AUTHORS: MATHEUS LOPES PULS; DANIEL PEDRO CASTELO BRANCO LOPES; FLÁVIO AUGUSTO BARBIERI; CIBELE REPELE DUCH; HENRIQUE LUIZ CARRASCOSSI; MARIANE ARANJUES MONTORO; LÍDIA GOMES DE MOURA; GIULIA LIA DUARTE; MATHEUS ROSSI LIMA PERUGINI.
INTRODUCTION:
Paracoccidioidomycosis (PCM) is a potentially systemic fungal infection caused by the thermodimorphic species Paracoccidioides brasiliensis (P. brasiliensis) and Paracoccidioides lutzii (P. lutzii) (1–3).
PCM is considered an endemic condition in Latin America, where 80% of the cases are concentrated in Brazilian territory, mainly in the states of São Paulo, Paraná, Rio Grande do Sul, Goiás and Rondônia (1,3). It is considered the eighth cause of mortality by chronic infectious and parasitic desease and, among systemic mycoses, the main reason for hospital admissions (1,2).
Among the main contamination risk factors, ocupational areas related to agricultural activities and fungus contaminated soil handling are included, presenting high prevalente on rural workers (1,2). Smoking, alcoholism and immunodeficiency or immunosuppression states are also related factors (1).
The disease acute/subacute form, also called juvenile, is less frequent, occuring in 5-25% of the cases and generally associated to the desease endemic areas. The incidence on both genres is equal and occurs mainly within the first two decades of life, and after 40 years of age (1,4–8).
The chronic form is responsible for up to 96% of the cases, affecting mainly males (1,6,9,10). The lungs are affected in up to 90% of the cases, and mucous membranes and skin are other common foci (1).
The aim of this study is to present a PCM clinical case that simulated a pancreatic cancer with jaundice, cholestasis and significant weight loss.
CASE REPORT:
A 61-year-old male patient, born and residing in the state of São Paulo, a rural worker in a lemon plantation from childhood. The patient sought medical care at an external health service due to a complaint of jaundice that started 2 months before, with a weight loss of 20 kg during this period. He reported that the symptoms were presented in rapid progression, associated with fecal acolia, choluria, intense itching and sporadic pains in the right hypochondrium.
A smoking patient (43 packs/year), previously obese (BMI 33.95), with a previous inguinal right herniorrhaphy surgery. He reported allergy to dipyrone and penicillin and denied alcoholism, use of illicit drugs and other comorbidities. There was no history of relevant family or hereditary illnesses. The pacient was not taking any continuous use medication.
On physical examination, the patient presented a regular general condition, ruddy, hydrated, jaundiced 2+/4+, acyanotic, eupneic in room air and afebrile to the touch. His cardiac auscultation had two rhythmic and hypophonetic sounds, with no audible murmurs, and a respiratory rate within the normal range. The abdomen was globose, flaccid, with present air-fluid noises, painless to superficial and deep palpation, without visceromegalies, without visceromegalies, palpable masses and signs of peritonitis. No further alterations were found.
In an external health service, an ultrasound study of the total abdomen was performed. The exam presented evidences of intra and extrahepatic bile duct dilatation without visualization of cholelithiasis, with a 1.0 cm diameter common bile duct, mild splenomegaly, diffuse periaortocaval lymph node enlargement and a nodular lesion of approximately 4 cm in the head of the pancreas.
A nuclear magnetic resonance with contrasted cholangiography visualized a solid nodular formation, peripancreatic, with extension to the duodenal papilla, measuring approximately 3.6 cm - suspicious for a primary neoplastic process with distally compression of the bile duct – and significant extra and intrahepatic bile duct upstream dilation associated with multiple heterogeneous lymph node enlargement in the retroperitoneum and mesentery, sometimes confluent, some with a necrotic center, compatible with secondary nodal involvement.
Due to the clinical condition and the results of the imaging exams, an endoscopic retrograde cholangiopancreatography (ERCP) was chosen for biliary decompression with an 8.5 FR prosthesis at an external health service.
The ERCP report showed an image of extensive stenosis in the middle and distal bile ducts, raising the suspicion of extrinsic compression due to pancreatic head neoplasm and dilated intrahepatic biliary tracts (Figure 1).