also observed that P. brasiliensis increase the secretion of aspartic proteases when cultivated at pH 4, and these acid proteases cleave BSA, collagen, and hemoglobin. These data suggest that aspartyl proteases are modulated by environmental conditions and during fungal thermo-dimorphism. Thus, this work brings new possibilities for studying the role of aspartyl proteases in the host-pathogen relationship and P. brasiliensis biology.

Development of a Multiplex qPCR Assay for Fast Detection and Differentiation of Paracoccidioidomycosis Agents.

Classic paracoccidioidomycosis (PCM) is a potentially deadly neglected tropical systemic mycosis caused by members of the Paracoccidioides brasiliensis complex (P. brasiliensis s. str., P. americana, P. restrepiensis, and P. venezuelensis) and P. lutzii. The laboratorial diagnosis of PCM relies on observing pathognomonic structures such as the "steering wheel" or "Mickey Mouse" shape in the direct mycological examination, fresh biopsied tissue in 10% KOH, histopathological analysis, and/or the isolation of the fungus in culture. However, these procedures are time-consuming and do not allow for the speciation of Paracoccidioides due to overlapping morphologies. Here, we propose a new one-tube multiplex probe-based qPCR assay to detect and recognize agents of the P. brasiliensis complex and P. lutzii. Primers (Paracoco-F and Paracoco-R) and TaqMan probes (PbraCx-Fam, Plu-Ned, and Paracoco-Vic) were developed to target the rDNA (ITS2/28S) in the Paracoccidioides genome. A panel of 77 Paracoccidioides isolates revealed a 100% specificity (AUC = 1.0, 95% CI 0.964-1.000, p < 0.0001) without cross-reacting with other medically relevant fungi or human and murine DNA. The lower limit of detection was 10 fg of gDNA and three copies of the partial rDNA amplicon. Speciation using qPCR was in perfect agreement with AFLP and TUB1-RFLP markers (kappa = 1.0). As a proof of concept, we assessed a panel of 16 formalin-fixed and paraffin-embedded specimens from histopathologically confirmed PCM patients to reveal a significant sensitivity of 81.25% and specificity of 100% (AUC = 0.906 ± 0.05, 95% CI = 0.756-0.979, p < 0.0001, Youden index J = 0.8125). Our assay achieved maximum sensitivity (100%) and specificity (100%) using fresh clinical samples (n = 9) such as sputum, bronchoalveolar lavage, and tissue fragments from PCM patients (AUC = 1.0, 95% CI 0.872-1.000, p < 0.0001, Youden index J = 1.0). Overall, our qPCR assay simplifies the molecular diagnosis of PCM and can be easily implemented in any routine laboratory, decreasing a critical bottleneck for the early treatment of PCM patients across a vast area of the Americas.

Molecular Phylogenetic Analysis of Paracoccidioides Species Complex Present in Paracoccidioidomycosis Patient Tissue Samples.

Paracoccidioidomycosis (PCM) is the main and most prevalent systemic mycosis in Latin America, that until recently, it was believed to be caused only by Paracoccidioides brasiliensis (P. brasiliensis). In 2006, researchers described three cryptic species: S1, PS2, PS3, and later, another one, PS4. In 2009, Paracoccidioides lutzii (Pb01-like) was described, and in 2017, a new nomenclature was proposed for the different agents: P. brasiliensis (S1), P. americana (PS2), P. restrepiensis (PS3), and P. venezuelensis (PS4). These species are not uniformly distributed throughout Latin America and, knowing that more than one cryptic species could coexist in some regions, we aimed to identify those species in patients' biopsy samples for a better understanding of the distribution and occurrence of these recently described species in Botucatu region. The Hospital of Medical School of Botucatu-UNESP, which is a PCM study pole, is located in São Paulo State mid-west region and is classified as a PCM endemic area. Genotyping analyses of clinical specimens from these patients that have been diagnosed and treated in our Hospital could favor a possible correlation between genetic groups and mycological and clinical characteristics. For this, molecular techniques to differentiate Paracoccidioides species in these biopsies, such as DNA extraction, PCR, and sequencing of three target genes (ITS, CHS2, and ARF) were conducted. All the sequences were analyzed at BLAST to testify the presence of P. brasiliensis. The phylogenetic trees were constructed using Mega 7.0 software and showed that 100% of our positive samples were from S1 cryptic species, therefore P. brasiliensis. This is important data, demonstrating the predominance of this species in the São Paulo State region.

