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.