Prevalence and Serological Diagnosis of Relapse in Paracoccidioidomycosis Patients

Abstract

A review of 400 clinical records of paracoccidioidomycosis (PCM) patients, 93 with the acute/subacute (AF) and 307 with the chronic form (CF), attended from 1977 to 2011, selected as to the schedule of release for study by the Office of Medical Records at the University Hospital of the Faculdade de Medicina de Botucatu – São Paulo State University – UNESP, was performed to detect cases in relapse. The control of cure was performed by clinical and serological evaluation using the double agar gel immunodiffusion test (DID). In the diagnosis of relapse, DID, enzyme-linked immunosorbent assay (ELISA) and immunoblotting assay (IBgp70 and IBgp43) were evaluated. Out of 400 patients, 21 (5.2%) went through relapse, 18 of them were male and 3 were female, 6∶1 male/female ratio. Out of the 21 patients in relapse, 15 (4.8%) showed the CF, and 6 (6.4%) the AF (p>0.05). The sensitivity of DID and ELISA before treatment was the same (76.1%). DID presented higher sensitivity in pre-treatment (80%) than at relapse (45%; p = 0.017), while ELISA showed the same sensitivity (80% vs 65%; p = 0.125). The serological methods for identifying PCM patients in relapse showed low rates of sensitivity, from 12.5% in IBgp70 to 65.0% in IBgp43 identification and 68.8% in ELISA. The sensitivity of ELISA in diagnosing PCM relapse showed a strong tendency to be higher than DID (p = 0.06) and is equal to IBgp43 (p = 0.11). In sum, prevalence of relapse was not high in PCM patients whose treatment duration was based on immunological parameters. However, the used methods for serological diagnosis present low sensitivity. While more accurate serological methods are not available, we pay special attention to the mycological and histopathological diagnosis of PCM relapse. Hence, direct mycological, cytopathological, and histopathological examinations and isolation in culture for P. brasiliensis must be appropriately and routinely performed when the hypothesis of relapse is considered.

New Insights on Pulmonary Paracoccidioidomycosis

“…Relapses need to be ruled out through microbiological and serological data; they are expected to occur in approximately 5% of patients. 146 Moreover, it is important to keep in mind that coinfections, especially tuberculosis, may occur after PCM treatment. Thus, microbiological examinations of sputum are mandatory, and BAL might be considered.…”

Etiologia, epidemiologia e manifestações clínicas da paracoccidioidomicose

“…Esse complexo primário pulmonar poderá manter-se latente por muitos anos e evoluir para a remissão da infecção ou progredir dando origem a formas generalizadas e viscerais da doença 2 . Os focos latentes cujo conteúdo séptico foi eliminado pelo hospedeiro sofrem remissão completa e não darão origem a relapses, mas os focos latentes em que fungos se mantiveram viáveis poderão dar origem às infecções crônicas, após mais de 30 anos do estabelecimento do complexo primário 19,28 , mantendo intensa reação cutânea a antígenos fúngicos, como a paracoccidioidina 2-4 . O complexo primário quando evolui produz infecção com manifestações clínicas inespecíficas ou mesmo sem sintomatologia.…”

Serological proteomic biomarkers to identify Paracoccidioides species and risk of relapse.

“…In addition, the recent identification of P. lutzii has required studies to identify PCM caused by every species. That study revealed that the sensitivity of the double immunodiffusion agar gel reaction (DID) was only 45% at relapse, and that the enzyme-linked immunosorbent assay (ELISA) was slightly better (65%), but with a sensitivity level much lower than that observed in treatment-naive patients [7].…”