Global Molecular Response of Paracoccidioides brasiliensis to Zinc Deprivation: Analyses at Transcript, Protein and MicroRNA Levels.

Zinc is one of the main micronutrients for all organisms. One of the defense mechanisms used by the host includes the sequestration of metals used in fungal metabolism, such as iron and zinc. There are several mechanisms that maintain the balance in the intracellular zinc supply. MicroRNAs are effector molecules of responses between the pathogen and host, favoring or preventing infection in many microorganisms. Fungi of the Paracoccidioides genus are thermodimorphic and the etiological agents of paracoccidioidomycosis (PCM). In the current pandemic scenario world mycosis studies continue to be highly important since a significant number of patients with COVID-19 developed systemic mycoses, co-infections that complicated their clinical condition. The objective was to identify transcriptomic and proteomic adaptations in Paracoccidioides brasiliensis during zinc deprivation. Nineteen microRNAs were identified, three of which were differentially regulated. Target genes regulated by those microRNAs are elements of zinc homeostasis such as ZRT1, ZRT3 and COT1 transporters. Transcription factors that have zinc in their structure are also targets of those miRNAs. Transcriptional and proteomic data suggest that P. brasiliensis undergoes metabolic remodeling to survive zinc deprivation and that miRNAs may be part of the regulatory process.

Biodistribution and Adjuvant Effect of an Intranasal Vaccine Based on Chitosan Nanoparticles against Paracoccidioidomycosis

Paracoccidioidomycosis (PCM) is a fungal infection caused by the thermodimorphic Paracoccidioides sp. PCM mainly affects the lungs, but, if it is not contained by the immune response, the disease can spread systemically. An immune response derived predominantly from Th1 and Th17 T cell subsets facilitates the elimination of Paracoccidioides cells. In the present work, we evaluated the biodistribution of a prototype vaccine based on the immunodominant and protective P. brasiliensis P10 peptide within chitosan nanoparticles in BALB/c mice infected with P. brasiliensis strain 18 (Pb18). The generated fluorescent (FITC or Cy5.5) or non-fluorescent chitosan nanoparticles ranged in diameter from 230 to 350 nm, and both displayed a Z potential of +20 mV. Most chitosan nanoparticles were found in the upper airway, with smaller amounts localized in the trachea and lungs. The nanoparticles complexed or associated with the P10 peptide were able to reduce the fungal load, and the use of the chitosan nanoparticles reduced the necessary number of doses to achieve fungal reduction. Both vaccines were able to induce a Th1 and Th17 immune response. These data demonstrates that the chitosan P10 nanoparticles are an excellent candidate vaccine for the treatment of PCM.

Diagnosis and Treatment of Pulmonary Coccidioidomycosis and Paracoccidioidomycosis.

Coccidioidomycosis (CM) and paracoccidioidomycosis (PCM) are systemic mycoses that are highly endemic in Latin America and have recently been included on the World Health Organization (WHO) Fungal Priority Pathogens List. Coccidioides immitis and Coccidioides posadasii are recognized as etiological agents of CM, with peculiarities in their geographic distribution. The genus Paracoccidioides now includes Paracoccidioides lutzii and the Paracoccidioides brasiliensis complex, which encompasses four phylogenetic species. In both diseases, pulmonary signs and symptoms are the main reasons for patients to seek medical assistance, and they are frequently misdiagnosed as tuberculosis. In this paper, we present a critical view of the strategies for diagnosis and clinical management of CM and PCM. Over the past few decades, there has been an increase in the number of reports of endemic fungal infections in areas previously thought to be "non-endemic" due to climate change and increased travel, among other factors. Learning to recognize their main epidemiological aspects and clinical manifestations is crucial so that clinicians can include them in the differential diagnosis of lung disease and avoid late diagnosis.

Myeloid-derived suppressor cells are associated with impaired Th1 and Th17 responses and severe pulmonary paracoccidioidomycosis which is reversed by anti-Gr1 therapy.

