P153 Comparison of clinical presentation of 2 cases of paracoccidioidomycosis in Shushufindi, Ecuador
Authors: España Jaime David Acosta , Altamirano-Jara Belén , Lafuente-Cevallos Lizeth , Lascano-Gallegos Natalie , Voigt Kerstin , Palacios-Alvarez Santiago 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objectives
Discuss the diagnosis of two cases of paracoccidioidomycosis (PMC) for the first time in the city of Shushufindi, Ecuador.
Report two different clinical presentations in two male patients diagnosed with PMC.

Methods
The diagnosis and treatment of two male patients with PMC is retrospectively described. Individual informed consents were obtained from each patient.

Results
The first case is a 39-year-old male patient, with a history of previous armadillo hunting, with no relevant history. Born and resident in Shushufindi, Amazon area of the province of Sucumbíos, Ecuador. He presents lesions of ∼ 7 years of evolution, characterized by ulcerated plaques with meliceric crusts in the nose and in the mouth at the level of the upper lip (Figs. 1a and b).
This patient had had several visits to different medical doctors, who unfortunately diagnosed other diseases. Due to his long clinical evolution, he was referred to a dermatological referral center in Quito. During the initial examination, a differential diagnosis of oncologic pathology, mycosis, mycobacteria, and cutaneous leshmaniasis was considered. A punch biopsy of the affected region was requested, and specimens were sent for culture, histopathology, and smears from the margins of the lesion to rule out leshmaniasis. As shown in Figure 1c, a histopathology report was submitted with yeast-like structures with multiple branches and a positive culture for Paracoccidiodes (Fig. 1d). Other clinical laboratory studies or chest imaging were within normal parameters.
The second case is a 54-year-old male patient, a farmer, with no relevant history. Born and resident in Shushufindi. No clinical or geographical relationship with case number 1. He presented lesions of ∼ 2.5 years of evolution, characterized by ulcerated plaques with meliceric crusts in the lower part of the nose, with lytic destruction of the anterior nasal septum and left nasal ala (Figs. 2a and b).
This patient has also consulted many physicians. At his last visit, he was treated for cutaneous leshmaniasis without a positive result. He was admitted to a specialized dermatological center in the city of Quito, 3 weeks after the first patient, so a similar protocol was used. Patient number two had a slight elevation of liver enzymes, other laboratory, and imaging tests were within normal parameters. Unfortunately, culture showed no fungal growing, and histopathology of a punch biopsy of the nasal septal mucosa showed yeast-like structures with multiple extensions suggestive of PCM (Fig. 2c).
In both patients, treatment was started with oral itraconazole 200 mg per day. In the first 2 months, the treatment showed little success, so it was decided to increase trimethopine-sulfamethoxazole to 8 mg/kg per day for 6 months.

Conclusion
Paracoccidioidomycosis is an endemic disease in South America characterized by infection with Paraccocidioides lutzi and Paracoccidioides brasiliensis. Several articles have described cases in Ecuador, but this is the first report from the city of Shushufindi. The patients had different orofacial manifestations. In the patient with the shortest duration of infection, lytic damage to the nasal septum was observed (Fig. 2b).