Paracoccidioidomycosis (PCM) is a systemic mycosis endemic in Brazil. It is classified by clinical form as acute or chronic; the acute form affects children and young adults with genetic predisposition or adults in the context of secondary immunosuppression. It is characterized by rapid dissemination from the lungs, predominantly involving the mononuclear phagocyte system. This report describes a 73-year-old man, living in an urban area of Rio de Janeiro, a psychologist, with well-controlled hypertension and diabetes. He developed dry cough and dyspnea in 11/2024, treated as bacterial pneumonia without improvement. After two months, he progressed with suppurative right cervical and inguinal lymphadenopathy, fever, nausea, vomiting, and facial skin lesions, and was hospitalized to receive intravenous amoxicillin/clavulanate with partial improvement. He was hospitalized again in 03/2025 with worsening inguinal lymphadenopathy and jaundice considered bacterial cholangitis, and received another cycle of beta-lactam therapy plus ciprofloxacin and metronidazole. During this hospitalization, skin lesions disseminated to the trunk and limbs, and he had 15 kg weight loss. Skin lesion biopsy was performed, diagnosing PCM. Itraconazole 200 mg/day was started with partial improvement of skin lesions. Imaging also identified a large expansive lesion in the right renal topography measuring 12 × 10.2 × 8.5 cm, infiltrating the renal sinus. He was referred to a specialized healthcare institution in 05/2025 for management. At the initial consultation, hospitalization was indicated for lipid complex amphotericin B and further investigation; he presented with a wasting syndrome and diarrhea. During this investigation, yeast-like cells were identified on stool parasitology and on biopsies obtained by colonoscopy from multiple lesions in the large intestine; histopathology showed marked chronic active colitis and fungal forms characteristic of Paracoccidioides spp. on Grocott and PAS staining (Figure 3). He is currently under outpatient treatment with itraconazole 200 mg/day and awaits surgical management of the renal mass; the main suspicions are neoplasia or even an adrenal lesion due to PCM, as this organ is frequently affected in PCM. This case reiterates the importance of considering PCM in an elderly patient without known risk factors. It also underscores that this patient presented the acute form of the disease.
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