Previous studies on paracoccidioidomycosis (PCM), the most prevalent systemic mycosis in Latin America, revealed that host immunity is tightly regulated by several suppressive mechanisms mediated by tolerogenic plasmacytoid dendritic cells, the enzyme 2,3 indoleamine dioxygenase (IDO-1), and regulatory T-cells (Tregs). IDO-1 orchestrates local and systemic immunosuppressive effects through the recruitment and activation of myeloid-derived suppressor cells (MDSCs), a heterogeneous population of myeloid cells possessing a potent ability to suppress T-cell responses. However, the involvement of MDSCs in PCM remains uninvestigated. The presence, phenotype, and immunosuppressive activity of MDSCs were evaluated at 96h, 2 weeks, and 8 weeks of pulmonary infection in C57BL/6 mice. Disease severity and immune responses were assessed in MDSC-depleted and nondepleted mice using an anti-Gr1 antibody. Both monocytic-like MDSCs (M-MDSCs) and polymorphonuclear-like MDSCs (PMN-MDSCs) massively infiltrated the lungs during Paracoccidioides brasiliensis infection. Partial reduction of MDSC frequency led to a robust Th1/Th17 lymphocyte response, resulting in regressive disease with a reduced fungal burden on target organs, diminishing lung pathology, and reducing mortality ratio compared with control IgG2b-treated mice. The suppressive activity of MDSCs on CD4 and CD8 T-lymphocytes and Th1/Th17 cells was also demonstrated in vitro using coculture experiments. Conversely, adoptive transfer of MDSCs to recipient P. brasiliensis-infected mice resulted in a more severe disease. Taken together, our data showed that the increased influx of MDSCs into the lungs was linked to more severe disease and impaired Th1 and Th17 protective responses. However, protective immunity was rescued by anti-Gr1 treatment, resulting in a less severe disease and controlled tissue pathology. In conclusion, MDSCs have emerged as potential target cells for the adjuvant therapy of PCM.

Paracoccidioidomycosis in a 64-year-old man: a case report

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by the thermo-dependent dimorphic fungus Paracoccidioides spp, limited to the American continent, but with a high incidence in Brazil, mainly in the Midwest, South and Southeast regions. This is a case report of a 64-year-old male patient that was referredat a hospital, complaining of pain in the mouth and dysphagia. The patient presented multiple and finely granular hemorrhagic pinpoint erosions with a mulberry-like appearance in oral mucosa. The patient underwent an incisional biopsy, and the histopathological analyses confirmed the presence of the fungus and the diagnosis of PCM. Lesions in oral mucosa may be the first visible clinical manifestation of PCM; so, a meticulous evaluation of oral cavity and well-conducted diagnostic techniques are indispensable for a correct diagnosis and an appropriate therapy of PCM.

Exposure of Paracoccidioides brasiliensis to Mebendazole Leads to Inhibition of Fungal Energy Production.

Paracoccidioidomycosis (PCM) is a fungal disease caused by organisms of the genus Paracoccidioides spp. The treatment of the disease is lengthy and includes several adverse effects. Various methodologies focus on the search for new treatments against fungal disease, including the repositioning of drugs. Our group showed the fungicidal effect of mebendazole in P. brasiliensis cells. Thus, understanding the effect of exposing fungal cells to mebendazole is significant for further studies in order to demonstrate it as a potential drug for the treatment of PCM. A proteomic analysis of P. brasiliensis exposed to mebendazole was carried out. Analyses showed that exposure strongly affected the pathways related to energy production, such as glycolysis, fermentation, and the electron transport chain. The quantification of adenosine triphosphate (ATP) and mitochondrial activity demonstrated that the drug alters the electron chain, resulting in an increase in oxidative stress. Enzymes such as superoxide dismutase (SOD) and cytochrome c oxidase (Cyt C) were repressed in cells exposed to mebendazole. The concentration of ethanol produced by the cells under treatment demonstrated that the attempt to produce energy through fermentation is also arrested. Thus, the drug inhibits fungal growth through changes in energy metabolism, making it a promising compound for use in the treatment of PCM.

Paracoccidioides and Paracoccidioidomycosis in the 21st Century.

Paracoccidioidomycosis (PCM) defines a broad spectrum of human and animal diseases caused by Paracoccidioides species (Onygenales). In the twenty-first century, Paracoccidioides advanced from a monotypic taxon to a genus that harbors seven species, including P. brasiliensis sensu stricto, P. americana, P. restrepiensis, P. venezuelensis, P. lutzii, P. loboi, and P. cetii. Classic PCM, acquired upon inhalation of propagules from P. brasiliensis sensu stricto, P. americana, P. restrepiensis, P. venezuelensis, and P. lutzii, affects the human lungs and may progress to systemic granulomatous disease with tegumentary and visceral involvement. On the other hand, PCM loboi and PCM ceti caused by the unculturable P. loboi and P. cetii are subcutaneous mycoses, typically observed as keloid lesions in humans and dolphins. Such heterogeneity highlights the importance of recognizing species boundaries in Paracoccidioides to gain insights into the ecology, evolution, clinical features, and mitigation strategies to tackle the advance of PCM.

