Paracoccidioidomycosis: epidemiological, clinical, diagnostic and treatment up-dating.

Paracoccidioidomycosis is an acute - to chronic systemic mycosis caused by fungi of the genus Paracoccidioides. Due to its frequent tegument clinical expression, paracoccidioidomycosis is an important disease for dermatologists, who must be up-to-date about it. This article focuses on recent epidemiological data and discusses the new insights coming from molecular studies, as well as those related to clinical, diagnostic and therapeutic aspects. In the latter section, we give particular attention to the guideline on paracoccidioidomycosis organized by specialists in this subject.

INTRODUCTION

Paracoccidioidomycosis (PCM) was a recurrent theme on the Continued Medical Education in Dermatology section (EMC-D) between 1998 and 2003. A decade after the last publications, it is once more necessary to open space for a disease that is still very prevalent and of long tradition and history in the field of Dermatology. The focuses will be limited to the epidemiological, clinical and therapeutic up-dates.

EPIDEMIOLOGY

The genus Paracoccidioides belongs to Phylum Ascomicota, Class Euromycetes, Order Onygenales and Family Ajellomycetaceae (Onygenaceae), the same as Histoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immites and Coccidioides posadasii, with which it shares the same thermally dimorphic character, infecting forms (arthroconidia and mycelium) and a geographically restricted habitat.[1]

Molecular methods used to study genus Paracoccidioides promoted significant advances on the ecologic knowledge of this agent. For instance, P.brasiliensis was detected in different animal species besides the previously described Dasypus novemcinctus (nine-banded armadillo), such as: D. septemcinctus (seven-banded armadillo), Procyon cancrivorus (raccoon), Cavia aperea (Brazilian guinea pig), Sphiggurus spinosus (Spiny Tree Porcupine), Gallictis vittata (ferret) e Eira barbara (tayra).[2] A study was published in 2011, confirming that paracoccidioidomycosis, as a disease, is not limited to the human species. The study described the second case of canine PCM, again in a Dobermann breed dog and once more showing the prevalence of lymph node involvement, with vast histologic, mycological and molecular evidences.[3] Treatment with Itraconazole provided cure in 24 months.[3] Molecular methods were equally primordial for the detection of P.brasiliensis in the soil samples collected inside and around armadillos' burrows, demonstrating definitely that infecting samples exist in the soil of areas that are the habitat of these fungi.[4] The most revolutionary contribution, however, was the molecular identification of cryptic species, hidden inside genus Paracoccidioides. This discover showed the genetic coherence of the several phenotypes exhibited by this fungus, either in a culture medium or in experiments, demonstrating the previously known diversity expressed by: mycelium colony aspect, distinctive production of conidia, variable microscopic aspect of yeast cells, virulence and thermal tolerance and even distinct clinical behavior.[1] Following this line of thought, Matute et al. (2006), used genetic sequencing of samples cultivated in Brazil, Venezuela and Colombia, to propose the existence of possibly three new species, temporarily denominated PS2 (prevalent in Brazil and Venezuela), PS3 (restricted to Colombia) and S1 of an ampler distribution.[5,6] Such findings were corroborated by several authors. In 2009, Teixeira et al. [7] based on genetic sequencing studies of 82 fungal isolates and phylogenetic studies of 40 isolates, proposed the identification of yet another species, previously denominated Pb-01. This species exhibited a clear divergence in terms of morphology and sequencing from the aforementioned S1, Ps2 and PS3. In this opportunity they suggested to name it Paracoccidioides lutzii in tribute to Adolpho Lutz (18551940).[7] Recently, Theodoro et al. (2012) built a map that expresses the predominance (or even exclusiveness) of each species of genus Paracoccidioides in South America. The authors used the snp (single nucleotide polymorphisms) technique as molecular marker along with morphologic data applied to 63 isolates from patients of several countries in South America (10 of which obtained from cutaneous lesions of patients from the endemic region of Botucatu-SP), as well as isolates from armadillos from various geographic areas. This map demonstrated that (until the present): species P.lutzii are more prevalent in the central areas of Brazil, S1 is vastly distributed and PS3 seems to be exclusively present in Colombia (Figure 1).[8] In 2012, the species P.lutzii was identified as etiologic agent in 2 cases diagnosed in the south region of the State of Pará, with confirmation of the species through serologic and molecular studies.[9]

