Boletín Micológico Vol. 10 (1-2): 63-66 1996

PULMONARY IN THE PNEUMOLOGY UNIT OF GENERAL HOSPITAL IN RECIFE (BRASIL). IJ

Paracoccidioidomicosis pulmonar en la .unidad de neumología de un hospital general en Recife (Brasil)/' .

Olian~,M.C. Magalhaes, * Lusinete, A.de Queiroz, * Cristi'na, M. de Sou~a*, Laura,Torres.** *Departamento de Micología, Centro de Ciencias Biol., Universidade Federal de Pernambuco, 50670-420, Recife, PE, Brasil ** Hospital Geral Otavio de Freitas(SANCHO), Recife,PE, Brasil.

Palabras clave: Paracoccidioidomicosis pulmonar Keywords: Pulmonary paracoccidioidomycosis SUMMARY RESUMEN

In order to determine the presence of fungi in clini­ Para determinar la presencia de hongos en muestras cal sal11ples of the respiratory system, 322 patients with clínicas de vias respiratorias, fueron pesquisados. 322 pneul110pathieswere surveyed. Al! ofthem had been hospi­ pacientes con pneumopatias internos en la unidad de talised in the Pneumology Unit of the Otavio de Freitas neumología del Hospital General Otavio de Freitas, Recife, . General Hospital, Recife, PE, Brazil. Paracoccidioidomy­ PE, Brasil. Se diagno,sticaron 7 casos de paracoccidio­ cosis was diagnosed in 7 male patients (2.1%), and idomicosis(2, 1%), todo~ del sexo masculino y relacionados 6 involvedwith work in the rural zone. In cases there was a a trabajos rurales. En 6 casos se constató " diagno.s.tir:o "diagnostic mistake" between pulmonary and errado" entre tuberculosis pulmonar y Para~oci.­ pull110nary paracoccidioidomycosis; in 1 case the associa­ dioidomicosis pulmonar; en 1 caso fué comprobada la !ion of these two pneumopathies was verified. asociación de estas 2 neumopatías.

twoofthem(Londero& Severo, 1981;Rippon, 1982;Wanke, .. INTRODUCTION 1984;Lacazetal.,1991). , .1 Paracoccidioidomycosis (P) is caused by the di mor­ Fungal pneumopathies present clinica1 aspecb W1U~_, phic Paracoccidioides brasiliensis (Splendore) may be suggestive of other pulmonary diseases, mainly pul­ Almeida. In Brasil it isthemostfrequentsystemicmYCosis, monary tuberculosis (PT) (Hendrix et al., 1992; Peres et specially in the SouthEast, South and Centre-West, with less a1.,1992; Stanleyetal., 1992). Many papershavefocussedon incidence in the Northeast and rarely in Amazonia (Wanke, the difficuIties in the diagnostic differential between fungal 1984). The objectives ofthis papers were detect, isolate and pneumopathies and other diseases, by highlight PT (Berkowitz identity fungi of the respiratory system of patients hosp­ & Diamond, 1987), occurrences ofthe two pneumopathies italised in the Pneumology Unit of the Otavio de Freitas simultaneously (Morozovetal., 1989), aswell asthe unleash­ General Hospital, Recife, PE, Brasil; to determine the exist­ ing of the post PT fungal pneumopathy (AI-Majed et al., ence of fungal pneumopathy; to verity the association of 1990). this pneumopathy with other pathologies ofthe respiratory Among the pulmonary mycoses, pulmonary system. paracoccidioidomycosis (PP) may be associated with PT (Rippon, 1982; Wanke, 1984; Tuderetal.,1985; Ferreira-da­ MATERIAL AND METHODS Cruz etal., 1987; Lacaz et al., 1991). On the other hand, due to the difficulties in differential diagnosis between these two Clinical samples were collected from patients with pneumopathies, "diagnostic mistake" mayoccur between the problems in therespiratory system who had been hospitali-

1 Part of dissertation for getting a Master's degree with support ofCoordenayao do Aperfeiyoamento de Nivel Superior (CAPES) 63 Pulmonary Paracoccidioidomycosis Oliane M.e. Magalhaes el al.