Acute paracoccidioidomycosis worsened by immunosuppressive therapy due to a misdiagnosis of Crohn's disease.

Paracoccidioidomycosis (PCM) is a systemic mycosis endemic in Latin America, mostly in Brazil. The involvement of the gastrointestinal tract is uncommon and usually associated with the acute form. Recently, a cluster of acute PCM cases has been described in Rio de Janeiro, Brazil. We report a 42-year-old male, resident of Rio de Janeiro, presenting chronic diarrhea and abdominal pain in the past 3 years, previously diagnosed as Chron´s disease. When immunosuppressive therapy was prescribed, the patient evolved with worsening of the previous symptoms in addition to odynophagia, 20 kg-weight loss, disseminated skin lesions, diffuse lymphadenopathy and adrenal insufficiency. Histopathological and mycological examination of a skin lesion were compatible with PCM. Itraconazole was prescribed in high doses (400 mg/day). After seven months of treatment, the patient presented with acute abdominal pain which led to an emergent appendectomy, revealing the presence of the fungus. After 24 months, the patient reached clinical cure and recovered from adrenal insufficiency. We emphasize the importance of PCM as a differential diagnosis in patients with chronic diarrhea. The risk of fungal infections should be considered prior to initiating immunosupressive therapies, particularly in endemic areas.

Itraconazole and neutrophil interactions in the immune-inflammatory response of paracoccidioidomycosis using a murine air pouch infection model

Paracoccidioidomycosis (PCM) caused by Paracoccidioides brasiliensis (Pb), is a severe mycosis, prevalent in tropical countries. The presence of polymorphonuclear neutrophils (PMN) in lesions is conspicuous, indicating their central role in innate immunity through the direct killing of Pb and the production of cytokines that activate acquired immunity in the presence of itraconazole (Itra). The toxicity and direct antifungal activity of Itra on Pb in splenocyte co-cultures were evaluated in vitro. Itra showed no toxic effect but marked antifungal activity against Pb. Purified PMN were obtained by the subcutaneous (SC) injection of Pb into mice. Results showed the effect of Itra on the size of the air pouch produced, the cellular population that migrated to the infection site, protein, and mitochondrial metabolism patterns, production of ROS an NO, and the number of cytokines synthesized. Lower doses (3 and 10 mg/kg) of Itra did not affect the cellular profile but led to a lower influx of viable more active PMN, and increased production of ROS and proteins. At a dose of 50 mg/kg the PMN profile remained unchanged along with all other parameters analyzed remained unaltered. Decreases in most cytokine levels were inversely proportional to the Itra concentration. Lower Itra concentrations may elicit activation of the immune response because the combined effects of therapy and immune response are needed, while the higher dose does not require it. Itra also promotes the activation of the cytokines which elicit PMN activation and consequently the resolution of Pb18 infection in the air pouch.

PARACOCCIDIOIDOMICOSE EM UM ADOLESCENTE IMUNOCOMPETENTE: UMA DOENÇA NEGLIGENCIADA

Acute Paracoccidioidomycosis (PCM) represents 5 to 10% of total PCM cases. The estimated incidence varies between 1-4 cases for 100.000 inhabitants in the endemic regions of Brazil. It is known that PCM can coexist with other systemic mycoses such as Histoplasmosis. We report a case of a 10-year-old adolescent from Barra Mansa, RJ, Brazil. He was hospitalized after recurrent visits to the emergency department for approximately one month, presenting with non-bloody diarrhea, weight-loss of 6kg in six weeks, dry cough and nocturnal fever (average temperature 38ºC). Counterimmunoelectrophoresis and lymph node biopsy were positive for Paracoccidioides brasiliensis. The treatment consisted of Amphotericin B IV 0,6 mg/kg of body weight per day for 10 days and Itraconazole PO 200mg per day for 12 months. After 5 years, the patient remains asymptomatic. Reports of similar cases are scant in the literature and, the few encountered, are of immunocompromised children. The incidence and prevalence estimation of PCM might be inaccurate due to underdiagnosis and under-reporting.

