Osteomyelitis and Aortic Arteritis with thrombosis as primary manifestations of systemic paracoccidioidomycosis: a case report

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Duarte-Neto, Katia C. Dantas, Suzete C. F. Spina Lombardi, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3822139/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Paracoccidioidomycosis (PCM) is a neglected deep mycosis caused by Paracoccidioides sp. We describe a fatal PCM case, presenting as osteomyelitis, in a man having frequent contact with an endemic region of São Paulo, Brazil. Case presentation: A 67-year-old man who lived in an urban area, had frequent fishing trips to an endemic region. He presented with osteomyelitis of the femur and iliac artery thrombosis at hospital admission. Thoracic CT revealed multiple cavitated lung nodules. The patient rapidly progressed to irreversible respiratory failure. The autopsy revealed disseminated PCM and thrombosis of the iliac artery. Laboratory investigation confirmed a P. brasiliensis infection with phylogenetic results revealing sequences recovered from patient samples grouped with sequences characterized as P. brasiliensis complex. Conclusion Atypical PCM remains a diagnostic challenge. Increased awareness of contagion sites and different clinical presentations will lead to improved patient management. osteomyelitis aortic arteritis thrombosis systemic paracoccidioidomycosis autopsy Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by thermodimorphic fungi of the genus Paracoccidioides . The disease is endemic in South and Central America, with imported cases reported in North America, Europe, Africa, and Asia by individuals who have visited or worked in endemic areas [ 1 – 4 ]. Brazil has approximately 80% of the reported PCM cases in South America, despite the lack of mandatory reporting [ 5 ], with cases concentrated in the southeastern states (including São Paulo, Rio de Janeiro, Minas Gerais, and Espírito Santo) [ 6 – 7 ]. The state of São Paulo is considered an endemic region with an average of 29.3 new cases per year [ 7 ]. The disease presents in two different forms. An acute/subacute form occurs usually, in patients younger than 30 years of age, and the chronic form, mainly affect adult males [ 8 ]. In the chronic form, the lungs, skin, and mucous membranes are most commonly infected, but any organ can be affected by this systemic infection [ 8 ]. Although PCM-related mortality is low, morbidity is high, with chronic sequelae occurring in almost 50% of patients despite treatment [ 9 ]. Lack of early clinical suspicion often leads to delay in treatment, especially in cases with an atypical presentation. Furthermore, a recent review of endemic mycoses showed that PCM is the disease with the least diagnostic tools available [ 10 ]. Although PCM is endemic in Brazil, there are few reports of PCM with vascular involvement, the vast majority of which are confused with arteriosclerotic manifestations [ 11 – 15 ]. Here we describe an undiagnosed, fatal PCM infection in a 67-year-old man living in an endemic area, whose initial manifestations were lower limb ischemic symptoms due to femoral osteomyelitis and extensive aortic arteritis with thrombosis. Such uncommon manifestations were rarely described in the literature and certainly contributed to the delay in diagnosis. Case presentation The study was approved by the Research Ethics Committee of the Clinical Hospital (HC-FMUSP) (CAPPesq #3.258.615, CAAE protocol number: 10248419.7.0000.0068). Informed consent was obtained from the patient’s family. Clinical case description A male patient, 67 years old, smoker, hypertensive, dyslipidemic, lifelong living in the urban area of Pirapora do Bom Jesus, in Sao Paulo State, Brazil (Fig. 1 ). The municipality is located in a valley on the banks of the Tietê River, an endemic region for PCM, with an average annual temperature of 18–22ºC, subtropical climate, and humidity of 54%. He worked in the food services industry within the urban area of the city. His hobby was frequent freshwater fishing in this endemic region. Figure 1 . Timeline of the paracoccidioidomycosis infection in a patient with arteritis and thrombosis of the iliac artery. ( A ) Schematic figure containing the diagnostic points, harvesting, and symptoms over time; ( B ) Highlight the state of São Paulo within Brazil, showing the location of the City of Pirapora do Bom Jesus within the State of São Paulo, and also highlighting the Tietê River where several fishing farms are located; We used R software, geobr package, (MIT license https://ipeagit.github.io/geobr/ ) to create the maps produced to visualize the spatial location of the atypical paracoccidioidomycosis case. RD = respiratory distress; ICU = intensive care unit. Since March 2019, he reported pain in his right lower leg and weight loss, without a history of trauma or perforating lesions. The patient had undergone computed tomography (CT) and biopsy during hospitalization at the secondary referral hospital close to his hometown. CT showed lytic lesions in the right femur suggestive of sarcoma. However, the biopsy showed a chronic inflammatory process and tissue necrosis with unspecified fungi. No specific treatment was administered. Pain in the right lower limb (RLL) worsened with pain onset also in the left lower limb (LLL), associated with non-fixed cyanosis and limb paralysis. Doppler ultrasonography revealed an intra-abdominal occlusion of the inguinal vessels. On August 21, 2019, upon admission to the tertiary Hospital das Clinicas of the Faculty of Medicine of Sao Paulo, a physical examination revealed cyanosis, reduced lower limb pulses, and absent femoral pulses. Angiography and magnetic resonance imaging showed partial occlusion of the infrarenal abdominal aorta, extending to the common, internal, and external iliac arteries. There was also an intraosseous abscess, deep collections of the adjacent muscles, and bursitis of the psoas bilaterally. On August 22, 2019, a chest CT scan was performed and showed multiple nodules distributed in both lungs, interpreted as septic embolism. An echocardiogram did not show cardiac vegetation as a possible focus of septic embolization of the lungs. A full anticoagulation regimen and antibiotic therapy (ceftriaxone and clindamycin) was initiated for the treatment of osteomyelitis. Regarding the detection and identification of bacteria, culture tests for anaerobes and aerobes were carried out on the right femur lesion and peripheral blood during hospitalization with negative results (08/22/2019; 09/02/2019; 09/03/2019). In addition, during admission, the direct test for acid-fast bacilli (Ziehl-Nielsen) of a biopsy of the right femur lesion was negative (02/09/2019); cultures for mycobacteria and fungi (biological material obtained from the biopsy of the right femur and peripheral blood) were negative (09/02/2019). A rectal swab was also tested for carbapenem-resistant Enterobacteria (09/03/2019) with negative results. The bacterioscopic examination of the biopsy of the right femur (09/02/2019) showed no microorganisms and only rare polymorphonuclear leukocytes. Laboratory exams at admission revealed a hemoglobin of 9.7 g/dl (12–15 g/dl), mild anisocytosis, total leukocytes of 19.8 (5–10 x 10 3 /mm 3 ), with 85% segmented cells (52–72%) and without left deviation; lymphocytes were 990 cells/mm 3 (100–3000 cells/mm 3 ); C-reactive protein was 320 (< 5.0 mg/L). Laboratory results at various times after presentation are in the Supplementary Appendix. The patient’s right lower limb pain progressed, and he developed a fistulizing orifice with drainage of purulent material, requiring progressively higher doses of opioids. On August 31, the patient developed acute respiratory failure and retrosternal chest pain, with symptomatic improvement after diuretic treatment and non-invasive ventilation. On September 2, he underwent an uneventful CT-guided biopsy of a lesion in the right femur (Fig. 2 ). On the same day, he experienced significant respiratory distress, requiring intensive care unit admission. Antibiotic therapy was increased to meropenem plus vancomycin, beyond of amphotericin B for treatment of possible fungal infection. He died on September 3rd . Autopsy findings The autopsy revealed disseminated PCM, with a granulomatous reaction associated with numerous yeasts compatible with Paracoccidiodes spp. (Fig. 2 ). The fungi were present in the skin of the LL, lungs (forming cavitations), aorta and right iliac artery, prostate, lymph nodes, spleen, and femur. The biopsy performed one day before death confirmed the presence of PCM in the femur. There was a 9.2 cm organized thrombus of the distal aorta, extending from the infrarenal artery to the iliac bifurcation, especially at the right iliac artery, and ischemic necrosis of all five toes in the right foot. Additional findings were bronchopneumonia with exudative diffuse alveolar damage (Fig. 2 ), acute tubular necrosis, cerebral congestion, lymphoid hypoplasia in the spleen, and generalized atherosclerosis. A microscopic (< 5 mm) pancreatic adenocarcinoma was an unexpected finding. Figure 2 . Systemic paracoccidioidomycosis with arteritis and thrombosis of the iliac artery: ( A ) Multiple lytic lesions in the right femur, with periosteal reaction (radiography); ( B ) Deep abscess in the right thigh, associated with femoral lytic lesions (RNM); ( C ) Ischemia of the right thigh; ( D ) Fistula on the lateral area the right thigh, associated with osteomyelitis and soft tissue abscess by Paracoccidioides ; ( E ) Right toe ischemia; ( F ) Atherosclerotic aorta with thrombus occluding right iliac artery (arrow); ( G-I ) Organized mycotic thrombus within the right iliac artery, with numerous yeasts (arrow, G, HE), compatible with Paracoccidioides spp (arrow, H and I, Grocott). The yeasts are round, wide size range, and multiple budding (I, insets); ( J-K ) Pulmonary nodules, with central necrosis (J, arrow), corresponding to granulomas with Paracoccidioides spp forms (K, arrow). Exudative diffuse alveolar damage is associated (K, asterisk). Laboratory and phylogenetic investigation – postmortem Confirmation of the identification of the fungal pathogen, Paracoccidioides brasiliensis , was possible only postmortem by serologic and sequencing analysis. Sequencing and mycological analysis from samples obtained from lung and skin lesions revealed co-infection with other fungal pathogens Apiotrichum montevideense and Candida albicans . Mycological analysis . Skin and lung tissue fragments were inoculated into Sabouraud-dextrose agar, Brain-Heart Infusion, Mycobiotic agar (Difco Laboratories, Detroit, MI), and Tryptone Soya broth (Oxoid, London, England), incubated at 25°C and 37°C and monitored for 45 days. Positive yeast cultures were placed on CHROMagar Candida medium (CHROMagar, Paris, France) for presumptive species identification. Micromorphological analysis did not identify Paracoccidioides spp , only Candida spp. and Trichosporon isolates [ 16 ], (Fig. 3 ). Culture at 37ºC on Brain-Heart Agar revealed a birefringent globose yeast-like form, with multiple budding (1–3) of small base linked to the large mother cell, micromorphology on corn meat at 25ºC confirmed Trichosporon spp. Figure 3 . A and D - Trichosporon spp. Micromorphology from the culture of lung and skin autopsy, respectively, cultured at 37°C. Birefringent globous yeast-like form, with multiple budding (1–3) of small base linked to the large mother cell. We observed the presence of integral and fragmented hyphae pseudohyphae and blastoconidia in D . B and E – Micromorphology on corn meal agar at 37°C. Micromorphology from lung and skin culture, respectively. We observed hyphae with arthrospore, lateral, and intercalary blastoconidia. There is disarticulation of hyphae in arthroconidia, with lateral and terminal blastoconidia. C and F : Micromorphology from culture on corn meal agar at 28°C, lung and skin autopsy, respectively. We observed the presence of both hyphae disarticulation into arthroconidia with lateral and terminal blastoconidia. Serological analysis . In sera samples, PCM was also confirmed by double immunodiffusion (DID) and immunoblotting (IBB) tests [ 17 – 19 ], using culture-filtered antigen from the yeast P. brasiliensis 113 (Pb-113) [ 17 ]. These tests use a 43 kDa glycoprotein (gp43) as the primary antigen of the P. brasiliensis complex to detect circulating antibodies with sensitivities between 85% and 100%. The DID and IBB assays in sera showed reactivity to the P. brasiliensis antigen. Antibodies at 1:32 dilution were detected by semi quantitative analysis [ 17 – 19 ]. Immunoblotting with the Pb113 antigen (AgPb113) showed positivity for antibodies against gp43 and 70 kDa [ 17 – 19 ]. Sequencing analysis .The DNA was extracted from patient samples obtained at autopsy, according to Erjefält et al. [ 20 ]. The presence of amplifiable DNA was confirmed by nested PCR of a fragment of the human glyceraldehyde-3-phosphate dehydrogenase gene (GADPH; GenBank: J04038.1), as described by Escolani et al. in 1988 [ 21 ]. For the detection of pathogenic fungi, conventional PCR was performed using primers specific for the 28S to 18S regions of the rRNA gene and gp43 specific for PCM, as described by White et al.[ 22 ] and Bialek et al. [ 23 ]. Samples positive for fungi were submitted to sequencing analysis using the Sanger method. To perform the gp43 assembly, and phylogenetic analysis, the obtained reads for the P. brasiliensis gp43 gene from skin and lung tissue samples were combined to produce two distinct consensus sequences (skin and lung) for the gp43 gene of P. brasiliensis . Briefly, to assemble the consensus sequences we used the Trace assembly module of the Tracy version 0.5.3 program [ 24 ], using the local operation reference-guided trace assembly (using as reference the sequence #AB304681). The output file with the aligned reads from Tracy was converted into a consensus sequence for each source tissue (skin and lung) using the EMBOSS Cons ( http://emboss.open-bio.org/rel/dev/apps/cons.html ). Yeast isolates obtained from lung and skin tissues were sequenced using internal transcribed spacer primers (5.8rDNA-ITS region), and the lung tissue isolates were identified as Trichosporon montividense with 99% similarity (MT322616) and Candida albicans with 100% similarity (MT322617). The skin tissue isolates were identified as Trichosporon montividense with 100% similarity (MT322618). In fresh frozen samples and paraffin tissue sections (FFPE) using different tissues (skin and lung), the results of identification with the species-specific primer of the gp43 gene identified Paracoccidioides brasiliensis and the sequences were deposited in GenBank under accession numbers MT346581 and MT346580, respectively. We used the recently revised classification of the genus Paracoccidioides as a model to classify the sequences obtained in the present study [ 24 , 25 ]. The dataset was aligned using MUSCLE version 3.8.1551, multiple sequence alignment with high accuracy and high throughput. A phylogenetic tree was reconstructed based on curated P. brasiliensis gp43 gene sequences using the Maximum Likelihood (ML) method implemented in IQ-Tree2 version 2.0.7 (26) with automatic model selection by ModelFinder and using the Bayesian Information Criterion (BIC) (27). The tree was displayed with FigTree version 1.4.3 ( tree.bio.ed.ac.uk/software/figtree/ ). All the datasets analyzed during the current study are available from the corresponding author upon reasonable request. Phylogenetic inference using partial gp43 sequences showed that the two sequences clustered in the P. brasiliensis complex (Fig. 4 . A and B). Figure 4 . Phylogenetic analysis of P. brasiliensis associated with a fatal human case. The maximum likelihood phylogenetic tree of the genus Paracoccidioides was based on partial gp43 gene sequences (n = 75). The black circles represent the bootstrap support values, and their sizes vary according to the support value (0 to 100). The black triangles highlight the samples characterized here from the atypical case of PCM, where the two samples cluster with sequences characterized as P. brasiliensis complex. Discussion and conclusion We report here the case of an elderly man with rare manifestations of chronic PCM who presented with lung lesions, femoral osteomyelitis, abdominal lymphadenitis, and aortitis leading to iliac artery thrombosis. The initial presentation of the infection was lower extremity symptoms, which contributed to the delay in diagnosis. There are rare descriptions of PCM involving the osteoarticular system or large vessels such as the aorta and iliac arteries. It is possible that the progression of the femoral infection, forming a perilesional abscess, caused fungal arteritis of the lower aorta and iliac arteries with thrombosis formation, causing the ischemia in the right leg. Interestingly, the autopsy revealed pancreatic adenocarcinoma, which may have predisposed to the thrombotic phenomena. In this case, the autopsy was crucial for the final diagnosis. To our knowledge, this is the first description of both manifestations occurring in the same patient. Although PCM disease is common and endemic in Brazil, there are no recent descriptions of vascular involvement as in the present case. Less than 10 cases have been described in the literature, with the last report dating from 1998 [ 11 – 15 ]. In all reports, the patients were adults, and the diagnosis was delayed or made only at autopsy. PCM aortitis was confused with arteriosclerotic manifestations, leading to a lack of early clinical suspicion, and delayed or no specific treatment. In 1996, Manns et al [ 14 ] described the case of a 59-year-old man with PCM who presented with the first symptoms of hematogenous origin 15 years after leaving South America. This patient's presentation illustrates the difficulty in suspecting PCM in patients without an adequate travel history who present with weight loss and pulmonary, mucosal, and cutaneous lesions. Osteoarticular PCM is also rarely described. The few studies addressing this report the bone infection occurring frequently in children or younger adults, in the acute/subacute phase of the disease [ 28 – 33 ]. Most of the described cases come from Brazil. One of the hypotheses described by Sevarese et al. [ 31 ] would be the fact that usually skin lesions and pulmonary involvement dominate the presentation