Multisystem Paracoccidioidomycosis With Rare Retinal Involvement: A Case Report

Paracoccidioidomycosis (PCM) is an endemic mycosis in Latin America caused by dimorphic fungi of the genus Paracoccidioides. Infection occurs predominantly through inhalation of conidia from soil. Clinically, PCM presents in two forms: acute (or juvenile), with lymph node involvement, and chronic (or adult), more prevalent, with predominant pulmonary disease but potential systemic dissemination. Ocular involvement is rare and, when present, is usually limited to the eyelids. Here we report an unusual case of retinal involvement in a patient with disseminated chronic PCM. A 41-year-old woman, previously healthy, was admitted to hospital with erythematous-violaceous skin lesions on the face and bilateral cervical lymphadenopathy beginning two years earlier. In the months prior to admission, lesions appeared on the trunk and facial lesions progressed, with tumefaction and granulomatous areas, some infected. She developed daily fever, 15 kg weight loss, odynophagia, arthralgia, and ultimately sudden loss of visual acuity in the right eye, prompting care. Systemic PCM was suspected; direct mycological examination of skin scraping showed yeasts with multiple budding, compatible with Paracoccidioides spp. CT revealed necrotic lymphadenopathy in cervical chains and the inguinal region. Brain MRI showed a right bulbar nodular lesion. Ophthalmologic evaluation identified subretinal fibrosis with retinal detachment in the right eye. Nasofibroscopy showed granulomatous lesions in the epiglottis and larynx. Liposomal amphotericin B was started along with antibiotic therapy with oxacillin and ceftriaxone. After 45 days of treatment, there was improvement of skin lesions, neurologic findings, and systemic symptoms. She was discharged on trimethoprim–sulfamethoxazole, considering its better central nervous system penetration, for maintenance for 18 to 24 months. She has done well in outpatient follow-up, but with irreversible right-sided vision loss. This report highlights an atypical disseminated form of PCM in an immunocompetent patient—unusually a woman of reproductive age—with rare neurologic and retinal involvement. It reinforces the importance of including PCM in differential diagnoses even in uncommon presentations, especially in endemic areas, aiming for early diagnosis and prevention of permanent sequelae.