Paracoccidioidomycosis in Immunocompromised Patients: A Literature Review

Abstract

Paracoccidioidomycosis (PCM) is an endemic mycosis found in Latin America that causes systemic disease mostly in immunocompetent hosts. A small percentage of PCM occurs in immunocompromised patients where low clinical suspicion of the infection, late diagnosis, and uncertainties about its management are factors that negatively impact their outcomes. We conducted a literature review searching reports on PCM associated to HIV, cancer, maligned hemopathies, solid organ transplantation, and immunotherapies, in order to check for peculiarities in terms of natural history and challenges in the clinical management of PCM in this population. HIV patients with PCM usually had low T CD4+ cell counts, pulmonary and lymph nodes involvement, and a poorer prognosis (≈50% mortality). Most of the patients with PCM and cancer had carcinoma of the respiratory tract. Among maligned hemopathies, PCM was more often related to lymphoma. In general, PCM prognosis in patients with malignant diseases was related to the cancer stage. PCM in transplant recipients was mostly associated with the late phase of kidney transplantation, with a high mortality rate (44%). Despite being uncommon, reactivation of latent PCM may take place in the setting of immunocompromised patients exhibiting clinical particularities and it carries higher mortality rates than normal hosts.

Emerging Epidemics in Transplant: Histoplasmosis, Blastomycosis, and Paracoccidioidomycosis

“…There are very few actual cases in the literature of paracoccidioidomycosis in SOT recipients however. A recent review counted a total of just ten, nine of which were in renal transplant recipients [64]. Furthermore, no case of paracoccidioidomycosis has ever been described in a HCT recipient.…”

“…The low burden of this disease in transplant recipients is surprising and could reflect a combination of underdiagnosis, relatively limited access to transplants in endemic areas, and the use of trimethoprimsulfamethoxazole, a drug with known activity against Paracoccidioides, as part of routine posttransplant prophylaxis regimens. For a similar reason, most cases of paracoccidioidomycosis reported in SOT recipients have occurred after the first year of transplant, when trimethoprim-sulfamethoxazole prophylaxis is withdrawn [64]. Mortality in SOT recipients is hard to define given the small numbers involved, but the mortality rate seen to date (44%) appears to be far higher than the 5-8% mortality seen in the general population [65].…”

Endemic Mycoses and Cryptococcus in Solid Organ Transplant Recipients

“…It is believed that paracoccidioidomycosis is found in soil, however it is only sporadically isolated from the environment and the true natural habitat has been difficult to identify [74]. Incidence rates of 0.7-3 cases/100,000 people in endemic regions and 9-40 cases/100,000 people in hyperendemic regions have been reported [75,76]. The prevalence of paracoccidioidomycosis is thought to be around 10 million in Latin America, but only 1%-2% of those infected will develop disease.…”

“…The acute form most commonly affects children and young adults, while the chronic form typically occurs in adults [76]. Acute paracoccidioidomycosis accounts for 5%-25% of cases with equal incidence between males and females [75,76]. Manifestations include fevers, weight loss, anorexia and it can also present with suppurative lymphadenopathy, hepatosplenomegaly, mucocutaneous lesions, osteoarticular involvement, and less commonly pulmonary involvement.…”

“…While there are no specific recommendations for prophylaxis against P. brasiliensis after transplantation, trimethoprim-sulfamethoxazole has been found to have activity against Paracoccidioides, and may account for the low incidence among SOT recipients [75,79]. In a review of paracoccidioidomycosis in transplant recipients, the majority of cases occurred after the first year of transplantation when trimethoprim-sulfamethoxazole had been stopped [75]. P brasiliensis and P lutzii are susceptible to most systemic antifungal agents as well as sulfonamide derivatives, and both species have similar susceptibility patterns [76].…”