FIGURE 1

Geographic distribution of species of genus Paracoccidioides and species Lacazia loboi

The future nomenclature, that might take effect, refers to the paracoccidioidomycosis causal agent as belonging to the "complex" Paracoccidioides brasiliensis or to the species Paracoccidioides spp. From the practical point-of-view, there is still the need to demonstrate that the different species of the Paracoccidioides complex produce distinct clinical profiles with regards to its severity, tropism to specific organs or systems, and varied susceptibility to different drugs (proved by diverging MIC - minimum inhibitory concentrationfor the same drug or for a battery of tests with medicaments known to be effective against paracoccidioidomycosis). If these conjectures were to be proved true, we might anticipate that the therapeutic choice for the treatment of paracoccidioidomycosis may become more complex, but also more effective.

Regarding incidence/prevalence of the disease, we highlight the report of autochthonous cases from the State of Ceará and the elevated number of cases in certain areas of the State of Maranhão (estimated as high as 10.8 cases/100,000 inhabitants in the period of 1997 to 2007), demonstrating that humid areas of the Northeast part of the country may also be considered endemic.[10,11] Of notice, also, from a clinic-epidemiologic standpoint is the situation observed at Foz do Iguaçu, in the State of Paraná (Loth et al., 2011), where 102 cases were diagnosed in a period of 18 months.[12] Besides the high incidence of the disease in this report, it is of special notice the elevated percentage of coinfection with tuberculosis (28,4% of all cases) and HIV (4,9%) and the 14,7% rate of death among the population studied.[12] These facts demonstrate, once more, the potential severity of paracoccidioidomycosis and the possibility of co-infections that interfere with the treatment and prognosis. A milestone as a well-conducted clinic-epidemiologic study, the publication of a series of 1,000 cases of paracoccidioidomycosis diagnosed in the region of Ribeirão Preto-SP (Belissimo-Rodrigues et al., 2011), presented data collected from 1960 to 1999, that showed: an estimated incidence of 1.6 to 3.7 new cases/100,000 inhabitants in the area; male/female rates of 6:1; a predominance of the adult chronic form (74.6%) and of patients with history of rural life (93.5%), high rates of smoking (64.7%) and heavy drinking (37.2%), co-infection with tuberculosis (8.3%) and HIV (4.2%).[13] These data reflect much of the knowledge already established in terms of clinic epidemiology of paracoccidioidomycosis, but this time, drawn from a single institution with a record number of cases.

Another study, from the same institution, compared data from 53 patients co-infected with paracoccidioidomycosis and HIV versus 106 cases without HIV co-infection. The results demonstrated that the co-infected were younger (33.5 years x 45.3), less likely to have rural activities either at the time of the diagnosis (27.5% x 59.4%) or previously (64.3% x 95.5%) and that they had a higher rate of associated hepatic disease, particularly infection with hepatitis C virus (15.5% x 3.8%). There was not any difference between co-infected and non co-infected regarding: rates of male-female incidence; smoking (79.2% x 84%); alcohol intake (58.5% x 64.2%) or co-infection with tuberculosis (9.4% x 5.7%).

From the clinic point-of-view, patients with HIV co-infection presented with significantly greater rates of fever (95.6% x 50.6%), lymphadenomegaly (80% x 50.6%), hepatomegaly (64.2% x 19.1%), splenomegaly (22.6% x 6.6%), cutaneous lesions (66.7% x 45.5%), but smaller rates of mucosal lesions (20.8% x 50.9%) and hoarseness (1.9% x 23.6%). It should be noticed that mucosal involvement and hoarseness, classic symptoms in the chronic form of the disease, were more frequent among patients without HIV co-infection. This fact, associated to the higher rates of the monocyte-macrophage system involvement in the co-infected patients, demonstrates the prevalence of an acute-sub acute profile of disease amongst this group. Other parameters compared between co-infected and non co-infected did not achieve statistic significance, such as: presence of lung disease (84.8% x 69.1), SNC involvement (3.8% x 5.7%), bone lesions (5.7% x 0.9%) and adrenal insufficiency (0% x 1.9%).[14] It must be highlighted that, the occurrence of paracoccidioidomycosis in patients with HIV/aids co-infection is linked to severe immunosuppression, and 83.7% of the cases studied by Marejon et al. had T CD4+ lymphocyte counts < 200 cells/mm3. This same department also published data regarding the serologic anti-P.brasiliensis response in patients coinfected with HIV.[15] The authors used 3 methods (double-agar gel immunodiffusion -IDD; counter immunoelectrophoresis - CIEF and ELISA) to study a group of 40 co-infected patients and another of 75 patients diagnosed only with paracoccidioidomycosis. They observed a marked reduction in the detection of anti P.brasiliensis in the co-infection group by all methods: IDD (65% x 89%), CIEF (79% x 99%) and ELISA (95% x 100%). Also, the titles obtained were significantly lower than those observed in the non co-infected group.[15]

