Sarcoid-like lesions in paracoccidioidomycosis: immunological factors*

Abstract

The clinical presentation of paracoccidioidomycosis is spectral. Spontaneous cure, state of latency or active disease with different levels of severity can occur after the hematogenous dissemination. The morphology and number of skin lesions will depend on the interaction of host immunity, which is specific and individual, and fungus virulence. Some individuals have natural good immunity, which added to the low virulence of the fungus maintain the presence of well-marked granulomas with no microorganism and negative serology for a long time, making the diagnosis a challenge. Factors inherent to the fungus, however, may modulate the immune response and modify the clinical picture over the time. We present a sarcoidosis-like clinical presentation and discuss the immunological factors involved.

Paracoccidioidomycosis with sarcoid-like lesions:a diagnostic challenge

“…However, at any time, failure of cellular immunity may lead to changes in the T helper response 2 with increased suppressive action of interleukin-10, interleukin-5, and transforming growth factor-β; these cytokines are responsible for fungal multiplication, dissolution of granulomas, and spread of disease. This contributes to the emergence of the typical clinical picture, as occurred in the present case, where the onset of ulceration led to the diagnosis; the final diagnosis was possibly favored by immunosuppression due to prolonged use of high doses of corticosteroid [6][7][8][9] . Histological diagnosis of tuberculoid granuloma is possible when there are characteristic features of a specific disease or sufficient quantity of infectious agents to be detected using special staining techniques.…”

“…Histology shows a tuberculoid granuloma with a paucity of fungi. This makes diagnosis of PCM challenging and may lead to misdiagnosis, often misinterpreted as other granulomatous conditions such as tuberculoid leprosy, leishmaniasis, and sarcoidosis [3][4][5][6] .…”

A case of paracoccidioidomycosis due to Paracoccidioides lutzii presenting sarcoid-like form

“…They may originate from hematogenous dissemination of the fungus, contiguous preexistent lesions or, rarely, direct inoculation into the skin [4] , [6] . The face is the most common site of skin lesions and ulcer or ulcerous-vegetative lesions are the main morphological pattern followed by the infiltrative one, although the sarcoid-type is unusual [5] , [6] . This latter form differs from the others due to the presence of tuberculoid granulomas in the histopathological exam [5] .…”

“…However, other patterns can be found, such as vegetative or ulcerovegetative lesions, papular lesions and infiltrated lesions [4] . The distinct cutaneous manifestations are related to different immunological responses in each individual [5] . When cutaneous presentation involves infiltrated lesions, it can be misinterpreted as other granulomatous diseases, such as sarcoidosis and tuberculoid leprosy, due to clinical and histopathological similarities among them [6] .…”

Paracoccidioidomycosis in a child: exuberant presentation due to the inadvertent use of systemic corticosteroids

“…[4][5][6] The sarcoid pattern of PCM can be determined by a specific immune response, which leads to a certain balance between agent and host and generates paucifungal histological exams, hindering the correct diagnosis. 7 In this case, treatment with prednisone probably altered such balance, favoring an immunosuppression that allowed lesions to evolve into ulcerated forms, which are more typical of the disease and contain an increased amount of yeasts, facilitating the correct diagnosis. Thus, this case illustrates the importance of isolating the causative agent in granulomatous diseases that are clinically and histopathologically similar to the sarcoid pattern.q…”