A 7-year-old child patient, from the central Andes of Peru, with a history of multiple trips to the tropical region in the last 4 years, without other significant medical history presented to the emergency department with 3-month illness characterized by general malaise, weight loss, and in the last month, respiratory distress was added to physical effort, difficulty walking, sensation of unquantified thermal rise and presence of diffuse adenopathy throughout the lymphatic tract.
His physical examination was remarkable decrease in subcutaneous cellular tissue, generalized joint pain that intensifies on movement, the presence of multiple lymphadenopathy in the cervical, axillary, thoracic, and inguinal region of different diameters of indurated consistency and painful on mobilization, presence of crackless in the base of both lungs and respiratory distress, distended abdomen painful on deep palpation, the patient is in an uncooperative state of alert and responds adequately to questioning.
Laboratory tests showed; white blood cell count 8.67 x 103 / uL, eosinophils 1.75 x 103/uL (17.1%), hemoglobin 10.2 g/dL(Table 1). Ultrasound showed markedly enlarged liver and spleen with presence of multiple mesenteric nodes and 180 mL free fluid in the peritoneal cavity; Chest tomography showed lung consolidation at the bases and bilateral pleural effusion of 130 mL. The patient underwent a cervical lymphadenopathy biopsy showing multinucleated giant cells and the presence of positive acid fast bacilli in the Zielh Nielsen stain (Fig. 1), for which he began anti-tuberculosis treatment with rifampicin, isoniazid, ethambutol and pyrazinamide with clinical improvement and a decrease in fever for which he was discharged from the hospital.
Three weeks after starting treatment for tuberculosis, the patient returned with generalized lymphadenopathy, fever, abdominal distension, lethargy, poor oral intake, cough with whitish sputum and dyspnea at rest, was noted to be tachycardic (heart rate of 119 beats per minute), tachypnoeic (respiratory rate of 28 breaths per minute) (Fig. 2), and had an oxygen saturation of 88% under room air. Arterial blood gas taken under room air revealed type 1 respiratory failure (pH 7.45, PO2 69 mmHg, PCO2 32 mmHg, HCO3 27 mmol/L). The patient was screened for HIV, HTLV1-2, with results negatives; and serologies were negative for antinuclear antibodies, antidouble-stranded DNA and anticardiolipin antibodies. Outpatient HIV testing was repeated five days later, this time including an HIV RNA, with results negatives.
Auscultation of lungs revealed reduced air entry over the lower area on both sides and chest radiograph of patient on admission revealed nodular and air space opacities bilaterally, no cavity, or pleural effusion was seen. Sputum smear examination showed multi-gemant yeasts and was negative for acid fast bacilli. Biopsy of the right cervical lymph node and of the thoracic region was performed, the histological study revealed presence of yeasts with multiple budding in ship's rudder compatible with paracoccidioidomycosis in both lymph node tissues (Fig. 2), therefore, the patient was treated as a case of disseminated CPM with secondary TB.
Amphotericin b deoxycholate and hydrocortisone were administered as per local Disseminated paracoccidioidomycosis treatment guidelines. He received amphotericin b deoxycholate 1 mg per kg of weight for 14 days through a central vein, with daily corrections of serum potassium for hypokalaemia, the patient presented clinical improvement from day 7 of receiving the medication.
The patient stayed in the hospital for almost two months. Upon discharge, her laboratory results are shown in Table 1. He showed significant improvement on the itraconazole regimen 200 mg daily and treatment for tuberculosis without any significant adverse effects. He has not had a recurrence of symptoms since.