when PCM is diagnosed, without an active and systematic search for bone lesions. In this patient, microscopic adenocarcinoma of the pancreas was diagnosed at autopsy. Concomitant PCM and solid tumors have been reported in 0.16 to 11% of PCM cases [ 34 ]. Most of the tumors are respiratory or gastrointestinal cancers, sometimes at the same site of infection. It is not known whether predisposing factors such as smoking and alcoholism are common to both conditions, or whether PCM may be an additive factor for cancer development due to chronic antigenic stimulation of epithelial cells [ 8 , 34 ]. In this case, the extent to which the pancreatic adenocarcinoma contributed to the thrombotic phenomena is not known. In other cases, PCM may mimic a solid malignancy, again leading to diagnostic delay [ 35 – 38 ]. Although classical laboratory techniques provide valuable information by visualizing the fungal pathogen Paracoccidioides spp, they do not have a significant discriminatory power on the type of species. Several PCR-based methods can detect polymorphisms in the DNA of Paracoccidioides and thus support species identification, mainly sequencing and taxonomic analysis, allowing the location of the strain as originating from the endemic region of Sao Paulo, P. brasiliensis complex [ 39 – 40 ]. The results of the phylogenetic reconstruction using gp43 sequences confirmed the diagnosis of the etiologic agent, and the grouping of the two sequences obtained from different tissues suggested a systemic infection. The long latency period before the first signs of PCM infection appear complicates efforts to trace clinical symptoms to events associated with initial exposure. In this environment, fungal sexual reproduction and competitive selection increase, with a greater likelihood of the emergence of more virulent variants [ 2 – 3 , 7 , 17 , 41 ]. Our hypothesis is that these sequences may be related to PCM survival strategies in saprophytic or specific host immunity, justifying the atypical clinical profile. In addition, PCM sequences contribute to the updating of maps identifying endemic fungal regions, which may improve global PCM surveillance. According to the World Health Organization, paracoccidioidomycosis is a neglected mycosis [ 1 ]. A limitation of our study is that Paracoccidioides spp. were not isolated from the patient's cultured specimens. However, the fungus was identified by histological analysis and sequenced using fresh frozen samples and FFPE from various tissues. T. montividense and C. albicans were also detected and identified by culture and confirmed by sequencing. It is possible that these faster growing pathogens may have inhibited the growth of P. brasiliensis in culture by competing for nutrients, explaining our negative results. Our methods allowed us to identify other fungal pathogens that may have contributed to the severity of the disease that are not commonly described. Disseminated trichosporonosis is known to be an intrahospital opportunistic mycosis with high mortality. T. montividense is an invasive fungus commonly associated with the insertion of central venous catheters, urinary catheters, and catheter-related peritoneal devices [ 42 ]. The ability to adhere and form biofilms on implanted devices may be responsible for the progression of invasive trichosporonosis, as it can promote antifungal drug leakage and alter the host immune response [ 43 – 44 ]. Trichosporonosis is often difficult to diagnose at autopsy because the causative species of Trichosporon are pathologically similar to other fungi, particularly Candida species. The results of our study should raise the clinical suspicion of PCM and lead to more rational and precise anti-infective treatments, especially for patients who are difficult to diagnose by conventional methods. This will have a positive impact on risk. Although relatively rare, endemic systemic mycoses should also be a potential for travelers, whether international or not. Epidemiologic exposures can guide diagnostic evaluation and treatment. The GeoSentinel website for clinical surveillance of travel-related diseases in international travelers and migrants does not present data on PCM ( www.istm.org/geosentinel ). One of the reasons for this omission is the lack of knowledge about PCM for clinical and laboratory identification. Although it is not possible to associate the infection with travel habits, our patient had a hobby of frequently fishing in an endemic area, i.e., the wetlands along the Tietê River in São Paulo, Brazil. The present report describes a rare, undiagnosed form of chronic PCM with osteoarticular involvement of the femur, aortitis, and iliac artery thrombosis in an elderly man with frequent contact with wetlands in an endemic area along the Tietê River, region of São Paulo, Brazil. Increased awareness of the transmission sites and different clinical presentations of this neglected tropical disease may lead to improved patient management. Abbreviations Abbreviation Meaning PCM Paracoccidioidomycosis RLL right lower limb LLL left lower limb CT Computerized tomography Genbank GenBank ® is the NIH genetic sequence database DID double immunodiffusion IBB Immunoblotting Gep43 gene 43-kDa-glycoprotein Declarations Acknowledgments : The authors thank all physicians and residents of the Pathology Department who participated in the autopsy procedures, all technicians in our histology laboratory, and the patient’s relatives who agreed to the autopsy. Authors’ contributions : ANDN.: Conceptualization, Investigation, Resources, Writing - Original Draft, Writing - Review & Editing, Visualization, Supervision, Project administration. KCD.: Conceptualization, Methodology, Validation, Formal analysis, Resources, Investigation, Writing - Original Draft. SCF. : Methodology, Validation, Formal analysis, Investigation, Writing - Original Draft. RSFX.: Methodology, Validation, Formal analysis, Investigation, Resources, Writing - Original Draft. APV.: Methodology, Validation, Formal analysis, Investigation, Resources, Writing - Original Draft. AMJ.: Writing - Original Draft. LFFS. : Resources, Writing - Original Draft. PHNS.: Resources, Writing - Original Draft. MD.: Resources, Writing - Original Draft. MPC.: Formal analysis, Investigation, Writing - Original Draft. TM.: Resources, Writing - review & editing, Supervision, Funding acquisition. All authors have read and approved the final manuscript. Funding : This study has received funding from São Paulo Research Foundation (FAPESP) #2013/17159‐ 2. Funder https://doi.org/10.13039/501100001807; Bill and Melinda Gates Foundation #INV‐002396. Funder https://doi.org/10.13039/100000865; Bolsa de produtividade em pesquisa: Conselho Nacional de Desenvolvimento Científico e Tecnológico #304987/2017-4 — Marisa Dolhnikoff. MPC was supported by FAPESP – grant number #2019/24518-5. Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Availability of data and materials All the datasets analyzed during the current study are available from the corresponding author on reasonable request. The new sequence here characterized was deposited in GenBank under the accession number MT346581 and MT346580. Ethics approval and consent to participate . The study was approved by the Research Ethics Committee of the Clinical Hospital (HC-FMUSP) (CAPPesq #3.258.615, CAAE protocol number: 10248419.7.0000.0068). Informed consent was obtained from the patient’s family. Informed Consent Statement : Written informed consent has been obtained from the patient’s parents to publish this paper. Declaration of competing interest : All authors read and approved the final manuscript. The authors declare no competing interests. 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PMID: 35429963. Passarin NP, Pereira AAC, Passos BL, Gil CM, Preciliano Marques LN, Silveira GL, Bonafé S, Moreira Neto LJ. Prostatic involvement in disseminated paracoccidioidomycosis: An unusual presentation mimicking malignant neoplasm. Med Mycol Case Rep. 2020; 28:46-48. doi: 10.1016/j.mmcr. 2020.04.006. Steinbrück K, Fernandes R. Biliary Paracoccidioidomycosis: An Unusual Infection Simulating Malignant Neoplasm. Ann Hepatol. 2019; 18(1):258-262. doi: 10.5604/01.3001.0012.7935. PMID: 31113602. : Ghani A, Weinberg M, Pathan N, Vidhun R, Sieber S. Paracoccidioides brasiliensis Infection Mimicking Recurrent Hodgkin Lymphoma: A Case Report and Review of the Literature. Mycopathologia. 2018; 183(6):973-977. doi: 10.1007/s11046-018-0252-y. Epub 2018 Feb 23. PMID: 29476307. Pinheiro BG, Hahn RC, Camargo ZP, Rodrigues AMP. Molecular Tools for Detection and Identification of Paracoccidioides Species: Current Status and Future Perspectives. J. Fungi 2020; 6: 0293. doi:10.3390/jof6040293. Vilela R, de Hoog S, Bensch K, Bagagli E, Mendoza L. A taxonomic review of the genus Paracoccidioides, with focus on the uncultivable species. PLoS Negl Trop Dis. 2023; 17(4): e0011220. https://doi.org/10.1371/journal. pntd.0011220. Bagagli E, Theodoro RC, Bosco SMG, McEwen JG. Paracoccidioides brasiliensis : phylogenetic and ecological aspects. Mycopathologia. 2008; 165: 197–207. doi: 10.1007/s11046-007-9050-7. de Macedo PM, Freitas DFS, Varon AG, Lamas CDC, Ferreira LCF, Freitas AD, Ferreira MT, Nunes EP, Siqueira MM, Veloso VG et al. COVID-19 and acute juvenile paracoccidioidomycosis coinfection. PLoS Negl. Trop. Dis . 