The control laboratory tests after three days of treatment showed a decrease in peripheral eosinophilia and thrombocytosis, in the levels of bilirubin and liver transaminases, until their normalization.
He was discharged stable, afebrile and asymptomatic with referral for follow-up.
DISCUSSION
Brazil is responsible for 80% of PCM cases in Latin America and has a heterogeneous distribution with endemic areas, being considered a neglected disease and a public health problem. (1,2,9).
The literature points to an increase in cases in non-endemic areas and countries in recent years, related to the contamination during visits to endemic regions (10,11).
Although isolated lymphadenopathy is more common in acute cases of the disease, our patient has epidemiological data on the chronic and most common form of the disease (74 to 96%) with slow and progressive clinical evolution pattern (1,3,9). The clinical condition is commonly associated with significant weight loss (72%), asthenia (65%), mucocutaneous pallor (62%), fever (51%), cough (50%), dysphonia, dysphagia, odynophagia, and in lower frequency, ulcerations in the mouth and throat (9). The main sites of involvement are the lungs (90%), the skin and mucous membranes, the lymph nodes, with lymph node enlargement (79%), and, less frequently, adrenals (50%), and digestive, bone (20%) and central nervous (25%) systems (1,2,9).
The chronic PCM lymph node involvement with its enlargement, may present itself with suppurative, and/or cancer-like features (9). Some lymph nodes may be superficial, with involvement of the cervical, submandibular, submental, supraclavicular, axillary and inguinal chains. The deep involvement of structures usually affects the intra-abdominal segment (9).
In the latter situation, the disease can present as a mass effect compressing a wide range of organs and structures, depending on its site.
Thus it can evolve with several clinical syndromes such as cholestasis, due to biliary tracts obstruction, pancreatitis, due to the pancreatic duct obstruction, chylous ascites, due to the thoracic duct compression, pyelonephritis and acute renal failure, due to the ureters compression, and malabsorption syndrome and acute abdomen, due to intestinal compression (4,9).
In the present case, Our patient presented a cholestatic syndrome resulting from extrinsic compression of the common bile duct by mesenteric lymph node enlargement in the hepatic hilum, peripancreatic and periaortic regions, evolving with cholestatic jaundice syndrome.
The performed imaging exams (US of the abdomen, MRI of the upper abdomen with cholangio-MRI, ERCP and CT of the abdomen and pelvis) showed evidence of extrinsic compression and suspicion of malignant neoplasm of the pancreas head with lymph node involvement. However, the neoplastic diagnosis was ruled after the laparoscopic biopsy findings of chronic fungal granulomatous lymphadenitis due to paracoccidioidomycosis.
The PCM gold standard diagnostic procedure is the fresh analysis of the sputum or other clinical sample and/or biopsy, with histopathological analysis of the affected organ, wich allows the visualization of fungal structures suggestive of Paracoccidioides spp. (1,2,7,10,12,13).
For the mild and moderate form of PCM, the first line of treatment is with daily 200 mg oral-Itraconazole (1,2,6,7,11,14,15). The length of treatment ranges from 6 to 12 months with periodic reassessments to verify the cure criteria that allow the withdrawal of the medication (1,7). After the treatment begins, the regression of symptoms differs according to the site of involvement, with lymphadenopathies regressing in two to three months and imaging exams becoming normal around six months (1).
The length of drug-treatment must be guided by the patient’s healing criteria, which involves clinical, mycological, radiological and immunological criteria. The definitive cure is not viable due to the impossibility of eradicating P. brasiliensis and P. lutzii from the human body. Therefore, the main objective of the treatment is to allow an improvement in cellular immunity by reducing the fungal load to re-establish a balance between parasite and host. (1,12,15).
CONCLUSION
The description of PCM simulating a malignant pancreatic neoplasm with jaundice in an immunocompetent patient is extremely rare to find in the scientific literature. We presented a case of atypical presentation of a condition poorly diagnosed in clinical practice. PCM should be considered as a differential diagnosis of abdominal obstructive syndromes due to supposed tumoral events. The guided biopsy might be a valuable diagnostic procedure in such cases.
This case report demonstrate the importance of the comprehension of PMC on its various presentation forms. This knowledge allowed an early diagnosis, treatment and follow-up, ruling out the hypothesis of a gloomy prognosis neoplasm.