The New England Journal of MedicineImages in Clinical Medicine: Paracoccidioidomycosis

Uncovering Paracoccidioidomycosis: A Diagnostic Challenge in Pediatric Patients

A 9-year-old boy, recently moved from Brazil to the United States, presented with alarming symptoms including neck swelling, fevers, and weight loss, leading to an unexpected diagnosis of Paracoccidioidomycosis. This case underscores the importance of considering endemic fungal infections in patients with eosinophilia and lymphadenopathy, especially in those from endemic regions. Through detailed investigation, including advanced laboratory testing and histopathological examination, the diagnosis was established, highlighting the critical role of a thorough diagnostic approach in managing unusual infectious diseases in pediatric patients.

Key Points:

• Patient Background: A 9-year-old Brazilian immigrant presented with a 3-week history of neck swelling, fevers, and weight loss.
• Clinical Findings: Examination revealed fixed, tender lymphadenopathy in various cervical chains without hepatosplenomegaly or rash.
• Laboratory Results: Notable findings included a significantly elevated eosinophil count, anemia, thrombocytosis, hypoalbuminemia, and negative HIV testing.
• Imaging and Biopsy: CT scans showed hyperattenuating cervical lymphadenopathy, and biopsy specimens revealed tissue eosinophilia, granulomatous formations, and yeast forms.
• Diagnosis: Paracoccidioidomycosis was confirmed through polymerase-chain-reaction (PCR) assay for Paracoccidioides brasiliensis.
• Treatment and Outcome: Initial treatment with itraconazole was switched to fluconazole due to adverse effects, leading to symptom resolution and continued therapy for one year.

Paracoccidioidomycosis is predominantly found in South America, with Brazil reporting the highest number of cases. It’s estimated that about 80% of the diagnosed cases in endemic regions are attributed to Paracoccidioides brasiliensis.

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