These data demonstrate that in patients diagnosed with both diseases, HIV-induced immunehumoral response alterations impair the sensibility of the aforementioned tests. Therefore, eventual negative serologic results in patients co-infected with HIV must be evaluated in the likelihood of a possible false-negative result.

The first reports of co-infection between paracoccidioidomycosis and HTLV-1 infection date from 2010.[16] Four patients coming from the Peruvian Amazon were diagnosed in Lima-Peru, and in three of them the overall clinical symptoms suggested an underlying case of immunosuppression. This observation alerts for the possibility of the association of both diseases in superimposed endemic areas and also for a probable impact of the co-infection in the evolution of the cases.

Still regarding the epidemiology, we emphasize the report of PCM in patients two and three-year-old, the youngest so far, both with clinical presentation suggestive of lymphoproliferative disorders and of late diagnostic confirmation through direct exam of an abscessed lymph node secretion. However, it is important to remember that the most affected age group is that between 30 and 50 years old and that the oldest patient recorded to date was 103 years old.[17,18] Studies on the specific mortality due to systemic mycoses began to be published in 2002. That year, the pioneer study of Coutinho et al. revealed that paracoccidioidomycosis was the eighth cause of death by predominantly chronic or recurrent diseases, infectious and parasitic, and the leading cause of death among the systemic mycoses in the period evaluated (1980-1995).[19] The results indicated a mean annual mortality rate of 1.45/ million inhabitants. This statement, along with data observed between 1980-1998 in Paraná State, which showed 3.48 deaths by paracoccidioidomycosis per million inhabitants are evidence that this disease is an important health problem in Brazil.[19,20] Another study to identify PCM as an associated cause of death in patients with aids in Brazil between 1998 and 2006 demonstrated: 125,633 deaths by aids; 5,898 (4.7%) associated to systemic mycoses, most frequently cryptococcosis (50.9% of all deaths), followed by candidiasis (30.2%); histoplasmosis (10.1%), aspergillosis (7.2%) and paracoccidioidomycosis (1.4%).[21] This same study, however, when evaluating the death mortality rates of patients not infected with HIV, showed diametrically opposed results, describing paracoccidioidomycosis as the major cause of death on the group of deep mycoses, corresponding to an average of 51.1% of all the deaths in the period.[21]

CLINICAL PRESENTATION

Although published in 1987, the generally used paracoccidioidomycosis clinical forms classification is little known in dermatology, therefore, it is depicted with adaptations, on chart 1.[22,23]

Chart 1

Clinical classification of paracoccidioidomycosis

1.	Paracoccidioidomycosis -infection
2.	Paracoccidioidomycosis -disease
2.1.	Form acute-sub acute (juvenile form)
2.1.1.	Moderate
2.1.2.	Severe
2.2.	Chronic form (adult form)
2.2.1.	unifocal: light, moderate, and severe
2.2.2.	multifocal: light, moderate, and severe
3.	Paracoccidioidomycosis - associated to immunosuppression
4.	Paracoccidioidomycosis - sequelae

Adapted source: Franco M, et al.[22]

It is important to remember that: 1-paracoccidioidomycosis-infection corresponds to the patient without signals and symptoms of the disease but with positive paracoccidioidin skin test reaction and differently from histoplasmosis, there is no image of pulmonary calcification. 2-paracoccidioidomycosis-disease is divided in two groups: 2.1 acute-sub acute form that usually affects patients under 30 years old, presenting a monocyte-macrophage system (lymph nodes, liver, spleen and bone marrow) fungal tropism (Figures 2 and 3) and 2.2 adult chronic form that may be unifocal (one organ or system) or multifocal (mixed) (Figures 4,5 and 6); 3-paracoccidioidomycosis associated to immunosuppression; 4-Sequelae, particularly pulmonary chronic obstructive disease, stenosis and obstruction of the superior airways and adrenal insuficiency.[24]