PARACOCCIDIOIDOMYCOSIS INFECTION IN AN IMMUNOCOMPETENT ADOLESCENT: A NEGLECTED DISEASE

Acute Paracoccidioidomycosis (PCM) represents 5 to 10% of total PCM cases. The estimated incidence varies between 1-4 cases for 100.000 inhabitants in the endemic regions of Brazil. It is known that PCM can coexist with other systemic mycoses such as Histoplasmosis. We report a case of a 10-year-old adolescent from Barra Mansa, RJ, Brazil. He was hospitalized after recurrent visits to the emergency department for approximately one month, presenting with non-bloody diarrhea, weight-loss of 6kg in six weeks, dry cough and nocturnal fever (average temperature 38ºC). Counterimmunoelectrophoresis and lymph node biopsy were positive for Paracoccidioides brasiliensis. The treatment consisted of Amphotericin B IV 0,6 mg/kg of body weight per day for 10 days and Itraconazole PO 200mg per day for 12 months. After 5 years, the patient remains asymptomatic. Reports of similar cases are scant in the literature and, the few encountered, are of immunocompromised children. The incidence and prevalence estimation of PCM might be inaccurate due to underdiagnosis and under-reporting

Paracoccidioides restrepiensis has undergone a severe population bottleneck

Genus Paracoccidioides now encompasses five species, P. lutzii, P. brasiliensis sensu stricto, P. americana, P. venezuelensis, and P. restrepiensis. All the paracoccidioidomycosis (PCM) cases reported in Colombia have been classified as P. restrepiensis, which was named in honor of Angela Restrepo, a leading researcher in the field of the biology of the fungus. Previous assessments of genetic diversity have suggested that Paracoccidioides species have differences in their level of polymorphism. To infer changes in effective population size, we used the Pairwise sequentially Markovian coalescent (PSMC) by generating two pseudodiploids for P. restrepiensis and one for P. brasiliensis sensu stricto. We found that P. restrepiensis diverged from its sister species recently, the divergence time from P. venezuelensis being 125,000 (± 42,000) years. The analyses using PSMC show a systematic reduction in the effective population size of P. restrepiensis with a rapid decrease in genetic variability compared to P. brasiliensis sensu stricto, which indicates that P. restrepiensis has undergone a systematic population bottleneck. None of the other two species show the dramatic effective population size reduction observed in P. restrepiensis. These comparisons suggest that the trajectory of P. restrepiensis is somehow different from the other Paracoccidioides species and poses the question regarding the biogeographic events that have led to such a dramatic population pattern.

Paracoccidioidomycosis: What We Know and What Is New in Epidemiology, Diagnosis, and Treatment.

Paracoccidioidomycosis (PCM) is a systemic mycosis endemic to Latin America caused by thermodimorphic fungi of the genus Paracoccidioides. In the last two decades, enhanced understanding of the phylogenetic species concept and molecular variations has led to changes in this genus’ taxonomic classification. Although the impact of the new species on clinical presentation and treatment remains unclear, they can influence diagnosis when serological methods are employed. Further, although the infection is usually acquired in rural areas, the symptoms may manifest years or decades later when the patient might be living in the city or even in another country outside the endemic region. Brazil accounts for 80% of PCM cases worldwide, and its incidence is rising in the northern part of the country (Amazon region), owing to new settlements and deforestation, whereas it is decreasing in the south, owing to agriculture mechanization and urbanization. Clusters of the acute/subacute form are also emerging in areas with major human intervention and climate change. Advances in diagnostic methods (molecular and immunological techniques and biomarkers) remain scarce, and even the reference center’s diagnostics are based mainly on direct microscopic examination. Classical imaging findings in the lungs include interstitial bilateral infiltrates, and eventually, enlargement or calcification of adrenals and intraparenchymal central nervous system lesions are also present. Besides itraconazole, cotrimoxazole, and amphotericin B, new azoles may be an alternative when the previous ones are not tolerated, although few studies have investigated their use in treating PCM.

Combined Silymarin and Cotrimoxazole Therapy Attenuates Pulmonary Fibrosis in Experimental Paracoccidioidomycosis.

