A surprising diagnosis of paracoccidioidomycosis from routine bacterial culture of chronic finger lesions

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ABSTRACT Background Paracoccidioidomycosis is a systemic mycosis endemic to Central and South America. Here, we describe an unusual case of an elderly female with cutaneous paracoccidioidomycosis and comorbidities limiting the use of first-line therapeutic agents. Case Summary An 89-year-old female with a past medical history of advanced systolic heart failure presented with decompensated heart failure along with chronic, progressive ulcerating lesions involving multiple fingers, unresponsive to antibiotic therapy. A biopsy showed evidence of yeast on pathology and samples grew Paracoccidioides brasiliensis within 5 days on routine bacterial culture. Further history revealed that she lived in Trinidad and Tobago for periods during her childhood and had visited Ecuador for 2 weeks decades prior. Due to her history of advanced congestive heart failure on dobutamine and ventricular arrhythmias, first-line therapy with itraconazole was contraindicated. Sulfamethoxazole-trimethoprim was initiated; however, she developed progressive renal dysfunction and hyperkalemia attributed to sulfamethoxazole-trimethoprim, necessitating a change in therapy. The patient was ultimately started on isavuconazole, which has been shown to be effective in the treatment of Paracoccidioides in a small phase 3 trial. Unfortunately, we were unable to observe clinical response to isavuconazole in our patient due to her demise in the setting of advanced heart disease. Conclusion This case highlights the variable nature of paracoccidioidomycosis, with our patient having a prolonged latency prior to development of clinical signs and symptoms, an unusual diagnosis by growth in routine bacterial culture, and the need for further research in alternative therapeutic options.

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