FIGURE 2

Paracoccidioidomycosis: acute form showing enlarged lymph nodes, with inflammatory aspect and abscess formation

FIGURE 3

Paracoccidioidomycosis: acute form demonstrating marked hepatoesplenomegalia

FIGURE 4

Paracoccidioidomycosis: eyelid and tarsus involvement depicting hemorrhagic dots on the mucosal area

FIGURE 5

Paracoccidioidomycosis: plantar ulcer with hyperkeratotic edges

FIGURE 6

Paracoccidioidomycosis: vegetant and ulcerated lesion with differential diagnosis for spinocellular carcinoma

As with other diseases caused by dimorphic fungi, the infection by P.brasiliensis occurs mainly by inhalation and besides experimental evidence for this, there are numerous case reports with evidence of silent primary infection or with clinical manifestations of the pulmonary primary complex. Martinez & Moya (2009) report a case of primary pulmonary infection in a young physician, otherwise healthy, non-smoker, non-drinker, eminently urban (however living in an endemic area), presenting with pulmonary symptoms associated to fever, leukocytosis with hyper eosinophilia, radiologic and tomographic signs of apical pleural-pulmonary lesions as well as hilar lymph nodes.[25] Investigations for tuberculosis, histoplasmosis and HIV infection were all negative, however the serology for PCM was positive, with an initial title of 1/16, and later 1/512. The patient was treated with Itraconazole 200 mg/day, with significant improvement after one week. He was considered cured after four months of follow-up.[25] This report demonstrates that even young individuals, with an adequate nutritional status and low exposure to infecting sources may develop infection with symptoms corresponding to primal infection and a progressive evolution to paracoccidioidomycosis-disease.

Several studies about the incidence of cancer in patients with paracoccidioidomycosis try to determine if there is a higher incidence of tumors in these patients, and if so, if it would be secondary to the immune deregulation associated to PCM or arising from habits prevalent in this population such as drinking and smoking. Shikanai-Yasuda et al. (2008)[26] performed a vast review on this subject and identified that most reports correspond to isolated cases or small case-series. However, the authors highlight two studies based on necropsy data, which showed discordant results: higher incidence of cancer in one study and no difference with the control group in another.[26] Severo et al. (2010), on the same topic, identified 25 cases of cancer in 808 consecutive patients with PCM in the same hospital (an incidence of 3.1%) and emphasized two aspects: first, that in 64% of the cases, the organ affected by the neoplasm was the same affected by PCM and second, cases of lung cancer (the most prevalent) were more frequent in patients with PCM which were also smokers.[27] Even if the cause-effect relation is not clear, it is important to be attentive to the synchronous clinical expression of paracoccidioidomycosis/carcinoma in the same anatomic region.[28] Although uncommon, paracoccidioidomycosis may occur as an opportunistic disease, following cancer treatments, therapy with corticoids or even the use of immunosuppressants, including anti-TNF α.

The potential severity of the acute-sub acute forms of paracoccidioidomycosis (juvenile form) was expressed in the study of associated bone marrow, lymph nodes, liver and spleen involvement.

Bone marrow infiltration by PCM may present in a moderate form, as histiocitary infiltrate, with fungal cells and limited clinical repercussion or in the other end of the spectrum, with medullar necrosis and osteonecrosis, having a major impact on the cause of death.[32,33] Acute-sub acute forms may occur in urban patients, with no history of living or staying in the rural zone, which can delay the diagnosis; also these patients must be investigated for a possible co-infection by HIV, because the have an atypical epidemiologic profile.[34,35] Monocyte-macrophage system tropism in the acute-sub acute forms includes the Payer's patches in the intestinal wall, as well as intra and extra-peritoneal lymph nodes; the latter may become abscessed and thus infect the psoas muscle on one or both sides, evolving slowly, gravely and difficult to diagnose.[36]

Genitourinary paracoccidioidomycosis is uncommon, occurring in 1.6% to 2% of chronic adult form cases, and even when present, there is wide clinic variability, with lesions often being mistaken by spinocellular carcinoma of the penis. Depending on the severity, the lesions may cause urethral obstruction and important esthetic and functional alterations.[37,38] When PCM affects the external genitalia, the main regions are the glans and scrotum, though there is no risk of sexual transmission, it is important to note that, these clinical cases are often associated to lung disease.[38]