Paracoccidioidomycosis (PCM), which mainly affects rural workers, is a systemic mycosis caused by the Paracoccidioides genus that induces pulmonary sequelae in most adult patients, causing serious disability and impairing their quality of life. Silymarin is herbal medicine with an effective antifibrotic activity. Considering that in PCM, antifibrotic treatment is still not available in pulmonary fibrosis, we aimed to evaluate combined silymarin and cotrimoxazole (CMX) therapy via the intratracheal route in BALB/c mice infected with P. brasiliensis yeast. After 12 weeks of treatment, the lungs were collected for the determination of fungal burden, production of OH-proline, deposition of collagen fibers, pulmonary concentrations of cytokines, and expression of fibronectin, α-SMA, MMP-2, MMP-9, and TIMP-2. Spleen cell cultures were also performed. Our results showed that infected mice treated with combined silymarin/CMX showed lower deposition of collagen fibers in the lungs and lower pulmonary concentrations of hydroxyproline than the placebo groups. Decreased levels of TGF-β1 and fibronectin and high levels of MMP-2 and IFN-γ were also observed in this group of mice. Collectively, our findings indicate that the combination of antifungal treatment with silymarin has a potent antifibrotic effect associated with an immunomodulatory effect that potentializes the antifungal immune response.

P197 Infant-juvenile paracoccidioidomycosis. Two Argentine endemic zones with different epidemiological and clinical aspects? What influences this situation?

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMArgentina has two endemic areas of paracoccidioidomycosis (PCM). It is noteworthy that epidemiological characteristics differ in both areas, especially in frequency, and clinical aspects of infant-juvenile PCM form (I-JF). In this work, we have reviewed and analyzed 10 years of juvenile PCM form (JF) in both areas emphasizing in acute/subacute I-JF cases. From January 2012 to December 2021 data of epidemiological characteristics, clinical history and laboratory results of I-JF cases were recorded on standardized protocols and entered into a database that helped consolidate the information. Although the more extensive area of PCM historically with the highest incidence is located in Northeast Argentina (NEA), the major number of I-JF was observed in the smaller PCM endemic area, located in the Northwest of the country (NWA).In NWA, 32 JF were recorded including 20 cases of I-JF form in children from 1-13 years old. No outbreak was registered. Cases were equally distributed over the 10 years.In NEA, 28 JF were recorded including 8 cases of I-JF form in children from 7-14 years old. Of these cases, 6/8 (75%) presented as an outbreak in 2012. The rest were only registered in 2018-2020.More frequent clinical manifestation of I-JF:NWA: 70% hepatosplenomegaly with peritonitis and ascites, 33% gastrointestinal symptoms including diarrhea. Adenomegaly (70% cervical, 15% mediastinal).Serology (ID) non-reactive: 32%NEA: 62% cutaneous, 37% hepatosplenomegaly, 25% osteolytic lesions, 25% pulmonary nodules, 25% pericardial effusion, 25% mucocutaneous. Adenomegaly (75% cervical, 62% mediastinal-retroperitoneal).Serology (ID) non-reactive: 12.5%NWA records most cases of I-JF with a constant frequency and with a lower median age. NEA seems to only occur in outbreaks. Are striking the different epidemiological characteristics observed? Predominantly hepatosplenomegaly and intestinal forms in NWA, being with fecal material the first sample where Paracoccidioides is detected in many cases. In contrast, more diverse clinical manifestations are observed in NEA. Most cases with cutaneous/mucocutaneous lesions and the presence of pulmonary and pericardial forms characterized I-JF in this zone. Considering serological tests are important in the PCM diagnosis and to follow up the treatment success, no-reactive tests obtained (32% in NWA, 12.5% in NEA) show a serious diagnostic problem emphasize the need to work on more sensitive tools to reduce the high mortality of this clinical form. The variable expression of gp43 among isolates of Paracoccidioides species may suggest not to use a single antigen preparation for serological tests and include autochthonous isolates. Our group reported climatic and anthropogenic changes influencing the appearance of I-JF outbreaks in the NEA, a region where the observation of these cases was historically very rare. Probably, NWA provides a different ecological niche for Paracoccidioides, which favors its constant appearance over time. We have already started a multicenter molecular epidemiological, probably include soil studies of NWA would be important to try to better understand this situation.

