BackgroundSince 1991 several outbreaks of acute coccidioidomycosis (CM) were diagnosed in the semi-arid Northeast of Brazil, mainly related to disturbance of armadillo burrows caused by hunters while digging them for the capture of these animals. This activity causes dust contaminated with arthroconidia of Coccidioides posadasii, which, once inhaled, cause the mycosis. We report on the identification of C. posadasii in soil samples related to outbreaks of CM.ResultsTwenty four soil samples had their DNA extracted and subsequently submitted to a semi-nested PCR technique using specific primers. While only 6 (25%) soil samples were positive for C. posadasii by mice inoculation, all (100%) were positive by the molecular tool.ConclusionThis methodology represents a simple, sensitive and specific molecular technique to determine the environmental distribution of Coccidioides spp. in endemic areas, but cannot distinguish the species. Moreover, it may be useful to identify culture isolates. Key-words: 1. Coccidioidomycosis. 2. Coccidioides spp. 3. C. posadasii. 4. Semi-arid. 5. Semi-nested PCR

Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Infection is acquired by inhalation of infective arthroconidia that live in the soil. In 60% of cases, the infection is benign and resolves spontaneously. In the northern hemisphere, coccidioidomycosis is endemic to arid and semi-arid regions at latitudes between 40 degrees N and 40 degrees S, particularly in the southwestern United States and in northern Mexico. In the semi-arid northeastern region of Brazil, cases of coccidioidomycosis have recently been reported in four states: Piauí (100 cases); Ceará (20 cases); Maranhão (6 cases); and Bahia (2 cases). The illness manifests in one of three clinical forms: the primary pulmonary form; the progressive pulmonary form; or the disseminated form. On average, the symptoms of respiratory infection appear 10 days after exposure. The diagnosis is made by the isolation of Coccidioides sp. in culture or by positive results from smear microscopy (10% potassium hydroxide test), periodic acid-Schiff staining or silver staining of any suspect material (sputum, cerebrospinal fluid, skin exudate, lymph node aspirate, etc.) Agar gel immunodiffusion is the diagnostic test most widely used. The most common finding on X-rays and CT scans is diffuse distribution of multiple pulmonary nodules, most of which are cavitated. The recommended treatment is fluconazole or itraconazole, the mean dose ranging from 200 to 400 mg/day, although as much as 1,200 mg/day is used in certain cases. In severe cases, amphotericin B can be the drug of choice. In cases of neurological involvement, the recommended treatment is administration of fluconazole, at a minimum dose of 400 mg/day.

Resumo: FUNDAMENTOS: A coccidioidomicose é micose sistêmica usualmente manifesta como infecção benigna de resolução espontânea; porém, uma pequena proporção dos infectados desenvolve quadros progressivos potencialmente fatais, podendo atingir a pele com lesões pleomórficas disseminadas. OBJETIVOS: Identificar e descrever as manifestações cutâneo-mucosas da coccidioidomicose, as ocupações de risco relacionadas à doença e o quadro clínico associado. MÉTODOS: Estudo realizado entre os anos 2003 e 2006 em 30 pacientes portadores de coccidioidomicose provenientes dos estados do Piauí e Maranhão e diagnosticados por exame microscópico direto, cultivo do escarro ou sorologia de triagem de imunodifusão dupla em gel de ágar, aliados à anamnese e exame físico. RESULTADOS: Identificaram-se lesões extrapulmonares em 13 casos (43,3%), com predomínio de manifestações dermatológicas de hipersensibilidade: eritema nodoso (26,6%), exantema com lesões eritemato-escamosas (26,6%) e eritema multiforme (23,3%), além de úlceras de língua (13,3%) e lábio (6,6%) e abscesso subcutâneo (3,3%). Tais manifestações foram observadas na fase aguda da doença. CONCLUSÕES: As manifestações cutâneas associadas à infecção respiratória aguda fortalecem a hipótese diagnóstica desta doença, especialmente, em caçadores de tatus ou pessoas expostas à escavação do solo. Palavras-chave: Coccidioidomicose; Diagnóstico; Epidemiologia; Eritema multiforme; Eritema nodoso; Exantema Abstract: BACKGROUND: Coccidioidomycosis is a systemic mycosis that usually presents as a benign infection. Patients generally recover spontaneously; however, a small proportion of infected individuals develop progressive complications that may affect the skin in the form of disseminated pleomorphic lesions and may become fatal. OBJECTIVES: To identify and describe skin and mucous membrane manifestations of coccidioidomycosis, to identify occupational hazards associated with the disease and to determine its associated clinical presentation. METHODS: A study conducted between 2003 and 2006 involving 30 patients from the Brazilian states of Piauí and Maranhão with coccidioidomycosis diagnosed by direct microscopy, sputum culture or screening serology using agar gel double immunodiffusion, in association with anamnesis and physical examination. RESULTS: Extrapulmonary lesions were found in 13 cases (43.3%), consisting predominantly of dermatological manifestations of hypersensitivity: erythema nodosum (26.6%), exanthema with erythematosquamous lesions (26.6%) and erythema multiforme (23.3%), as well as ulcerations of the tongue (13.3%), lip ulcers (6.6%) and subcutaneous abscess (3.3%). These manifestations were seen during the acute phase of the disease. CONCLUSIONS: Skin manifestations associated with an acute respiratory infection reinforce the hypothesis of a diagnosis of coccidioidomycosis, particularly in individuals who hunt armadillos or in those exposed to soil excavation.

Serologic diagnosis has been presented as a safe alternative for coccidioidomycosis. However, commercial kits based on coccidioidal antibodies available in the USA are considered too expensive for laboratories outside that country. In this study, we describe the preparation of antigens for detection of human coccidioidal antibodies by the immunodiffusion test (ID) and enzyme immunoassay (EIA). Antigens were tested against serum samples from patients with coccidioidomycosis, histoplasmosis and paracoccidioidomycosis, as well as healthy individuals. The highest reactivity in the ID tests was seen in the F0-90 antigen. In the EIAs, the best results were obtained with the F60-90 antigen. None of the serum samples from healthy individuals were recognized by any of the antigen extracts tested by ID or EIA. In conclusion, the F0-90 and F60-90 antigens have the potential to be commercially employed in presumptive diagnosis of coccidioidomycosis by ID or EIA, respectively. The tests could improve serological diagnosis of coccidioidomycosis in South America.

The hypothesis that exposure to silica might be associated with a wide range of autoimmune diseases including SLE (Systemic Lupus Erythematosus) has been discussed over the last decade, but only few cases of silicosis and SLE were described in the literature. We report the case of a male patient in his fifth decade of life, with previous exposure to silica, who worked as a well digger for ten years. The patient’s clinical picture started with articular symptoms, sporadic peaks of fever, anemia, positive anti-nuclear factor, peripheral (1/10) and homogeneous (1/500) standard, and productive cough. Computed tomography of the chest showed a diffuse interstitial process, bilateral nodules, para-aortic and para-tracheal hilar calcifications, compatible with pulmonary and ganglial silicosis. He developed acute respiratory distress syndrome (ARDS) and died