Paracoccidioidomycosis is an endemic mycosis in Latin America caused by Paracoccidioides brasiliensis, a fungal agent that can infect humans mainly through inhalation of spores. In immunocompetent individuals, the fungus is usually phagocytosed by macrophages, halting infection immediately or after granuloma formation. The aim of this report is to describe a case of paracoccidioidomycosis in an immunocompetent patient from a non-endemic region. A 35-year-old Haitian man living in Brazil for 17 months presented with painful right posterior cervical lymphadenopathy with gradual growth over 30 days. Fifteen days after symptom onset, he developed disseminated lymphadenopathy (cervical, retroauricular, occipital, supraclavicular, axillary, and inguinal), progressing with unmeasured fever, malaise, asthenia, anorexia, productive cough, chest discomfort, and 3 kg weight loss, along with papulovesicular skin lesions on the face, trunk, and limbs, sparing palms and soles. On examination, there was generalized, mobile, tender lymphadenopathy, the same skin lesions, and mild hepatosplenomegaly. Laboratory tests showed marked leukocytosis with significant eosinophilia (36.7%), anemia, hypoalbuminemia, elevated bilirubin, and systemic inflammation (CRP 117 and ESR 133). The main hypotheses included systemic mycoses, lymph node tuberculosis, lymphoma, and leukemia. Lymph node and skin biopsies were performed, showing granulomatous lymphadenitis associated with fungal structures, and lymph node immunophenotyping was negative for clonal cells. Microbiological investigation identified P. brasiliensis in culture from a skin lesion and sputum, and intradermal testing for paracoccidioidomycosis was positive. The diagnosis of acute/subacute paracoccidioidomycosis (juvenile form) was established based on generalized lymphadenopathy, cutaneous involvement, and systemic manifestations. The patient started outpatient treatment with trimethoprim–sulfamethoxazole, with follow-up planned for prolonged antifungal therapy. The atypical nature of this case lies in the exuberant systemic involvement in an immunocompetent patient. Haitian nationality and recent residence in Brazil suggest that lack of previous exposure to the fungus may have favored the acute form of the disease, reinforcing the importance of considering individual epidemiological context in the diagnostic approach.
Maison et al. (Sun,) studied this question.