Extra-pulmonary manifestations of paracoccidioidomycosis associated with\nacquired immunodeficiency syndrome: a case report
A 28-year-old male from Santarém, Pará, Brazil, with a history of leisure activities in\na rural area, tractor driver, a known carrier of the HIV virus since 2010, however\nwithout previous follow-up, contacted us for the first time at Fundação de Medicina\nTropical Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brazil, for investigation of left\nknee chronic monoarthritis associated with tegumentary lesions. He had been using\nzidovudine, lamivudine, lopinavir/ritonavir for three weeks, this being the first\nantiretroviral regimen used. He had never used prophylactic\ntrimethoprim-sulfamethoxazole. He denied being a smoker or alcohol user. He reported\nthat the left knee arthritis appeared after local trauma identified five months before,\npreceding the tegumentary lesions that appeared two months after the fact. During the\nclinic exam, polymorphism of skin lesions was noted with pustules of follicular\ndistribution, papules with central necrosis, erythematous-infiltrated plaques covered\nwith pustules and ulcerated plaques, located on the face, trunk, abdomen and limbs,\nassociated with left knee arthritis (,\n and ). Oral and genital mucosa were spared. Lymphadenopathy and hepatosplenomegaly\nwere not observed. Blood cultures for aerobes, mycobacteria, fungi and leukocyte cream\nwere negative. VDRL resulted non-reagent. The Leishmaniasis screening exam was negative.\nThe analysis of synovial fluid suggested infectious arthritis. Left knee x-ray showed\nreduction of joint space and osteolytic patellar lesion (). Patient underwent surgical cleansing of joint, biopsy of synovial\nmembrane and skin. Both exams identified round cells, birefringent, with multiple\nbuddings compatible with P. brasiliensis (). Culture of synovial tissue confirmed the finding.\nComplementary propedeutics suggested pulmonary involvement and the Xpert/MTB\nRIF® sputum test was negative. At the time of diagnosis T CD4+ count was\n44 cells/mm3 . Patient was treated with Amphotericin B deoxycholate 50mg/day\n(cumulative dose of 650mg) but despite the therapy, his clinical condition worsened,\nprogressing to death on the 20th day of hospitalization. Necropsy revealed\ninvolvement of lungs, liver, spleen, kidneys, adrenals and bone marrow, in addition to\nthe previously described sites ().