2020; 14: e0008559. https://doi.org/10.1371/journal.pntd.0008559. Duarte-Oliveira C, Rodrigues F, Gonçalves SM, Goldman GH, Carvalho A and Cunha C. The Cell Biology of the Trichosporon-Host Interaction. Front. Cell. Infect. Microbiol. 2017; 7:118. doi: 10.3389/fcimb.2017.00118. Mehta V, Nayyar C, Gulati N, Singla N, Rai S, Chandar J. A Comprehensive Review of Trichosporon spp.: An Invasive and Emerging Fungus. Cureus. 2021; 13(8): e17345. doi: 10.7759/cureus.17345. Additional Declarations No competing interests reported. Supplementary Files SupplementaryAppendixBMCInfectiousDiseases.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3822139","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":265698792,"identity":"f87d70cf-08ca-4159-a7ef-54d99fbb97cf","order_by":0,"name":"Amaro N. Duarte-Neto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBADxgYQ+cEGwmMmUgszA+OMNFK1MPMQo4V/2uFnHz4w3JHdzt5/8LFNwjYGg/NnDzAX7sGtReJ2mvHMGQzPjHf2HGY2zkm4zWBwIy+BecYzPNbcTjBm5mE4nLjhRjKbdO4PkBYeA2aeA7h1yN9O/wzRcv8xm7QFyJbzZ/BrMbidA7OFmU2aAaTlQA5+LYa3c4oZZxgcNt5wJtnYsCfhNo8k0C+HZ+DRInc7fTPDh4rDshuOH3z44EfCbTm+82cPPi7AowXqPASTB4QIakAHPKRqGAWjYBSMgmEOAJVEU7J8xlDHAAAAAElFTkSuQmCC","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":true,"prefix":"","firstName":"Amaro","middleName":"N.","lastName":"Duarte-Neto","suffix":""},{"id":265698793,"identity":"bd666d49-c167-4c76-ae35-e950d86eed1c","order_by":1,"name":"Katia C. Dantas","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Katia","middleName":"C.","lastName":"Dantas","suffix":""},{"id":265698794,"identity":"336e8a78-d2e0-4178-917d-204ac6007469","order_by":2,"name":"Suzete C. F. Spina Lombardi","email":"","orcid":"","institution":"Fundação Pro-Sangue Hemocentro de Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Suzete","middleName":"C. F. Spina","lastName":"Lombardi","suffix":""},{"id":265698795,"identity":"b306cb50-30a8-4970-ac3d-d4805edcc4ec","order_by":3,"name":"Roseli S. Freitas-Xavier","email":"","orcid":"","institution":"HCFMUSP and Institute of Tropical","correspondingAuthor":false,"prefix":"","firstName":"Roseli","middleName":"S.","lastName":"Freitas-Xavier","suffix":""},{"id":265698796,"identity":"45e141f3-0ce7-4887-baf9-b0fac7ae7b8a","order_by":4,"name":"Adriana P. Vicentini","email":"","orcid":"","institution":"Adolfo Lutz Institute","correspondingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"P.","lastName":"Vicentini","suffix":""},{"id":265698797,"identity":"18d13564-9227-44f9-8718-434ff1f297cb","order_by":5,"name":"Alfredo Mendroni Junior","email":"","orcid":"","institution":"Fundação Pro-Sangue Hemocentro de Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Alfredo","middleName":"Mendroni","lastName":"Junior","suffix":""},{"id":265698798,"identity":"8f1b0684-8a8f-42da-8442-9a4295824689","order_by":6,"name":"Simon Claros Claros","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Simon","middleName":"Claros","lastName":"Claros","suffix":""},{"id":265698799,"identity":"4a9f8f6a-ba58-4ec8-9f25-1dbfb8c22807","order_by":7,"name":"Luiz Fernando F. Silva","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Luiz","middleName":"Fernando F.","lastName":"Silva","suffix":""},{"id":265698800,"identity":"ba8e4e04-6fc6-4c5d-a303-5591f74c7043","order_by":8,"name":"Paulo H. N. Saldiva","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Paulo","middleName":"H. N.","lastName":"Saldiva","suffix":""},{"id":265698801,"identity":"46ec219d-8473-4dee-b05a-01c20eb179e0","order_by":9,"name":"Marisa Dolhnikoff","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Marisa","middleName":"","lastName":"Dolhnikoff","suffix":""},{"id":265698802,"identity":"b5079c5a-0b82-4865-b0a0-2aca2268f7bd","order_by":10,"name":"Marielton dos Passos Cunha","email":"","orcid":"","institution":"Pasteur Institute of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Marielton","middleName":"dos Passos","lastName":"Cunha","suffix":""},{"id":265698803,"identity":"9c4aff99-949b-42b5-94f8-bffcb438ee08","order_by":11,"name":"Thais Mauad","email":"","orcid":"","institution":"University of Sao Paulo","correspondingAuthor":false,"prefix":"","firstName":"Thais","middleName":"","lastName":"Mauad","suffix":""}],"badges":[],"createdAt":"2023-12-29 18:59:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3822139/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3822139/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49324939,"identity":"6dd498f8-7073-4d60-ad2f-5b5d345e72df","added_by":"auto","created_at":"2024-01-08 17:21:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225970,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of the paracoccidioidomycosis infection in a patient with arteritis and thrombosis of the iliac artery. (\u003cstrong\u003eA\u003c/strong\u003e) Schematic figure containing the diagnostic points, harvesting, and symptoms over time; (\u003cstrong\u003eB\u003c/strong\u003e) Highlight the state of São Paulo within Brazil, showing the location of the City of Pirapora do Bom Jesus within the State of São Paulo, and also highlighting the Tietê River where several fishing farms are located; We used R software, geobr package, (MIT license https://ipeagit.github.io/geobr/) to create the maps produced to visualize the spatial location of the atypical paracoccidioidomycosis case. RD = respiratory distress; ICU = intensive care unit.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/1ee10c7d22654652492d3a42.png"},{"id":49323825,"identity":"8ba53406-6f37-41ea-b833-72b245334818","added_by":"auto","created_at":"2024-01-08 17:13:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":986436,"visible":true,"origin":"","legend":"\u003cp\u003eSystemic paracoccidioidomycosis with arteritis and thrombosis of the iliac artery: (\u003cstrong\u003eA\u003c/strong\u003e) Multiple lytic lesions in the right femur, with periosteal reaction (radiography); (\u003cstrong\u003eB\u003c/strong\u003e) Deep abscess in the right thigh, associated with femoral lytic lesions (RNM); (\u003cstrong\u003eC\u003c/strong\u003e) Ischemia of the right thigh; (\u003cstrong\u003eD\u003c/strong\u003e) Fistula on the lateral area the right thigh, associated with osteomyelitis and soft tissue abscess by \u003cem\u003eParacoccidioides\u003c/em\u003e; (\u003cstrong\u003eE\u003c/strong\u003e) Right toe ischemia; (\u003cstrong\u003eF\u003c/strong\u003e) Atherosclerotic aorta with thrombus occluding right iliac artery (arrow); (\u003cstrong\u003eG-I\u003c/strong\u003e) Organized mycotic thrombus within the right iliac artery, with numerous yeasts (arrow, G, HE), compatible with \u003cem\u003eParacoccidioides spp \u003c/em\u003e(arrow, H and I, Grocott). The yeasts are round, wide size range, and multiple budding (I, insets); (\u003cstrong\u003eJ-K\u003c/strong\u003e) Pulmonary nodules, with central necrosis (J, arrow), corresponding to granulomas with \u003cem\u003eParacoccidioides spp\u003c/em\u003e forms (K, arrow). Exudative diffuse alveolar damage is associated (K, asterisk).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/7c13a2ddd7122c0ebc3df973.png"},{"id":49323829,"identity":"16ae776f-b4b2-410c-8ff8-7103217b13f8","added_by":"auto","created_at":"2024-01-08 17:13:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":977686,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA and D \u003c/strong\u003e- \u003cem\u003eTrichosporon\u003c/em\u003e spp. Micromorphology from the culture of lung and skin autopsy, respectively, cultured at 37°C. Birefringent globous yeast-like form, with multiple budding (1 – 3) of small base linked to the large mother cell. We observed the presence of integral and fragmented hyphae pseudohyphae and blastoconidia in \u003cstrong\u003eD\u003c/strong\u003e. \u003cstrong\u003eB and E\u003c/strong\u003e – Micromorphology on corn meal agar at 37°C. Micromorphology from lung and skin culture, respectively. We observed hyphae with arthrospore, lateral, and intercalary blastoconidia. There is disarticulation of hyphae in arthroconidia, with lateral and terminal blastoconidia. \u003cstrong\u003eC\u003c/strong\u003e and\u003cstrong\u003e F\u003c/strong\u003e: Micromorphology from culture on corn meal agar at 28°C, lung and skin autopsy, respectively. We observed the presence of both hyphae disarticulation into arthroconidia with lateral and terminal blastoconidia.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/ad947340620bb5632244bd35.png"},{"id":49323827,"identity":"f543d20d-cf3f-4ccb-99ba-5b9c2db44545","added_by":"auto","created_at":"2024-01-08 17:13:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":325517,"visible":true,"origin":"","legend":"\u003cp\u003ePhylogenetic analysis of \u003cem\u003eP. brasiliensis\u003c/em\u003e associated with a fatal human case. The maximum likelihood phylogenetic tree of the genus Paracoccidioides was based on partial \u003cem\u003egp43\u003c/em\u003e gene sequences (n = 75). The black circles represent the bootstrap support values, and their sizes vary according to the support value (0 to 100). The black triangles highlight the samples characterized here from the atypical case of PCM, where the two samples cluster with sequences characterized as \u003cem\u003eP. brasiliensis\u003c/em\u003e complex.