The dissociation between clinical symptoms and pulmonary radiologic involvement was observed whilst studying patients with diffuse interstitial pulmonary PCM (85.7% of all cases) when compared to patients without radiologic evidence of involvement.[39] This demonstrates the relatively silent character of lung lesions, that when initially present are interpreted by the patient as a consequence of the smoking habit, thus delaying the search for medical attention. Anyway, it is important to point the potential severity of lung involvement, for often post-treatment fibrosis evolves to chronic obstructive disease. Bearing this in mind, studies with mice susceptible to P.brasiliensis lung infection showed significant reduction of the scaring sequelae in those treated with an association of itraconazole + pentoxifylline compared to isolated itraconazole or itraconazole plus corticoids.[40]

One study evaluated bone involvement secondary to paracoccidioidomycosis in 19 consecutive cases with proven bone lesions and showed that: the incidence was higher in younger patients (mean 16.1 years old, varying from 4 to 49), it affected mostly long bones (80.4% of the lesions), in the metaphysis region (46.6%), with an osteolytic pattern (62.7%), without marginal sclerosis (82.4%) or periosteal reaction (90.2%). These data reinforced the prevalence of bone involvement in association with the acute-sub acute forms of the disease.[41]

Two studies evaluated the possibility of late relapse, reporting on patients recurring 10 years (patient a) and 25 years (patient b) after the initial diagnosis and treatment.[42,43] Both were treated with the association of sulfamethoxazole plus trimethoprim (patient a) with added sulphadiazine and ketoconazole (patient b), however dosage or length of treatment were not informed, thus letting the possibility of insufficient or incomplete treatment, the main causes of relapse, unanswered. In both cases, patients moved to the urban area of large cities, outside the endemic zones, which suggests that those were real relapses instead of reinfections.[42,43] The unpublished statistics in our service show that 75% of all relapses occur up to 3 years after the initial treatment and are correlated with the sustained alcohol intake abuse, as well as irregular or incomplete treatments.

Several conference abstracts and two full publications studied paracoccidioidomycosis expressed by cutaneous lesions of a sarcoid-like pattern.[44,45] This is the typical dermatologic manifestation of PCM, with a clinical expression almost exclusively cutaneous, showing infiltrated, well-delimited and cephalic lesions that may be clinically and histologically mistaken by hanseniasis (Figure 7). Histology in these cases shows a tuberculoid, granulomatous, inflammatory pattern with a paucity of fungi. Patients are young and may present with infarcted cervical lymph nodes, but the general status is often good and the skin lesions trigger the search for medical attention. Equally atypical, but not anecdotal, is the report of carpal tunnel syndrome due to PCM.[46] The authors report a male patient with a history of serologically negative rheumatoid arthritis, in treatment with methotrexate, chloroquine and sporadic intra-articular corticoid infiltrations that evolved to tenosynovitis and carpal tunnel syndrome. Investigation revealed important demyelination of the median nerve and partial denervation of the abductor pollicis brevis muscle, consistent with carpal tunnel syndrome associated to tenosynovitis and specific paracoccidioidomycosis osteoarthritis, besides lung PCM.[46] Treatment involved surgery and combination of sulfamethoxazole plus trimethoprim, with complete cure.

FIGURE 7

Paracoccidioidomyco sis: infiltrated erythematous- violaceous lesion of a sarcoid pattern, with differential diagnosis for erythematous lupus and sarcoidosis

A systematic review on SNC paracoccidioidomycosis comprising 257 cases and 81 studies was presented by Pedroso et al. (2009).[47] The authors compiled data on reports of predominantly motor symptomatology or intracranial hypertension and showed: a prevalence of the pseudotumoral form; length of complaint for a mean of 4.9 months; supratentorial (66.8%) or hemispherical (47.6%) location, particularly in frontal and parietal lobes; associated pulmonary involvement in 59.1% of all cases and an extremely high rate of mortality (44%). Neuroparacoccidioidomycosis is almost exclusively associated to the adult chronic forms of the disease (98.3%) and might be meningoencephalic (10.6%).[47] The therapeutic recommendation is at first to combine sulfamethoxazole plus trimethoprim or fluconazole, in high intravenous doses at least in the initial phase of treatment.[48] A cohort study with 213 consecutive PCM cases, with systematic search for SNC involvement, demonstrated a prevalence of 3.8% of specific lesions, with all cases presenting parenchymal location and other findings in accordance to the literature.[49]

