Paracoccidioidomycosis in people living with HIV/AIDS: A historical retrospective cohort study in a national reference center for infectious diseases, Rio de Janeiro, Brazil

Abstract

Paracoccidioidomycosis (PCM) is one of the main endemic systemic mycoses in Latin America, usually occurring in rural areas. When PCM occurs simultaneously with underlying immunosuppressive conditions, it can present as an opportunistic disease. Between 2000 and 2017, literature reported around 200 PCM cases in people living with HIV/AIDS (PLWHA). To address research gaps on this co-infection and to study its possible temporal changes in the last decade, we performed an active co-infection case search on the HIV/AIDS and PCM cohorts from a Brazilian reference center database from 1989 to 2019. We found 20 PLWHA among 684 PCM patients (2.92%), predominantly male (70.0%) and urban workers (80.0%). The median age of patients was higher in the 2010–2019 decade (p = 0.006). The occurrence of PCM in PLWHA was lower when compared with other fungal diseases. Although 50.0% of the patients had already been diagnosed with HIV infection and presented CD4+ T cell counts greater than 200/mm3 at the time of PCM diagnosis, the suspicion of immunosuppression in the context of atypical and more severe clinical forms of PCM revealed the diagnosis of HIV infection in 35.0% of the patients. Two (10.0%) patients had an evolution compatible with immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral therapy (ART).We highlight the importance of considering a PCM diagnosis in PLWHA to prevent a late-onset treatment and progression to severe manifestations and unfavorable outcomes. In addition, HIV investigation is recommended in PCM patients, especially those with atypical and more severe clinical presentations.

Acute paracoccidioidomycosis worsened by immunosuppressive therapy due to a misdiagnosis of Crohn’s disease

“…The acute form is less frequent but usually more severe due to an immunological susceptibility of the host induced by a genetic predisposition or other immunosuppressive conditions, mostly HIV/AIDS [ 3 ]. In this clinical form, the reticuloendothelial system and intraabdominal organs are usually affected.…”

“…The occurrence of PCM in urban areas exposes immunocompromised patients to a higher risk of infection and they may present disease with higher severity [ 3 ]. The misdiagnosis of PCM as CD represents an additional risk because the immunosuppressive therapy for CD modifies the natural history of PCM, reactivating latent foci and/or aggravating an active disease as drug-induced immunosuppression leads to a greater bloodstream spread of the fungal agent, increasing the risk of complications, sequelae, and deaths [ 10 ].…”

Paracoccidioidomycosis: What We Know and What Is New in Epidemiology, Diagnosis, and Treatment

“…In patients with the mixed form, multiple, exuberant skin involvement; lytic bone lesions; and central nervous system involvement can be present, indicative of severe disease ( Figure 2 D). Patients with HIV co-infected with PCM make up the bulk of immunosuppressed patients with PCM; however, cases of PCM in transplant patients and those receiving immunobiological therapy have also been reported [ 63 , 64 , 65 , 66 ].…”

Immunologic Diagnosis of Endemic Mycoses

“…This test has high efficiency, which may range from 65 to 100%, depending on the antigenic preparation employed [ 104 ]. The test performance is not affected by HIV-driven immunosuppression [ 105 ]. For many years, different antigens have been used for paracoccidioidomycosis immunologic diagnosis, and various antigens lack a standardized preparation from one laboratory to another.…”