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/f4dcfe52da1e6d2971876002.png"},{"id":50245321,"identity":"e2118b96-7422-4048-a9d1-f8a5b40f113d","added_by":"auto","created_at":"2024-01-27 10:38:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2643305,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/43eb7786-0714-49e9-898c-d7aef1fd41a8.pdf"},{"id":49323826,"identity":"df54c2b4-4270-4aa2-ad16-f296a08e12fe","added_by":"auto","created_at":"2024-01-08 17:13:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23111,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendixBMCInfectiousDiseases.docx","url":"https://assets-eu.researchsquare.com/files/rs-3822139/v1/35dd1c7a4bce6916e65b3a5b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Osteomyelitis and Aortic Arteritis with thrombosis as primary manifestations of systemic paracoccidioidomycosis: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eParacoccidioidomycosis (PCM) is a systemic fungal infection caused by thermodimorphic fungi of the genus \u003cem\u003eParacoccidioides\u003c/em\u003e. The disease is endemic in South and Central America, with imported cases reported in North America, Europe, Africa, and Asia by individuals who have visited or worked in endemic areas [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Brazil has approximately 80% of the reported PCM cases in South America, despite the lack of mandatory reporting [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], with cases concentrated in the southeastern states (including S\u0026atilde;o Paulo, Rio de Janeiro, Minas Gerais, and Esp\u0026iacute;rito Santo) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The state of S\u0026atilde;o Paulo is considered an endemic region with an average of 29.3 new cases per year [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe disease presents in two different forms. An acute/subacute form occurs usually, in patients younger than 30 years of age, and the chronic form, mainly affect adult males [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the chronic form, the lungs, skin, and mucous membranes are most commonly infected, but any organ can be affected by this systemic infection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although PCM-related mortality is low, morbidity is high, with chronic sequelae occurring in almost 50% of patients despite treatment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Lack of early clinical suspicion often leads to delay in treatment, especially in cases with an atypical presentation. Furthermore, a recent review of endemic mycoses showed that PCM is the disease with the least diagnostic tools available [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Although PCM is endemic in Brazil, there are few reports of PCM with vascular involvement, the vast majority of which are confused with arteriosclerotic manifestations [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHere we describe an undiagnosed, fatal PCM infection in a 67-year-old man living in an endemic area, whose initial manifestations were lower limb ischemic symptoms due to femoral osteomyelitis and extensive aortic arteritis with thrombosis. Such uncommon manifestations were rarely described in the literature and certainly contributed to the delay in diagnosis.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe study was approved by the Research Ethics Committee of the Clinical Hospital (HC-FMUSP) (CAPPesq #3.258.615, CAAE protocol number: 10248419.7.0000.0068). Informed consent was obtained from the patient\u0026rsquo;s family.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical case description\u003c/h2\u003e \u003cp\u003eA male patient, 67 years old, smoker, hypertensive, dyslipidemic, lifelong living in the urban area of Pirapora do Bom Jesus, in Sao Paulo State, Brazil (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The municipality is located in a valley on the banks of the Tiet\u0026ecirc; River, an endemic region for PCM, with an average annual temperature of 18\u0026ndash;22\u0026ordm;C, subtropical climate, and humidity of 54%. He worked in the food services industry within the urban area of the city. His hobby was frequent freshwater fishing in this endemic region.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Timeline of the paracoccidioidomycosis infection in a patient with arteritis and thrombosis of the iliac artery. (\u003cb\u003eA\u003c/b\u003e) Schematic figure containing the diagnostic points, harvesting, and symptoms over time; (\u003cb\u003eB\u003c/b\u003e) Highlight the state of S\u0026atilde;o Paulo within Brazil, showing the location of the City of Pirapora do Bom Jesus within the State of S\u0026atilde;o Paulo, and also highlighting the Tiet\u0026ecirc; River where several fishing farms are located; We used R software, geobr package, (MIT license \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ipeagit.github.io/geobr/\u003c/span\u003e\u003cspan address=\"https://ipeagit.github.io/geobr/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) to create the maps produced to visualize the spatial location of the atypical paracoccidioidomycosis case. RD\u0026thinsp;=\u0026thinsp;respiratory distress; ICU\u0026thinsp;=\u0026thinsp;intensive care unit.\u003c/p\u003e \u003cp\u003eSince March 2019, he reported pain in his right lower leg and weight loss, without a history of trauma or perforating lesions. The patient had undergone computed tomography (CT) and biopsy during hospitalization at the secondary referral hospital close to his hometown. CT showed lytic lesions in the right femur suggestive of sarcoma. However, the biopsy showed a chronic inflammatory process and tissue necrosis with unspecified fungi. No specific treatment was administered. Pain in the right lower limb (RLL) worsened with pain onset also in the left lower limb (LLL), associated with non-fixed cyanosis and limb paralysis. Doppler ultrasonography revealed an intra-abdominal occlusion of the inguinal vessels.\u003c/p\u003e \u003cp\u003eOn August 21, 2019, upon admission to the tertiary Hospital das Clinicas of the Faculty of Medicine of Sao Paulo, a physical examination revealed cyanosis, reduced lower limb pulses, and absent femoral pulses. Angiography and magnetic resonance imaging showed partial occlusion of the infrarenal abdominal aorta, extending to the common, internal, and external iliac arteries. There was also an intraosseous abscess, deep collections of the adjacent muscles, and bursitis of the psoas bilaterally. On August 22, 2019, a chest CT scan was performed and showed multiple nodules distributed in both lungs, interpreted as septic embolism. An echocardiogram did not show cardiac vegetation as a possible focus of septic embolization of the lungs. A full anticoagulation regimen and antibiotic therapy (ceftriaxone and clindamycin) was initiated for the treatment of osteomyelitis.\u003c/p\u003e \u003cp\u003eRegarding the detection and identification of bacteria, culture tests for anaerobes and aerobes were carried out on the right femur lesion and peripheral blood during hospitalization with negative results (08/22/2019; 09/02/2019; 09/03/2019). In addition, during admission, the direct test for acid-fast bacilli (Ziehl-Nielsen) of a biopsy of the right femur lesion was negative (02/09/2019); cultures for mycobacteria and fungi (biological material obtained from the biopsy of the right femur and peripheral blood) were negative (09/02/2019). A rectal swab was also tested for carbapenem-resistant Enterobacteria (09/03/2019) with negative results. The bacterioscopic examination of the biopsy of the right femur (09/02/2019) showed no microorganisms and only rare polymorphonuclear leukocytes.\u003c/p\u003e \u003cp\u003eLaboratory exams at admission revealed a hemoglobin of 9.7 g/dl (12\u0026ndash;15 g/dl), mild anisocytosis, total leukocytes of 19.8 (5\u0026ndash;10 x 10\u003csup\u003e3\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e), with 85% segmented cells (52\u0026ndash;72%) and without left deviation; lymphocytes were 990 cells/mm\u003csup\u003e3\u003c/sup\u003e (100\u0026ndash;3000 cells/mm\u003csup\u003e3\u003c/sup\u003e); C-reactive protein was 320 (\u0026lt;\u0026thinsp;5.0 mg/L). Laboratory results at various times after presentation are in the Supplementary Appendix. The patient\u0026rsquo;s right lower limb pain progressed, and he developed a fistulizing orifice with drainage of purulent material, requiring progressively higher doses of opioids.\u003c/p\u003e \u003cp\u003eOn August 31, the patient developed acute respiratory failure and retrosternal chest pain, with symptomatic improvement after diuretic treatment and non-invasive ventilation. On September 2, he underwent an uneventful CT-guided biopsy of a lesion in the right femur (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). On the same day, he experienced significant respiratory distress, requiring intensive care unit admission. Antibiotic therapy was increased to meropenem plus vancomycin, beyond of amphotericin B for treatment of possible fungal infection. He died on September 3rd .