A white, sixty-six-year-old man born and residing in Miracema,Rio de Janeiro, was admitted in August 2014 for having had cough for three months, weight loss of six kg in a month, and febrile episodes over the 10 previous days. The patient underwent renal transplantation in January 2013 and he was using prednisone, 5 mg/day; mesalazine, 1,080 mg/day; and tacrolimus, 8 mg/day. He had systemic arterial hypertension, diabetes mellitus and gout, controlled with oral medications. He used to visit a farm and perform soil management frequently. Physical examination showed good general conditions, there was no palpable lymphadenopathy; dermatological examination revealed shallow ulcerated lesions on the palate surrounded by erythema, measuring about 8 mm; multiple mulberry-like erythematous eroded papules giving to the lesion a cobblestone appearance (Aguiar-Pupo stomatitis); erythematous papule with a central umbilication of about 3 mm located at the left nasal wing (Fig. 1); and an infiltrated erythematous plaque with irregular borders and indistinct boundaries, of approximately 1 cm in diameter, located on the left flank (Fig. 2).
Chest x-rays showed bilateral nodular infiltrate, so it was started empirical treatment for tuberculosis and bacterial pneumonia. AFB bronchial lavage was negative however, the direct mycological examination found fungal structures compatible with paracoccidioidomycosis. Biopsies in the described mucocutaneous lesions were performed, including oral ulcers, which were consistent with this diagnosis (Fig. 3). All materials were subjected to culture and there was growth of P. brasiliensis. Itraconazole, 400 mg daily, was started, but after five days of treatment the patient had clinical worsening and liposomal amphotericin B was introduced. The basal serum cortisol was normal and abdominal CT scan showed no specific changes; however, in lung CT (Fig. 4) an extensive involvement with bilateral nodular infiltrates, an excavated area suggestive of necrosis in the middle third of the right lung, and bilateral pleural effusion, largest in the right lung, were seen. Despite the prescribed therapies, the patient died.