zed in mentioned institution. In 322 patient surveyed, 225 individual s who have never undertaken rural work (Conant were males and 97 females. From each patient who had not etal., 1971 ;Rippon, 1982; Wanke , 1984; Lacazetal.,1991). been drainedand wasfasting, sputumsampleswerecollected The 7 patiens with PP had been previously treated 3 times at intervals of 3 to 4 days in sterilized Petri dishes; has having PT, 1 with positive BAAR (Bacilo-aIcohol-acid samples of secretions of the lesions from buccal (cheek and resistant), 5 with negativeBAARand 1 without BAAR ha· gums) mucosa were al so collected from one patient and ving been undertaken (Table 1). In 6 of these cases it was transferred by physiological drip contained in a test tube. verified that the pneumopathy was PP and only 1 case was After collection, the c1inical samples were transported to the the association confirmed between the 2 pneumopathies,Pll Department of Mycology where they were duly processed and PT. Among the 6 patients uniquely with PP, only 1 was for direct examination and culture. The time between collec­ also a carrier of diabetes mellitus (Table 1). tion and manipulation ofthe samples dit not exceed 2 hours. The association of PP and PT has been reported by The direct exarnination both of the sputum and the secretions various authors (Rippon, 1982; Wanke, 1984; Tuder et al, of lesions from buccal mucosa was undertaken in the native 1985; Ferreira-da-Cruz etal., 1987; Lacaz etal., 1991). state (without colouring and without c1arifier), and c1arified According to Wanke (1984), PP may l?e associated with aqueous solution with 20% potassium hydroxide. with PT as well as with neoplasias, reflecting irnmunologi· In duplicate, the c1inical samples were seeded by cal compromise which accompanies the disease. spreading on their surface agar infusion ofbrain and heart Clinical and radiological examinations do not help (BHIDifco) andwith Sabouraudagar+O,5%ofyeastextract much in the diagnosis of PP, because they may sugges t> (YE), to both of which 50 mg ofCaf.!1 were added. A plate diagnoses for other pneumopathies, such as tuberculosis and of each method was left at room temperature (RT 28°C neoplasia. As a result ofthis, many patients are treated as jf, approx.) and the other at 37°C. Culture pI ates were incubated they were bearers of PT even without laboratory confirma· for 3 weeks. The pure culture obtained were maintained in tion (negative BAAR) (Wanke, 1984; Lacaz etal., 1991). The BHI agar and Sabouraud + 0.5% of YE and at RT. The mycological examination detecting P.brasiliensis, in aIl identification of P. brasiliensis was confirmed through casesofPP,only took placesome months after treatmentfol Conant etal., 1971; Rippon, 1982; Lacazetal., 1991. PT without clinical and radiological inmprovement, thus indicating "diagnostic mistake". This same type of" diagnos· RESULTS AND DISCUSSION tic" has already been reported in the Iiterature (Londero & Severo, 1981;Rippon, 1982; Wanke, 1984 ; Lacazetal ., 199J~1 "Diagnostic mistake" has also been taking place be· PP Was diagnosed through thedirect examination of tween PT and other mycoses such as: , peni· sputumof 7 (2. 1%) patients (Table 1). Onlyoneofthesewas cilosis, , cryptococosis and aspergilIosis a bearer of lesions in the buccal mucosa and the direct (Frean et al., 1983;Berkowitz & Diamond, 1987;Pautleret examination of the secretion ofthe latter also revealed the al., 1984;Forsbachetal.,1985;Shang& Song, 1987; Hendlú presenceof Thedirectexaminationofsputum P. brasiliensis. etal.,1992). andsecretion revealed the presence ofyeast-likecellswith The ocurrence of a case of P in the State of Pero double contour, single and multiple budding, resulting in nambuco, Northeast ofBrasil was reported by Guimaraeset "Mickey mouse" formations, in a chain and in helm shape, al. (1985); since then personal communication by profession· characteristic of parasitic phase of (Figures P. brasiliensis als in the Health field has indicated various cases ofthis 1 to 7). in the same State. On the other hand, Carneiro( 1993), In BHI + Caf. cultures, P.brasiliensis wereobtained found 20% of positiveness for paracoccidioidine in school for 3 patients (Table 1). The strains were deposited in the children of Greater Recife, these results indicate the contact Micoteca-URM, of the Mycology Department ,Centre of of these childrens have with P. brasiliensis, and suggest the Biol. Sc,Federal Univ. ofPemambuco, underN' 3633 ,3634, possible occurrence of this illness in Recife's inhabitants. 3635. So we can concluded tha t no case of PP associated AH the cases of PP were diagnosed in male patients, with another mycosis has been found; PP, occurred in an with a rninimum age of 17 and a maximum of76 years, the isolated manner in most cases; PP may be associated with majority of cases being between the ages of 31 and 48. PT; there may be "diagnostic mistake" between PP and PT. Among the 7 patients, 6 were from the rural zone ofthe State The direct examination of the sputum was conclusive for of Pernambuco, and engaged in ruml work; only one patient diagnosing PP. was a native of the$tate o"f Alagoas and aIthough he had been a resident ofthe city of Recife for 20 years working as a watchman, he had once been a rural worker (Table .1) These results agree with those previously reported in the Iiterature according to which the rural worker over 30 years old. is the representative of the majority ofthe reports of P ; however there are reports of the afores aid mycosis in

64 Pulmonary Paracoccidioidomycosis Oliane M.e. Magalhaes el al. \

4

Fig.l to 7. -Paracoccidioides brasiliensis in the sputum. 1-2.-Cells with double refractary contour, without budding 960x, 1360x. 3-4.-Cells with double refractary contour, and single budding, 1360x, 650 x. 5-6-7.-Cells with doublerefractary contC)\~r, andmultiple budding, 1360x. Pulmonary Paracoccidioidomycosis Oliane M.e. Magalhaes el al.

Table 1. ASJlects related to the cases of Paracoccidioidomycosis diagnosed in patients hosJlitalized

ASSOCIA TlON CASE SEX AGE RESID OCCUPATlON BEFORE DIAGNOSIS MYCOLOGY DIAGNOSIS INFIRMITY LAB. I CLlN. C. S. I D. E. I CULTURE

1° AJS M 17 lbimirim Rural BAAR - PT ~putum + Paracoccidioides NHD brasiliensis Pulmonar)" 2" BBF M 31 Barreiros Rural BAAR + PT bucal + P. brasilienru OBT tuberculosi~ les ion! sputum / 3° GLS M 40 Petrolina Rural · BAAR - PT 'puh.m + P. brasiliensis NOD 4° PPS M 42 Re<:ife Vigilant BAAR - PT sputum + P. brasiliensis NOD

So JAS M 4S Nazaré da Rural BAAR - PT 'putum + P. brasiliensis NOD Diabetes Mata mellitu. 6° PAL M 48 Afogado. da Rural BAAR - PT sputum + P. brasiliensis OBT Ingazeira 7° JAS M 76 Ca~ina Rural BAAR NU PT sEutum + P. brasiliensis OBT M - Scx male C. s. - Clinical sample + - Positi"e PT Pulmonar\' tuberculosis LAB = Labora!ory D.E . = Dircct examinaction - = Negative N.H.D = Not have development 00 growth CL! = Clinic BAAR = Bacillus alcohol-acid resistan! OBT = Obtained NU = No! undcrtakcn

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