P153 Comparison of clinical presentation of 2 cases of paracoccidioidomycosis in Shushufindi, Ecuador

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectivesDiscuss the diagnosis of two cases of paracoccidioidomycosis (PMC) for the first time in the city of Shushufindi, Ecuador.Report two different clinical presentations in two male patients diagnosed with PMC.MethodsThe diagnosis and treatment of two male patients with PMC is retrospectively described. Individual informed consents were obtained from each patient.ResultsThe first case is a 39-year-old male patient, with a history of previous armadillo hunting, with no relevant history. Born and resident in Shushufindi, Amazon area of the province of Sucumbíos, Ecuador. He presents lesions of ∼ 7 years of evolution, characterized by ulcerated plaques with meliceric crusts in the nose and in the mouth at the level of the upper lip (Figs. 1a and b).This patient had had several visits to different medical doctors, who unfortunately diagnosed other diseases. Due to his long clinical evolution, he was referred to a dermatological referral center in Quito. During the initial examination, a differential diagnosis of oncologic pathology, mycosis, mycobacteria, and cutaneous leshmaniasis was considered. A punch biopsy of the affected region was requested, and specimens were sent for culture, histopathology, and smears from the margins of the lesion to rule out leshmaniasis. As shown in Figure 1c, a histopathology report was submitted with yeast-like structures with multiple branches and a positive culture for Paracoccidiodes (Fig. 1d). Other clinical laboratory studies or chest imaging were within normal parameters.The second case is a 54-year-old male patient, a farmer, with no relevant history. Born and resident in Shushufindi. No clinical or geographical relationship with case number 1. He presented lesions of ∼ 2.5 years of evolution, characterized by ulcerated plaques with meliceric crusts in the lower part of the nose, with lytic destruction of the anterior nasal septum and left nasal ala (Figs. 2a and b).This patient has also consulted many physicians. At his last visit, he was treated for cutaneous leshmaniasis without a positive result. He was admitted to a specialized dermatological center in the city of Quito, 3 weeks after the first patient, so a similar protocol was used. Patient number two had a slight elevation of liver enzymes, other laboratory, and imaging tests were within normal parameters. Unfortunately, culture showed no fungal growing, and histopathology of a punch biopsy of the nasal septal mucosa showed yeast-like structures with multiple extensions suggestive of PCM (Fig. 2c).In both patients, treatment was started with oral itraconazole 200 mg per day. In the first 2 months, the treatment showed little success, so it was decided to increase trimethopine-sulfamethoxazole to 8 mg/kg per day for 6 months.ConclusionParacoccidioidomycosis is an endemic disease in South America characterized by infection with Paraccocidioides lutzi and Paracoccidioides brasiliensis. Several articles have described cases in Ecuador, but this is the first report from the city of Shushufindi. The patients had different orofacial manifestations. In the patient with the shortest duration of infection, lytic damage to the nasal septum was observed (Fig. 2b).

Systematic review of neuroparacoccidioidomycosis: The contribution of neuroimaging.

Advanced neuroimaging demonstrated that neurological involvement occurs in up to 30% of paracoccidioidomycosis (PCM) cases. Current knowledge of neuroparacoccidioidomycosis (NPCM) is based on a 2009 systematic review. However, in the last decade, several new cases have been published, with modern neuroimaging techniques. We believe a new systematic review is needed to summarise these advances. We searched PubMed/MEDLINE, Embase and LILACS for studies from January 2010 to May 2022. Case series and case reports of NPCM were included. We performed a metaproportion to estimate a summary proportion with 95% confidence intervals (CI). Thirty-four studies including 104 patients were evaluated. We combined our data with the results from the previous review that included 257 cases, totalling 361 patients. We found no new important demographic, clinical or laboratory characteristics. On magnetic resonance imaging (MRI), we found that 72% (95%CI: 38-91) had hyperintensity on T1-weighted image; 84% (95%CI: 71%-92%) had hypointensity on T2-weighted image; 80% (95%CI: 66-89) had contrast enhancement with the classical ring-enhancing pattern. All 8 patients undergoing spectroscopy presented lipid peaks. We found a 16% mortality, lower than in the previous review (44%). NPCM presents a characteristic pattern on MRI that may help to differentiate it from other causes of single or multiple brain lesions. Albeit there is a frequent pattern, it is not specific, as other granulomatous diseases may show similar findings. Advances in neuroimaging with early diagnosis and appropriate management of the disease may have contributed to reducing its mortality.