Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis (P. brasiliensis) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii (P. lutzii), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

INTRODUÇÃOMicose sistêmica endêmica de grande interesse para os países da América Latina, a paracoccidioidomicose (PCM) é causada pelo fungo termo-dimórfico Paracoccidioides brasiliensis. Apresenta distribuição heterogênea, havendo áreas de baixa e alta endemicidade. No adulto, a forma clínica predominante é a crônica, mas quando acomete crianças ou adolescentes apresenta-se na forma aguda ou subaguda. Quando não diagnosticada e tratada oportunamente, pode levar a formas disseminadas graves e letais, com rápido e progressivo envolvimento dos pulmões, tegumento, gânglios, baço, fígado e órgãos linfóides do tubo digestivo.De acordo com dados de inquéritos epidemiológicos realizados com paracoccidioidina no Brasil, Venezuela, Colômbia e Argentina, acredita-se que em torno de 50% dos habitantes de zonas endêmicas tenham sido expostos ao agente desta micose. Felizmente, apenas uma proporção muito pequena de indivíduos expostos a P. brasiliensis desenvolve alguma manifestação clínica da micose. Esta micose representa um importante problema de Saúde Pública devido ao seu alto potencial incapacitante e à quantidade de mortes prematuras que provoca, principalmente para segmentos sociais específicos, como os trabalhadores rurais, que além de tudo isso apresentam grandes deficiências de acesso e suporte da rede dos serviços de saúde favorecendo o diagnóstico tardio. A faixa etária mais acometida situa-se entre 30 e 50 anos de idade e mais de 90% dos casos são do sexo masculino. Os indivíduos acometidos pela micose, usualmente encontram-se na fase mais produtiva da vida, sendo que a doença leva a impacto social e econômico.Este documento tem como objetivo estabelecer as diretrizes para o consenso da abordagem clínica, diagnóstica e tratamento da PCM, visando subsidiar os profissionais da saúde no atendimento primário e secundário da doença. ECOEPIDEMIOLOGIANa natureza, P. brasiliensis apresenta-se como estruturas filamentosas contendo propágulos infectantes chamados conídios. Uma vez inalados, os propágulos dão origem a formas leveduriformes do fungo que constituirão sua forma parasitária nos tecidos do hospedeiro. Até recentemente, os humanos eram tidos como os únicos hospedeiros naturalmente infectados por este fungo. Atualmente, alguns animais foram encontrados portadores da infecção, como o tatu.Ao longo das últimas décadas, têm sido observadas notáveis alterações na freqüência, nas características demográficas da população atingida e na distribuição geográfica da PCM. Dependendo da região, a incidência se alterou, sem que se possam justificar totalmente as suas causas. É possível que o aumento da urbanização e melhoria do diagnóstico expliquem, em parte, estas alterações. Além disto, fatores ambientais decorrentes da abertura de novas fronteiras agrícolas, com a derrubada de florestas, sobretudo nas regiões Centro-Oeste e Norte, atingindo marcadamente a Amazônia, também contribuíram para o atual panorama da micose. Como é adquirida a infecção por P. brasiliensis?O grande fator de risco para aquisição da infecção são as...

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Background:This review article summarizes and updates the knowledge on paracoccidioidomycosis. P lutzii and the cryptic species of P. brasiliensis and their geographical distribution in Latin America, explaining the difficulties observed in the serological diagnosis.Objectives:Emphasis has been placed on some genetic factors as predisposing condition for paracoccidioidomycosis. Veterinary aspects were focused, showing the wide distribution of infection among animals. The cell-mediated immunity was better characterized, incorporating the recent findings.Methods:Serological methods for diagnosis were also compared for their parameters of accuracy, including the analysis of relapse.Results:Clinical forms have been better classified in order to include the pictures less frequently observesiod.Conclusion:Itraconazole and the trimethoprim-sulfamethoxazole combination was compared regarding efficacy, effectiveness and safety, demonstrating that azole should be the first choice in the treatment of paracoccidioidomycosis.

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Cellular immune response to specific and non-specific stimulants was investigated, both in vivo and in vitro, in 29 healthy controls and in 53 previously untreated patients with the chronic isolated organic form (CIOF), the chronic mixed form (CMF) and the acute progressive form (APF) of paracoccidioidomycosis. The study included skin tests to Paracoccidioides brasiliensis antigen (PbAg) and phytohaemagglutinin (PHA), DNCB sensitization, determination of T lymphocytes and complement rosette-forming cells, lymphocyte transformation and leucocyte migration inhibition tests using PbAg and PHA. Patients displayed staggered cutaneous response to PHA and to PbAg, with marked decrease in intensity in the APF group. DNCB sensitization test and proliferative response of lymphocytes to PHA and PbAg were severely depressed in most of the patients. Leucocyte migration inhibition indices to PbAg were highly positive, while response to PHA was slightly decreased regardless of the clinical form. The number of T lymphocytes was reduced in most of patients and in them the number of complement-rosette forming cells was normal. The distribution of patients according to a suppression index, based in the results of the tests employed, revealed a tendency towards an increased degree of cellular immunosuppression from the least severe (CIOF) to the most severe (APF) clinical form of the disease. On the whole, the present study demonstrated a gamut of immunological reactivity in paracoccidioidomycosis.

Introduction:In 1956, Africanized honeybees (AHB) migrated from Brazil to other regions of the Western Hemisphere, including South, Central, and North America, except for Canada. Despite being productive, they are highly aggressive and cause fatal accidents. This study aimed to evaluate patients at the Clinical Hospital of Botucatu Medical School (HC-FMB) and to propose treatment guidelines. Methods: From 2005 to 2006, the clinical and laboratorial aspects of 11 patients (7 male and 4 female) and the anatomopathological aspects of one patient who had died in 2003 were analyzed. Results: The age of the surviving patients varied from 5 to 87 years, with a mean of 42.5 years. The majority of accidents occurred in the afternoon, and the number of stings ranged from 20 to 500. The principal signs and symptoms were pain and local inflammatory signs, nausea, tachycardia, and vomiting. Biochemical findings presented increased levels of creatine phosphokinase, lactate dehydrogenase, and aspartate/alanine aminotransferase. An 11-year-old male patient died upon entering the attic of a two-storey building where he was attacked by a swarm, receiving more than 1,000 stings. He was sent to HC-FMB where he was treated, but he died 24h later. Observed at the autopsy were erythematous-purpuric skin lesions besides necrosis at the sting locations, rhabdomyolysis, focal myocardial necrosis, tubular hydropic degeneration and focal tubular acute necrosis of the kidneys, myoglobinuria, and centrolobular necrosis in the liver. Conclusions: Accidents caused by multiple AHB stings always constitute a medical emergency. As there is no specific antivenom, we have developed guidelines, including first aid, drugs, and the proper removal of stingers.

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