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Imported endemic mycosis remains a challenge in non-endemic settings and its incidence in travelers is probably underestimated. Here we report an international traveler from Mexico with respiratory symptoms. High-risk exposure should be considered in this context. The diagnosis was made by serological conversion for Paracoccidioides brasiliensis.

A healthy 42-year-old Spanish male was attended in our Tropical Medicine Unit 6 days after his return from a 6-day business trip to Mexico in May 2019. He complained of daily fever, arthromyalgias, mild dyspnoea, dry cough and sweating, starting 1 day after his arrival. He said he visited a non-tourist underground cenote (natural wells) for working reasons located in Valladolid (in the Yucatan peninsula). He did not look for pre-travel advice. He referred that another two non-local people of the working group consulted in different local medical facilities with similar symptoms. On physical examination, a mildly decreased respiratory murmur in both pulmonary bases and generalized non-itchy cutaneous rash were found. No mucosal involvement, peripheral lymphadenopathy, spleen or liver enlargement was observed. Mild hypoalbuminemia (3.34 g/dL), mild increase of liver enzyme levels (AST 58 U/L, ALT 70 U/L, GGT 240 U/L, ALP 143 U/L, LDH 355 U/L) and an elevated C Reactive Protein (62.2 mg/L) were detected in serum. The peripheral blood count was normal. A chest X-ray showed bilateral multiple small nodules with no hilar enlargement nor pleural effusion (Figure 1). A computed tomography (CT) scan performed 28 days later showed multiple and disseminated pulmonary nodules (with discretely irregular edges and some cavitated); one subcarinal adenopathy (12.5 mm) and mild splenomegaly (Figure 2). A short course of oral azithromycin was started with no response. Urine antigens for Streptococcus pneumoniae and Legionella and serology for atypical respiratory pathogens were all negative. Other infectious diseases such as HIV or arboviral infections were ruled out. An endemic fungal infection was suspected and serum samples were sent to the National Microbiology Centre in Madrid. An immunodiffusion based serological tests (IMMY®) targeting the fungal agents causing endemic mycoses (Blastomyces dermatitidis, Coccidioides spp, Histoplasma capsulatum and Paracoccidioides brasiliensis) was performed on three different occasions: the first, performed 7 days after the onset of symptoms, showed no positive results; the second, on day 14, was positive for P. brasiliensis and was weakly positive for Coccidioides spp (interpreted as possible cross-reaction); and the third, on day 30, was strongly positive for P. brasiliensis and negative for all the others fungi. Sputum samples for fungal culture were negative and a Polymerase Chain Reaction (PCR) for fungal agents was not performed.

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Clinical Pearl
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