Reactivation of Paracoccidioidomycosis With Extensive Cutaneomucosal Involvement and Adrenal Insufficiency: A Challenging Case in the Context of Self-Medication

Paracoccidioidomycosis (PCM) is an endemic mycosis in Latin America, caused by fungi of the genus Paracoccidioides , with diverse clinical presentations. Despite good treatment response, relapses are not uncommon. We report a case of late reactivation of PCM with extensive cutaneomucosal involvement and adrenal insufficiency. A 57-year-old man, former farm worker (corn, cassava, and beans), born in Bahia and residing in Osasco (São Paulo), former smoker. He was diagnosed with PCM 30 years earlier, with relapse 10 years ago; he was treated with itraconazole 200 mg/day but was lost to follow-up in 2019. Since then, he had been irregularly using compounded antifungal medication (itraconazole 300 mg every 12 hours) on his own. He sought medical care due to nasal and oral mucosal lesions present for five years, with progressive worsening over the past six months, associated with nasal obstruction, purulent rhinorrhea, local pain, odynophagia, and tooth loss. He evolved with ulcerated, crusted lesions on the face, trunk, and genitalia, dyspnea, fever, and weight loss. Physical examination revealed pulmonary crackles, axillary lymphadenopathy, disseminated dermatosis with ulcerovegetative plaques and central hemorrhagic crusts; nasal and perioral lesions with honey-colored crusts and purulent discharge causing anatomical deformation, complete obstruction of the common meatus and nasal ostia; and ulcerative lesions in the hypopharynx and uvula. Direct mycological examination showed birefringent yeasts with double membrane and multiple budding; serology for PCM was reactive (1:1). CT scans showed ground-glass opacities and pulmonary nodules, adrenal thickening with calcifications, and abdominal lymphadenopathy. Endocrine evaluation revealed subclinical adrenal insufficiency. Due to disease dissemination, amphotericin B was initiated for 26 days, followed by transition to itraconazole 400 mg/day, in addition to hydrocortisone during hospitalization and subsequent prednisone and fludrocortisone therapy. The patient showed complete healing of lesions and remains under outpatient follow-up. Prolonged and inappropriate use of compounded antifungal medication may have contributed to disease progression. Active search for other sites of involvement was essential for early identification of adrenal involvement. Treatment with amphotericin B followed by itraconazole and hormonal replacement resulted in good clinical response. This case highlights the importance of continuous outpatient follow-up, early management of reactivations, and surveillance for endocrine complications of PCM.