A 47-year-old male patient who was a rural worker reported "wounds in the mouth" and persistent cough for about 6 months. He reported chronic smoking and denied comorbidities.
A granulomatous ulcer with hemorrhagic dots and moriform aspect was observed in the posterior mandibular alveolar ridge and in the right jugal mucosa (Figure 1). Some dental elements presented severe mobility, which began after lesion emergence. He had an ulcerated lesion in the right cervical region with serous exudate (Figure 2). Cervical contrast CT scan revealed images compatible with cervical lymphadenopathy in the right side and exteriorization of the infectious process through cutaneous fistula (Figure 3). Chest X-ray showed infiltrative lesions with reticulonodular aspect in butterfly-wing shape.
A direct mycological examination was performed from cervical lymph node puncture, sputum, and intraoral mucosal scraping. The result was positive for the presence of yeasts with multiple buds surrounding mother cells, suggestive of P. brasiliensis. Thus, culture with fungal isolation was carried out, and the final result was Paracoccidioides spp. DNA-PCR examination for Mycobacterium tuberculosis was negative, and the result was nonreagent for the rapid HIV test, revealing leukocytosis (13,500/mm3), without left deviation.
Incisional biopsy of the intraoral lesion was performed under local anesthesia. Histological sections revealed a mucosal fragment coated with parakeratinized stratified squamous epithelial tissue, exhibiting pseudoepitheliomatous hyperplasia constituted by dense connective tissue. An intense granulomatous inflammatory infiltrate with predominance of eosinophils and formation of granulomas and microabscesses were observed, as well as numerous multinucleated giant cells. Spherical fungi of different diameters and birefringent membrane located both within multinucleated giant cells or dispersed through the tissue were also present. In depth, there were fragments of mineralized tissue and hemorrhagic areas (Figure 4).
The patient was referred to an infectologist who followed up the case. An association of sulfamethoxazole 2400 mg + trimethoprim 480 mg was prescribed three times a day during 12 months. After 1-year follow-up, the patient was asymptomatic and presented remission of the oral and cervical lesions (Figures 5 and 6).