https://orcid.org/0009-0000-6222-9052
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Lorra Monpierre, Françoise Foulet, Camille Hua, Audrey Melin, Frédéric Schlemmer, Pierre Cappy, Laurence Le Cleach, Nicolas Ortonne, Françoise Botterel, An axillary skin lesion revealing disseminated paracoccidioidomycosis, Journal of Travel Medicine, Volume 31, Issue 6, August 2024, taae086, https://doi.org/10.1093/jtm/taae086
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Case report
In July 2023, a 58-year-old man consulted at the dermatology department of Henri Mondor Hospital, Creteil, France, for an axillary skin nodule that had appeared one month before. His past medical history was unremarkable apart from active smoking and regular drinking. Originally from Colombia, he had been living in the Parisian region since 2002. He visited Colombia once in 2016 and stayed two months where he worked on farms. The clinical examination revealed a single right axillary nodule of 8 × 12 mm with a central crusty ulcer suggesting a cutaneous neoplasia origin (Figure 1A and B), in addition to brief episodes of shortness of breath on exertion. No other abnormalities were detected in the clinical examination. A punch skin biopsy of the lesion was sent for histopathological examination and showed no cancer but rather a dense, polymorphic inflammatory reaction with multiple round yeast buddings of variable sizes reaching 40 μm, suggesting a fungal aetiology (Figure 1D-E). Consequently, a second skin biopsy was taken and sent for mycological analysis, which confirmed the presence of several large yeasts with multiple buds on direct examination with specific stain (Figure 1F), and the growth of white filamentous fungi after two weeks (Figure 1G). To identify the fungus, molecular analyses were performed on the skin biopsy, involving PCR, targeting the Internal Transcribed Spacer (ITS) region, and metagenomic next-generation sequencing (mNGS). Sanger Sequencing showed 100% identity to Paracoccidioides brasiliensis sequences. The mNGS analysis using metaMIC software v2.3.0 detected 227 DNA reads among 378 microbial reads and 997 RNA reads among 988 225 microbial reads, mapped to the P. brasiliensis genome. Accordingly, the patient was hospitalized for further investigation and initially put on 200 mg/d itraconazole orally associated with surgical excision of the lesion. Blood analyses showed normal values, and fungal biomarkers (beta D-glucan and galactomannan antigens) were negative. Chest scan revealed extensive lung damage affecting 50% of the lung parenchyma (Figure 1H), suggesting fungal dissemination. Combined antifungal therapy of amphotericin B 3 mg/kg/d and itraconazole 200 mg/d was given intravenously for 15 days, followed by 200 mg/d itraconazole alone orally for at least six months. Three months after treatment, the axillary nodular lesion significantly regressed (Figure 1C), and the lungs lesions showed partial improvement (Figure 1I).