One of the most important studies regarding the paracoccidioidomycosis diagnosis, and related to the cryptic species, was published by Batista Jr et al. (2010).[50] In an elegant experiment, the authors analyzed serums of several patients from São Paulo (SP) and Mato Grosso (MT), to test for antibodies by the IDD method using antigens obtained through isolates specifically from MT State or isolates used in reference laboratories in São Paulo. When the antigen obtained from the Mato Grosso isolate was used in the IDD, serologic results were positive in 92.3% of MT serums versus 41.3% of SP serums. When using the reference antigen, the results were positive in 26.2% (MT serums) versus 100% (SP serums).[50] such results demonstrate that antigenic compositions are probably related to the different species of the Paracoccidioides "complex" that prevail (or are exclusive), in one or the other region. From a practical standpoint, each macrogeographical region in Brazil will have to prepare antigens from isolates from their own areas to ensure the greatest possible sensibility rate of the diagnostic methods. Equally important was the study on diagnostic accuracy comprising 401 patients with proven PCM, seen in the Infectious Diseases Department, that showed the following rates of sensibility for each method: histopathology (positive in 96% of all biopsied cases) > serology (90%) > direct tissue exam (74.5%) > direct sputum exam (62.5%) > cell block sputum (55.3%).[51] These results are very important, because a patient with paracoccidioidomycosis does not always have a lesion that is easily accessible to biopsy. Unpublished data from our hospital on 29 consecutive and proven PCM cases with skin and/or mucosal lesions demonstrated the diagnostic accuracy of different methods on the following proportions: histopathology (positive in 100% of the cases) > serology (ELISA 89% and IDD 80%) > molecular (Nested PCR in biopsy fragment 56%) > biopsy fragment culture in Mycosel® 37º C (37.5%). These results reflect the extreme importance of biopsy as a diagnostic method with high sensibility, corroborating the role of the dermatologist in the process and the still discrete and secondary role of molecular methods, which steps (retrieval and transportation) need to be improved as other alternative molecular techniques must be tested.

The aforementioned highlights the clinical variability of PCM, its multidisciplinary characteristics and the important role of dermatologists in the care of patients, due to the high frequency of cutaneous and mucosal lesions and their access to diagnostic methods.[52]

TREATMENT

The main article on treatment for the period comprising this EMCD is the consensus in paracoccidioidomycosis prepared by a specialists committee including dermatologists.[53] The preparation of this consensus involved exhaustive discussions and was difficult due to the paucity of clinical trials focused on treatments with adequate scientific methodology to define the correct hierarchy of drugs, their dosage and length of treatment.

There was full agreement as to the determination of criteria that would define the light, moderate and severe forms of PCM and which treatment would be adequate to them. The recommended drugs for the light and moderate forms are still itraconazole and the combination of sulfamethoxazole plus trimethoprim, and for the severe forms amphotericin B deoxycholate (Classic amphotericin B) as seen on chart 2.

Chart 2

Treatment of paracoccidioidomycosis

Itraconazole	Adults - 200 mg/day		Light form: 6 to 9 months
	Once daily		Moderate form: 12 to 18 months
	Children -	> 30 kg or
		>5 years old = 5 to 10mg/kg
Sulfamethoxazole + trimethoprim	Adults -1200 mg + 480 mg		Light form: 12 months
		q 12 h	Moderate form: 18-24 months
	Children - 50mg/Kg + 10mg/Kg
		q 12 h
Amphotericin B	0,5 to 1,0 mg/Kg/day or in alternate day		Severe form: total dosage ≈30mg/Kg

Adapted source: Shikanai-Yasuda MA, et al [53]

