Disseminated Paracoccidioidomycosis and Coinfection with HIV

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     A 32-year-old man infected with the human immunodeficiency virus (HIV) who had a CD4 count of 9 cells per cubic millimeter had a 9-month history of weight loss, with progressive weakness and numerous ulcerated lesions of various dimensions on the face (Panel A), trunk, and arms and legs. Hepatomegaly was also noted on physical examination. Radiographic examination revealed numerous rounded lytic lesions on the bones of the hands (Panel B), arms, legs, feet, and skull. A reticulonodular infiltrate was present in both lungs. Histopathological examination of a skin ulcer and culture of purulent discharge from the lesions revealed Paracoccidioides brasiliensis. Since paracoccidioides is susceptible to trimethoprim–sulfamethoxazole, the use of this medication as prophylaxis for Pneumocystis jiroveci infection may provide protection against paracoccidioidomycosis as well. Paracoccidioidomycosis is rare in HIV-infected patients, perhaps in part because of the use of trimethoprim–sulfamethoxazole as prophylaxis for pneumocystis infection, which this patient had not received. His paracoccidioidomycosis was treated with amphotericin B followed by 3 years of azole therapy, which resulted in a clinical cure. He also received antiretroviral therapy and did well for 9 years but eventually died from complications of advanced HIV infection, without any recurrence of the paracoccidioides infection.

    Gleusa Castro, M.D.

    Roberto Martinez, M.D.

    University of S?o Paulo

    14048-900 Ribeirao Preto, Brazil

    gcastro@hcrp.fmrp.usp.br

    http://www.100md.com/html/DirDu/2007/01/16/34/07/79.htm