Makindo Medical Notes

🌎 Anyone living in or visiting endemic areas of Central & South America (esp. Brazil) can get paracoccidioidomycosis. ⚠️ Mortality is <5%, but chronic complications like pulmonary fibrosis and adrenal insufficiency can cause major morbidity.

🦠 About

• Caused by the dimorphic fungus Paracoccidioides.
• Primary route: inhalation of spores.
• Also called Almeida disease, Lutz–Splendore–Almeida disease, Lutz’s mycosis, South American blastomycosis.

📍 Geography & Risk

• Endemic in Mexico, Central & South America (esp. Brazil 🇧🇷).
• Rural outdoor workers (farmers, manual labourers) most affected; men > women (oestrogen protective).
• Thrives in humid, forested areas with rivers and seasonal rains.
• Traditional habit of using twigs to clean teeth → predisposes to oral lesions.

🧬 Pathophysiology

• Inhaled spores trigger a granulomatous reaction, mediated by neutrophils, macrophages, and T-helper lymphocytes.
• Immune response determines whether infection is latent, mild, or disseminated.

🩺 Clinical Features

• Constitutional: fatigue, weight loss, fever.
• Pulmonary: cough, dyspnoea, eventual fibrosis.
• Lymphoreticular: prominent lymphadenopathy, hepatosplenomegaly.
• Bone marrow: anaemia, cytopenias.
• Oral mucosa: painful gingival “mulberry” lesions 🍇 (classic).
• CNS: meningoencephalitis (rare but severe).

🔬 Investigations

• Basic labs: FBC, U&E, Ca, LFTs, CRP.
• CXR: pulmonary infiltrates or fibrosis.
• Biopsy: yeast cells with multipolar budding → “Mickey Mouse head” 🐭 or “pilot’s wheel” 🛞 appearance.
• Culture: Sabouraud agar (slow, 20–30 days).
• Histology: silver or PAS stain highlights fungal elements.
• Immunodiffusion serology: sensitivity ~84%, specificity ~99% in endemic areas.
• Lung biopsy: yeast forms with giant cells & granulomas.

⚠️ Complications

• Pulmonary fibrosis and chronic respiratory failure.
• Adrenal insufficiency (Addison’s disease).
• Secondary infections (bacterial/fungal).
• Severe malnutrition & anaemia.

💊 Management (specialist-led)

• No person-to-person transmission.
• Itraconazole 100–400 mg OD (first line, ~12 months).
• Alternatives:
  • Voriconazole (loading 400 mg BD day 1 → 200 mg BD).
  • Ketoconazole (200–400 mg/day, but less used).
  • Amphotericin B (for severe cases).
  • TMP-SMX or Sulfadiazine (longer courses, up to 24 months).
• Treatment typically continued for ~1 year to prevent relapse.

📚 References

• Paracoccidioidomycosis – NCBI StatPearls