This consensus had a very instructive approach when addressing the treatments for special situations such as: paracoccidioidomycosis during pregnancy, when amphotericin B is recommended; PCM in patients with renal failure, for whom itraconazole or other azole derivatives should be used; patients with liver failure in which the drug of choice should be amphotericin B and children for whom sulfonamides or itraconazole are the more practical choices. As a rule, the treatment for severe forms is based on the use of amphotericin B, while in situations where potential drug interaction may occur or critical kidney failure is present, the choice of treatment must be carefully made, selecting always the less damaging option. In all the circumstances cited above, there must be an extremely rigorous monitoring of lab results and clinical evolution.[53] We must stress that, besides the treatment of the disease itself, it is vital to address the nutritional status of the patient, the possibility of alcohol withdraw syndrome, other co-morbidities and the patient's social situation. An interesting and practical conduct, if the patient has an evident pulmonary lesion on the radiography, is to point such lesion to him and explain that the resolution of the cutaneousmucosal lesions is not enough; there must also be a healing on the lung lesion, which will occur much later. This initiative helps the patient realize why such a lengthy treatment is necessary and why he should not interrupt the medication when the visible lesions disappear. Cessation of smoking and drinking are likewise important to the therapeutic success in the long run. Lab controls during treatment depend on the specifications of the chosen drug. Revaluations must be performed monthly during the first three months and quarterly until the end of the first year, including biochemical, serological and radiologic tests (the latter should be repeated each three to six months in the first year).

Criteria for cure and discharge were also discussed in this consensus and they include clinical, serological and radiologic evaluation. The maintenance of a long term follow-up is advisable when the patient had a severe initial clinical presentation, or in case of relapse or lack of treatment adherence.[53]

Besides the classic drugs used to treat paracoccidioidomycosis, one must also consider the azoles of second generation. One drug of this group, voriconazole was tested in an opened clinical trial, where 53 patients were randomized in the ratio of 3:1 to receive voriconazole (400 mg on the first day, followed by 200 mg/day) versus itraconazole (200 mg/day), for six months to a year, as seen fit by the investigator.[54] Intention to treat analysis showed 88.6% of complete and partial responses for those treated with voriconazole versus 94.4% on the itraconazole group, which did not achieve statistical significance. Both drugs had a good safety profile, demonstrating that voriconazole is yet another option to treat PCM.

Gryschek et al. (2010) discussed the possibility of a "paradoxical reaction" when treating severe forms of paracoccidioidomycosis.[55] Paradoxical reaction was define by the authors as the clinical deterioration that may occur even if the treatment of that particular infectious disease is adequate. This reaction was previously described in cases of tuberculosis, hanseniasis and mainly in the context of immune reconstitution in patients with aids, which are treated with highly active antiretroviral therapy (HAART).[56,57] In case reports on PCM, the anti-HIV serology was repeatedly negative and in both cases an improvement in clinical conditions was observed when adding corticoids as adjuvant therapy.[55] This initiative generated an original publication about the use of corticoids as adjunct therapy in severe forms of PCM.[58] The rationale is based on the fact that severe forms launch an intense inflammatory reaction that, for a certain period, might be more damaging to the patient that the infection itself.[58]

This argument is supported by previous publications that demonstrated the high levels of circulating TNF-α in patients with severe forms of PCM and discussed its deleterious role for the patient.[56,60] However, we must point that there are no clinical trials that support the routine use of corticoids in severe forms of paracoccidioidomycosis.

The possibility of the use of vaccines as primary prevention for PCM has been studied and tested in mice, using as antigen one peptide known as P10, that corresponds to a molecular fraction of antigen gp43, specific for genus Paracoccidioides. P10, used in combination to IL-12 to immunize mice susceptible to the virulent strain Pb18 of P. brasiliensis was efficient in reducing the rates of pulmonary infections in the animals.[61] By intramuscular injections of a combination of plasmids expressing P10 and a weekly dose of IL-12 for a month, the authors were able to eradicate the infection in a group of animals. Such results suggest that, the immunization with plasmids expressing P10 plus IL-12 is effective in preventing and treating experimental PCM and clinical trials in humans may be viable in the future.[61]

In conclusion, paracoccidioidomycosis is still a largely important disease for dermatologists, mainly due to their role in early diagnosis, the possibility of study and learning provided by the extreme variability of the clinical manifestations of this disease, new epidemiological data and the constant evolution of etiopathogenesis. Although treatment is still based on classic drugs, there are adjuvant therapies that may enhance the results in both short and long terms and it is up to each of us to gather the knowledge to achieve the goals that patients and departments yearn for.

Answer key

Cutaneous mosaicisms: concepts, patterns and classification . An Bras Dermatol. 2013;88(4):507-17.

1) B	6) B	11) B	16) B
2) A	7) B	12) A	17) A
3) B	8) C	13) D	18) D
4) D	9) A	14) A	19) B
5) C	10) A	15) C	20) C