\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAutopsy findings\u003c/h3\u003e\n\u003cp\u003eThe autopsy revealed disseminated PCM, with a granulomatous reaction associated with numerous yeasts compatible with \u003cem\u003eParacoccidiodes\u003c/em\u003e spp. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The fungi were present in the skin of the LL, lungs (forming cavitations), aorta and right iliac artery, prostate, lymph nodes, spleen, and femur. The biopsy performed one day before death confirmed the presence of PCM in the femur. There was a 9.2 cm organized thrombus of the distal aorta, extending from the infrarenal artery to the iliac bifurcation, especially at the right iliac artery, and ischemic necrosis of all five toes in the right foot. Additional findings were bronchopneumonia with exudative diffuse alveolar damage (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), acute tubular necrosis, cerebral congestion, lymphoid hypoplasia in the spleen, and generalized atherosclerosis. A microscopic (\u0026lt;\u0026thinsp;5 mm) pancreatic adenocarcinoma was an unexpected finding.\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Systemic paracoccidioidomycosis with arteritis and thrombosis of the iliac artery: (\u003cb\u003eA\u003c/b\u003e) Multiple lytic lesions in the right femur, with periosteal reaction (radiography); (\u003cb\u003eB\u003c/b\u003e) Deep abscess in the right thigh, associated with femoral lytic lesions (RNM); (\u003cb\u003eC\u003c/b\u003e) Ischemia of the right thigh; (\u003cb\u003eD\u003c/b\u003e) Fistula on the lateral area the right thigh, associated with osteomyelitis and soft tissue abscess by \u003cem\u003eParacoccidioides\u003c/em\u003e; (\u003cb\u003eE\u003c/b\u003e) Right toe ischemia; (\u003cb\u003eF\u003c/b\u003e) Atherosclerotic aorta with thrombus occluding right iliac artery (arrow); (\u003cb\u003eG-I\u003c/b\u003e) Organized mycotic thrombus within the right iliac artery, with numerous yeasts (arrow, G, HE), compatible with \u003cem\u003eParacoccidioides spp\u003c/em\u003e (arrow, H and I, Grocott). The yeasts are round, wide size range, and multiple budding (I, insets); (\u003cb\u003eJ-K\u003c/b\u003e) Pulmonary nodules, with central necrosis (J, arrow), corresponding to granulomas with \u003cem\u003eParacoccidioides spp\u003c/em\u003e forms (K, arrow). Exudative diffuse alveolar damage is associated (K, asterisk).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory and phylogenetic investigation \u0026ndash; postmortem\u003c/h2\u003e \u003cp\u003eConfirmation of the identification of the fungal pathogen, \u003cem\u003eParacoccidioides brasiliensis\u003c/em\u003e, was possible only postmortem by serologic and sequencing analysis. Sequencing and mycological analysis from samples obtained from lung and skin lesions revealed co-infection with other fungal pathogens \u003cem\u003eApiotrichum montevideense\u003c/em\u003e and \u003cem\u003eCandida albicans\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMycological analysis\u003c/b\u003e. Skin and lung tissue fragments were inoculated into Sabouraud-dextrose agar, Brain-Heart Infusion, Mycobiotic agar (Difco Laboratories, Detroit, MI), and Tryptone Soya broth (Oxoid, London, England), incubated at 25\u0026deg;C and 37\u0026deg;C and monitored for 45 days. Positive yeast cultures were placed on CHROMagar Candida medium (CHROMagar, Paris, France) for presumptive species identification. Micromorphological analysis did not identify \u003cem\u003eParacoccidioides spp\u003c/em\u003e, only \u003cem\u003eCandida\u003c/em\u003e spp. and \u003cem\u003eTrichosporon\u003c/em\u003e isolates [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Culture at 37\u0026ordm;C on Brain-Heart Agar revealed a birefringent globose yeast-like form, with multiple budding (1\u0026ndash;3) of small base linked to the large mother cell, micromorphology on corn meat at 25\u0026ordm;C confirmed \u003cem\u003eTrichosporon\u003c/em\u003e spp.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. \u003cb\u003eA and D\u003c/b\u003e - \u003cem\u003eTrichosporon\u003c/em\u003e spp. Micromorphology from the culture of lung and skin autopsy, respectively, cultured at 37\u0026deg;C. Birefringent globous yeast-like form, with multiple budding (1\u0026ndash;3) of small base linked to the large mother cell. We observed the presence of integral and fragmented hyphae pseudohyphae and blastoconidia in \u003cb\u003eD\u003c/b\u003e. \u003cb\u003eB and E\u003c/b\u003e \u0026ndash; Micromorphology on corn meal agar at 37\u0026deg;C. Micromorphology from lung and skin culture, respectively. We observed hyphae with arthrospore, lateral, and intercalary blastoconidia. There is disarticulation of hyphae in arthroconidia, with lateral and terminal blastoconidia. \u003cb\u003eC\u003c/b\u003e and \u003cb\u003eF\u003c/b\u003e: Micromorphology from culture on corn meal agar at 28\u0026deg;C, lung and skin autopsy, respectively. We observed the presence of both hyphae disarticulation into arthroconidia with lateral and terminal blastoconidia.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSerological analysis\u003c/b\u003e. In sera samples, PCM was also confirmed by double immunodiffusion (DID) and immunoblotting (IBB) tests [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], using culture-filtered antigen from the yeast \u003cem\u003eP. brasiliensis\u003c/em\u003e 113 (Pb-113) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These tests use a 43 kDa glycoprotein (gp43) as the primary antigen of the \u003cem\u003eP. brasiliensis\u003c/em\u003e complex to detect circulating antibodies with sensitivities between 85% and 100%. The DID and IBB assays in sera showed reactivity to the \u003cem\u003eP. brasiliensis\u003c/em\u003e antigen. Antibodies at 1:32 dilution were detected by semi quantitative analysis [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Immunoblotting with the Pb113 antigen (AgPb113) showed positivity for antibodies against gp43 and 70 kDa [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eSequencing analysis\u003c/b\u003e.The DNA was extracted from patient samples obtained at autopsy, according to Erjef\u0026auml;lt et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The presence of amplifiable DNA was confirmed by nested PCR of a fragment of the human glyceraldehyde-3-phosphate dehydrogenase gene (GADPH; GenBank: J04038.1), as described by Escolani et al. in 1988 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For the detection of pathogenic fungi, conventional PCR was performed using primers specific for the 28S to 18S regions of the rRNA gene and gp43 specific for PCM, as described by White et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Bialek et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Samples positive for fungi were submitted to sequencing analysis using the Sanger method. To perform the gp43 assembly, and phylogenetic analysis, the obtained reads for the \u003cem\u003eP. brasiliensis\u003c/em\u003e gp43 gene from skin and lung tissue samples were combined to produce two distinct consensus sequences (skin and lung) for the gp43 gene of \u003cem\u003eP. brasiliensis\u003c/em\u003e. Briefly, to assemble the consensus sequences we used the Trace assembly module of the Tracy version 0.5.3 program [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], using the local operation reference-guided trace assembly (using as reference the sequence #AB304681). The output file with the aligned reads from Tracy was converted into a consensus sequence for each source tissue (skin and lung) using the EMBOSS Cons (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://emboss.open-bio.org/rel/dev/apps/cons.html\u003c/span\u003e\u003cspan address=\"http://emboss.open-bio.org/rel/dev/apps/cons.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eYeast isolates obtained from lung and skin tissues were sequenced using internal transcribed spacer primers (5.8rDNA-ITS region), and the lung tissue isolates were identified as \u003cem\u003eTrichosporon montividense\u003c/em\u003e with 99% similarity (MT322616) and \u003cem\u003eCandida albicans\u003c/em\u003e with 100% similarity (MT322617). The skin tissue isolates were identified as \u003cem\u003eTrichosporon montividense\u003c/em\u003e with 100% similarity (MT322618).