Paracoccidioidomicose pulmonar como diagnóstico diferencial de nódulo pulmonar solitário: um estudo de caso

Abstract

Introduction: Paracoccidioidomycosis (PCM) is one of the main human mycoses, with fungi of the genus Paracoccidioides as the etiological agent, with a wide variety of clinical and radiological presentations. Case report: Male patient, 63 years old, former alcoholic with a previous diagnosis of chronic parenchymal liver disease, hospitalized due to clinical decompensation. Abdominal imaging tests were compatible with a diagnosis of hepatocellular carcinoma (HCC). The attending team began to assess the feasibility of liver transplantation, at which time the patient underwent imaging tests of other sites to investigate metastatic disease. Computed tomography (CT) of the chest identified a spiculated pulmonary nodule, measuring 22 x 15 x 12 mm, in the anterior segment of the right upper lung lobe, suspicious for neoplasia. A percutaneous transbronchial biopsy guided by tomography was performed, and the anatomopathological study revealed a chronic granulomatous inflammatory process, without necrosis, with the presence of fungal cells with cryptosporulation identified as P. brasiliensis. Triazole therapy was initiated, with itraconazole chosen at a dose of 100 mg/day, with a treatment duration expected for 6 months. Subsequent consultations were scheduled for early reassessment and monitoring for adverse effects and hepatotoxicity. Discussion: PCM presents diverse clinical presentations, ranging from acute/subacute disease, which can present as multisystem involvement with constitutional symptoms and shock, to chronic disease, which can be oligosymptomatic or even asymptomatic, sometimes with incidental diagnosis. In its chronic form, it typically presents as a lung infection, and may assume different imaging patterns on chest radiography, which may mimic neoplastic and lymphoproliferative conditions, as well as other infectious conditions. We highlight a case of chronic PCM with lung involvement with radiological translation suggestive of neoplastic disease. Conclusion: in endemic areas, such as Brazil, when pulmonary nodules are found, it is important to have a high level of suspicion for fungal disease, even in patients who share multiple risk factors for oncological disease. In the case reported here, the identification of Paracoccidioides in the pulmonary nodule, with exclusion of neoplasia in the sample examined, implied in the decision of the multidisciplinary team regarding the indication of liver transplantation for treatment of the underlying clinical condition.