Paracoccidioidomycosis (PCM) is a systemic mycosis endemic in Latin America, caused by Paracoccidioides spp. In people living with HIV, it may present with unusual and disseminated clinical forms, requiring a high index of diagnostic suspicion. A 55-year-old man, HIV-positive since 2015, on regular therapy with tenofovir 300 mg + lamivudine 300 mg/day and ritonavir 100 mg + darunavir 800 mg/day. He had a history of treated pulmonary tuberculosis, alcohol use, and illicit drug use, but with sustained adherence to antiretroviral therapy in the previous 6 months. He was admitted to the General Hospital of Itapevi with papulovesiculoulcerative and nodular lesions predominantly on the face and chest, associated with intense pain and pruritus for about 20 days. Physical examination revealed lymphadenopathy in the left posterior cervical chain, without other relevant findings. At admission, HIV viral load was 32 copies/mL and CD4 count 252 cells/mm³. Skin lesion biopsies, excision of a cervical lymph node for histopathology, and complementary tests for opportunistic infections were requested. Blood and urine cultures were negative; monkeypox PCR (two samples) was undetectable. CSF analysis was unremarkable. Chest CT showed mediastinal, hilar, and axillary lymphadenopathy with preserved lung parenchyma. Lymph node biopsy confirmed PCM. Reactivation of tuberculosis was ruled out by negative smear microscopy and molecular testing of sputum. The patient received antimicrobials in a stepwise approach, adjusted according to laboratory results. The precarious epidemiological history hindered the initial diagnostic workup. PCM can present atypically in people living with HIV. In this case, the absence of respiratory symptoms and predominance of cutaneous and lymph node manifestations delayed early diagnosis. Biopsy was essential to confirm the etiology. HIV/PCM coinfection is associated with a higher risk of severe forms and a guarded prognosis. The patient was already under outpatient follow-up but with limited access to tests and progressive clinical worsening culminating in hospitalization. This case reinforces the importance of considering endemic mycoses in the differential diagnosis of cutaneous lesions and lymphadenopathy in immunosuppressed patients, even in the absence of pulmonary symptoms. Early biopsy is essential given the broad etiologic spectrum and should not be delayed.
Teixeira et al. (Sun,) studied this question.