\u003c/p\u003e \u003cp\u003eIn fresh frozen samples and paraffin tissue sections (FFPE) using different tissues (skin and lung), the results of identification with the species-specific primer of the gp43 gene identified \u003cem\u003eParacoccidioides brasiliensis\u003c/em\u003e and the sequences were deposited in GenBank under accession numbers MT346581 and MT346580, respectively. We used the recently revised classification of the genus \u003cem\u003eParacoccidioides\u003c/em\u003e as a model to classify the sequences obtained in the present study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The dataset was aligned using MUSCLE version 3.8.1551, multiple sequence alignment with high accuracy and high throughput. A phylogenetic tree was reconstructed based on curated \u003cem\u003eP. brasiliensis\u003c/em\u003e gp43 gene sequences using the Maximum Likelihood (ML) method implemented in IQ-Tree2 version 2.0.7 (26) with automatic model selection by ModelFinder and using the Bayesian Information Criterion (BIC) (27). The tree was displayed with FigTree version 1.4.3 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003etree.bio.ed.ac.uk/software/figtree/\u003c/span\u003e). All the datasets analyzed during the current study are available from the corresponding author upon reasonable request. Phylogenetic inference using partial gp43 sequences showed that the two sequences clustered in the \u003cem\u003eP. brasiliensis\u003c/em\u003e complex (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. A and B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Phylogenetic analysis of \u003cem\u003eP. brasiliensis\u003c/em\u003e associated with a fatal human case. The maximum likelihood phylogenetic tree of the genus Paracoccidioides was based on partial \u003cem\u003egp43\u003c/em\u003e gene sequences (n\u0026thinsp;=\u0026thinsp;75). The black circles represent the bootstrap support values, and their sizes vary according to the support value (0 to 100). The black triangles highlight the samples characterized here from the atypical case of PCM, where the two samples cluster with sequences characterized as \u003cem\u003eP. brasiliensis\u003c/em\u003e complex.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003eWe report here the case of an elderly man with rare manifestations of chronic PCM who presented with lung lesions, femoral osteomyelitis, abdominal lymphadenitis, and aortitis leading to iliac artery thrombosis. The initial presentation of the infection was lower extremity symptoms, which contributed to the delay in diagnosis. There are rare descriptions of PCM involving the osteoarticular system or large vessels such as the aorta and iliac arteries. It is possible that the progression of the femoral infection, forming a perilesional abscess, caused fungal arteritis of the lower aorta and iliac arteries with thrombosis formation, causing the ischemia in the right leg. Interestingly, the autopsy revealed pancreatic adenocarcinoma, which may have predisposed to the thrombotic phenomena. In this case, the autopsy was crucial for the final diagnosis. To our knowledge, this is the first description of both manifestations occurring in the same patient.\u003c/p\u003e\n\u003cp\u003eAlthough PCM disease is common and endemic in Brazil, there are no recent descriptions of vascular involvement as in the present case. Less than 10 cases have been described in the literature, with the last report dating from 1998 [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. In all reports, the patients were adults, and the diagnosis was delayed or made only at autopsy. PCM aortitis was confused with arteriosclerotic manifestations, leading to a lack of early clinical suspicion, and delayed or no specific treatment. In 1996, Manns et al [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] described the case of a 59-year-old man with PCM who presented with the first symptoms of hematogenous origin 15 years after leaving South America. This patient\u0026apos;s presentation illustrates the difficulty in suspecting PCM in patients without an adequate travel history who present with weight loss and pulmonary, mucosal, and cutaneous lesions.\u003c/p\u003e\n\u003cp\u003eOsteoarticular PCM is also rarely described. The few studies addressing this report the bone infection occurring frequently in children or younger adults, in the acute/subacute phase of the disease [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Most of the described cases come from Brazil. One of the hypotheses described by Sevarese et al. [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] would be the fact that usually skin lesions and pulmonary involvement dominate the presentation when PCM is diagnosed, without an active and systematic search for bone lesions.\u003c/p\u003e\n\u003cp\u003eIn this patient, microscopic adenocarcinoma of the pancreas was diagnosed at autopsy. Concomitant PCM and solid tumors have been reported in 0.16 to 11% of PCM cases [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Most of the tumors are respiratory or gastrointestinal cancers, sometimes at the same site of infection. It is not known whether predisposing factors such as smoking and alcoholism are common to both conditions, or whether PCM may be an additive factor for cancer development due to chronic antigenic stimulation of epithelial cells [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. In this case, the extent to which the pancreatic adenocarcinoma contributed to the thrombotic phenomena is not known. In other cases, PCM may mimic a solid malignancy, again leading to diagnostic delay [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAlthough classical laboratory techniques provide valuable information by visualizing the fungal pathogen \u003cem\u003eParacoccidioides\u003c/em\u003e spp, they do not have a significant discriminatory power on the type of species. Several PCR-based methods can detect polymorphisms in the DNA of \u003cem\u003eParacoccidioides\u003c/em\u003e and thus support species identification, mainly sequencing and taxonomic analysis, allowing the location of the strain as originating from the endemic region of Sao Paulo, \u003cem\u003eP. brasiliensis\u003c/em\u003e complex [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. The results of the phylogenetic reconstruction using gp43 sequences confirmed the diagnosis of the etiologic agent, and the grouping of the two sequences obtained from different tissues suggested a systemic infection. The long latency period before the first signs of PCM infection appear complicates efforts to trace clinical symptoms to events associated with initial exposure. In this environment, fungal sexual reproduction and competitive selection increase, with a greater likelihood of the emergence of more virulent variants [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our hypothesis is that these sequences may be related to PCM survival strategies in saprophytic or specific host immunity, justifying the atypical clinical profile. In addition, PCM sequences contribute to the updating of maps identifying endemic fungal regions, which may improve global PCM surveillance. According to the World Health Organization, paracoccidioidomycosis is a neglected mycosis [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eA limitation of our study is that \u003cem\u003eParacoccidioides\u003c/em\u003e spp. were not isolated from the patient\u0026apos;s cultured specimens. However, the fungus was identified by histological analysis and sequenced using fresh frozen samples and FFPE from various tissues. \u003cem\u003eT. montividense\u003c/em\u003e and \u003cem\u003eC. albicans\u003c/em\u003e were also detected and identified by culture and confirmed by sequencing. It is possible that these faster growing pathogens may have inhibited the growth of \u003cem\u003eP. brasiliensis\u003c/em\u003e in culture by competing for nutrients, explaining our negative results.\u003c/p\u003e\n\u003cp\u003eOur methods allowed us to identify other fungal pathogens that may have contributed to the severity of the disease that are not commonly described. Disseminated trichosporonosis is known to be an intrahospital opportunistic mycosis with high mortality. \u003cem\u003eT. montividense\u003c/em\u003e is an invasive fungus commonly associated with the insertion of central venous catheters, urinary catheters, and catheter-related peritoneal devices [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. The ability to adhere and form biofilms on implanted devices may be responsible for the progression of invasive trichosporonosis, as it can promote antifungal drug leakage and alter the host immune response [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]. Trichosporonosis is often difficult to diagnose at autopsy because the causative species of Trichosporon are pathologically similar to other fungi, particularly \u003cem\u003eCandida\u003c/em\u003e species.\u003c/p\u003e\n\u003cp\u003eThe results of our study should raise the clinical suspicion of PCM and lead to more rational and precise anti-infective treatments, especially for patients who are difficult to diagnose by conventional methods. This will have a positive impact on risk. Although relatively rare, endemic systemic mycoses should also be a potential for travelers, whether international or not. Epidemiologic exposures can guide diagnostic evaluation and treatment.\u003c/p\u003e\n\u003cp\u003eThe GeoSentinel website for clinical surveillance of travel-related diseases in international travelers and migrants does not present data on PCM (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.istm.org/geosentinel\u003c/span\u003e\u003c/span\u003e). One of the reasons for this omission is the lack of knowledge about PCM for clinical and laboratory identification. Although it is not possible to associate the infection with travel habits, our patient had a hobby of frequently fishing in an endemic area, i.e., the wetlands along the Tiet\u0026ecirc; River in S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\n\u003cp\u003eThe present report describes a rare, undiagnosed form of chronic PCM with osteoarticular involvement of the femur, aortitis, and iliac artery thrombosis in an elderly man with frequent contact with wetlands in an endemic area along the Tiet\u0026ecirc; River, region of S\u0026atilde;o Paulo, Brazil. Increased awareness of the transmission sites and different clinical presentations of this neglected tropical disease may lead to improved patient management.