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).