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAbbreviation\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMeaning\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePCM\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eParacoccidioidomycosis\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRLL\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eright lower limb\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLLL\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eleft lower limb\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCT\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eComputerized tomography\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGenbank\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eGenBank \u0026reg; is the NIH genetic sequence database\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDID\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003edouble immunodiffusion\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIBB\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eImmunoblotting\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGep43 gene\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e43-kDa-glycoprotein\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: The authors thank all physicians and residents of the Pathology Department who participated in the autopsy procedures, all technicians in our histology laboratory, and the patient\u0026rsquo;s relatives who agreed to the autopsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;ANDN.:\u003c/strong\u003e Conceptualization, Investigation, Resources, Writing - Original Draft, Writing - Review \u0026amp; Editing, Visualization, Supervision, Project administration.\u003cstrong\u003e\u0026nbsp;KCD.:\u003c/strong\u003e Conceptualization, Methodology, Validation, Formal analysis, Resources, Investigation, Writing - Original Draft. \u003cstrong\u003eSCF.\u003c/strong\u003e: Methodology, Validation, Formal analysis, Investigation, Writing - Original Draft. \u003cstrong\u003eRSFX.:\u0026nbsp;\u003c/strong\u003eMethodology, Validation, Formal analysis, Investigation, Resources, Writing - Original Draft. \u003cstrong\u003eAPV.:\u003c/strong\u003e Methodology, Validation, Formal analysis, Investigation, Resources, Writing - Original Draft. \u003cstrong\u003eAMJ.:\u003c/strong\u003e Writing - Original Draft. \u003cstrong\u003eLFFS.\u003c/strong\u003e: Resources, Writing - Original Draft. \u003cstrong\u003ePHNS.:\u0026nbsp;\u003c/strong\u003eResources, Writing - Original Draft. \u003cstrong\u003eMD.:\u0026nbsp;\u003c/strong\u003eResources, Writing - Original Draft. \u003cstrong\u003eMPC.:\u003c/strong\u003e Formal analysis, Investigation, Writing - Original Draft. \u003cstrong\u003eTM.:\u0026nbsp;\u003c/strong\u003eResources, Writing - review \u0026amp; editing, Supervision, Funding acquisition. All authors have read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This study has received funding from S\u0026atilde;o Paulo Research Foundation (FAPESP) #2013/17159‐ 2. Funder https://doi.org/10.13039/501100001807; Bill and Melinda Gates Foundation #INV‐002396. Funder https://doi.org/10.13039/100000865; Bolsa de produtividade em pesquisa: Conselho Nacional de Desenvolvimento Cient\u0026iacute;fico e Tecnol\u0026oacute;gico #304987/2017-4 \u0026mdash; Marisa Dolhnikoff. MPC was supported by FAPESP \u0026ndash; grant number #2019/24518-5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the datasets analyzed during the current study are available from the corresponding author on reasonable request. The new sequence here characterized was deposited in GenBank under the accession number MT346581 and MT346580.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of the Clinical Hospital (HC-FMUSP) (CAPPesq #3.258.615, CAAE protocol number: 10248419.7.0000.0068). Informed consent was obtained from the patient\u0026rsquo;s family.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e: Written informed consent has been obtained from the patient\u0026rsquo;s parents to publish this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e: All authors read and approved the final manuscript. The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained for publication of this study by the patient\u0026rsquo;s family members.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript. The authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO fungal priority pathogens list to guide research, development and public health action. World Health Organization 2022. https://www.who.int/publications/i/item/9789240060241.\u003c/li\u003e\n\u003cli\u003eMartinez R. Epidemiology of Paracoccidioidomycosis. 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Ann Hepatol. 2019; 18(1):258-262. doi: 10.5604/01.3001.0012.7935. PMID: 31113602.\u003c/li\u003e\n\u003cli\u003e: Ghani A, Weinberg M, Pathan N, Vidhun R, Sieber S. \u003cem\u003eParacoccidioides brasiliensis\u003c/em\u003e Infection Mimicking Recurrent Hodgkin Lymphoma: A Case Report and Review of the Literature. Mycopathologia. 2018; 183(6):973-977. doi: 10.1007/s11046-018-0252-y. Epub 2018 Feb 23. PMID: 29476307.\u003c/li\u003e\n\u003cli\u003ePinheiro BG, Hahn RC, Camargo ZP, Rodrigues AMP. Molecular Tools for Detection and Identification of Paracoccidioides Species: Current Status and Future Perspectives. J. Fungi 2020; 6: 0293. doi:10.3390/jof6040293. \u003c/li\u003e\n\u003cli\u003eVilela R, de Hoog S, Bensch K, Bagagli E, Mendoza L. A taxonomic review of the genus Paracoccidioides, with focus on the uncultivable species. PLoS Negl Trop Dis. 2023; 17(4): e0011220. https://doi.org/10.1371/journal. pntd.0011220.\u003c/li\u003e\n\u003cli\u003eBagagli E, Theodoro RC, Bosco SMG, McEwen JG. \u003cem\u003eParacoccidioides brasiliensis\u003c/em\u003e: phylogenetic and ecological aspects. Mycopathologia. 2008; 165: 197\u0026ndash;207. doi: 10.1007/s11046-007-9050-7. \u003c/li\u003e\n\u003cli\u003ede Macedo PM, Freitas DFS, Varon AG, Lamas CDC, Ferreira LCF, Freitas AD, Ferreira MT, Nunes EP, Siqueira MM, Veloso VG et al. COVID-19 and acute juvenile paracoccidioidomycosis coinfection. PLoS Negl. Trop. Dis\u003cem\u003e.\u003c/em\u003e 2020; 14: e0008559. https://doi.org/10.1371/journal.pntd.0008559.\u003c/li\u003e\n\u003cli\u003eDuarte-Oliveira C, Rodrigues F, Gon\u0026ccedil;alves SM, Goldman GH, Carvalho A and Cunha C. The Cell Biology of the Trichosporon-Host Interaction. Front. Cell. Infect. Microbiol. 2017; 7:118. doi: 10.3389/fcimb.2017.00118.\u003c/li\u003e\n\u003cli\u003eMehta V, Nayyar C, Gulati N, Singla N, Rai S, Chandar J. A Comprehensive Review of Trichosporon spp.: An Invasive and Emerging Fungus. Cureus. 2021; 13(8): e17345. doi: 10.7759/cureus.17345.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"osteomyelitis, aortic arteritis, thrombosis, systemic paracoccidioidomycosis, autopsy","lastPublishedDoi":"10.21203/rs.3.rs-3822139/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3822139/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParacoccidioidomycosis (PCM) is a neglected deep mycosis caused by \u003cem\u003eParacoccidioides\u003c/em\u003e sp. We describe a fatal PCM case, presenting as osteomyelitis, in a man having frequent contact with an endemic region of S\u0026atilde;o Paulo, Brazil.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 67-year-old man who lived in an urban area, had frequent fishing trips to an endemic region. He presented with osteomyelitis of the femur and iliac artery thrombosis at hospital admission. Thoracic CT revealed multiple cavitated lung nodules. The patient rapidly progressed to irreversible respiratory failure. The autopsy revealed disseminated PCM and thrombosis of the iliac artery. Laboratory investigation confirmed a \u003cem\u003eP. brasiliensis\u003c/em\u003e infection with phylogenetic results revealing sequences recovered from patient samples grouped with sequences characterized as \u003cem\u003eP. brasiliensis\u003c/em\u003e complex.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAtypical PCM remains a diagnostic challenge. Increased awareness of contagion sites and different clinical presentations will lead to improved patient management.\u003c/p\u003e","manuscriptTitle":"Osteomyelitis and Aortic Arteritis with thrombosis as primary manifestations of systemic paracoccidioidomycosis: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-08 17:13:28","doi":"10.21203/rs.3.rs-3822139/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd3c5499-1fc8-4b47-a41c-d0356ca68468","owner":[],"postedDate":"January 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-27T10:29:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-08 17:13:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3822139","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3822139","identity":"rs-3822139","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}