Case report
Photodynamic therapy in the treatment of oral lesions caused by paracoccidiomycosis

https://doi.org/10.1016/j.pdpdt.2021.102648Get rights and content

Highlights

  • Paracoccidioidomycosis (PCM) is a disease caused by P. brasiliensis and P. lutzii.

  • Oral ulcers are usually the first clinical signs of PCM.

  • Local treatments are considered complementary, such as photodynamic therapy (aPDT).

  • aPDT may accelerate the healing process and provide fungal decontamination.

Abstract

Paracoccidioidomycosis (PCM) is an endemic disease caused by the dimorphic fungus Paracocdioides brasiliensis and Paracoccidioides lutzii. Oral ulcers are usually the first clinical signs of the disease. As it is a systemic fungal disease, local treatments are considered complementary, such as photodynamic therapy (aPDT). We present a patient with ulcerated lesions in the oral cavity of about 6 months duration. The pain complaint in the oropharynx led to a reduction in food acceptance and a weight loss of around 40 kg. He underwent biopsy of the lip lesion, and the histopathological report described yeast with multiple buds compatible with PMC. Our team opted for treatment with aPDT sessions. Two sessions were carried out in the ward and six in the ICU, showing satisfactory results in the remission of ulcerated lesions associated with PCM as well as the painful symptoms in the oral cavity. Also, the patient underwent Amphotericin B and Sulfamethoxazole-trimethoprim. We believe that the association of aPDT with pharmacological therapy possibly accelerated the repair process of oral lesions, as well as providing fungal lesion decontamination, improving progressively the healing of oral lesions.

Introduction

Paracoccidioidomycosis (PCM) is an endemic disease caused by the dimorphic fungus Paracocdioides brasiliensis and Paracoccidioides lutzii. The disease is more prevalent in men, with a mean age of 51.3 years. In Brazil, the south and southeast are the regions with the highest incidence, and mortality in endemic areas is around 20% [1]. The disease sets in when the spores are inhaled, mainly affecting the lungs. Other regions and organs are affected by lympho-hematological dissemination, including the oral mucosa [2].

PCM can be classified as acute (or subacute or juvenile) and chronic (unifocal or multifocal). In the first one, the manifestation occurs in children and young people up to 30 years of age, of both sexes. The chronic form affects adults over 30 years of age, with a 15:1 male-to-female ratio [1–4]. In both forms, the treatment must be done individually, using antifungal agents and systemic antibiotics, taking into account the morbidities, nutritional status and administration of medications for continuous use [4].

Manifestations in the oral mucosa are usually the first clinical signs of the disease, aiding in the clinical diagnosis, which is often delayed. Due to the ulcerated aspect, lesions associated with PCM have squamous cell carcinoma as a differential diagnosis [2,3]. The diagnosis is confirmed through incisional biopsies, showing pseudoepitheliomatous hyperplasia, epithelial discontinuity, chronic inflammatory infiltrate with multinucleated giant cells. Special staining techniques such as Periodic Acid Schiff (PAS) and Grocott-Gomori methenamine silver can identify Paracocdioides brasiliensis yeasts in biopsied tissues, which present multiple daughter buds in a so-called aspect of “Mickey Mouse ears” [1].

As it is a systemic fungal disease, local treatments are considered complementary, such as the photodynamic therapy (aPDT). In addition to being potentially effective in healing and analgesia, aPDT acts to eliminate pathogenic microorganisms, with the advantage of not inducing microbial resistance [5,6].

The therapy is based on the application of a photosensitizing agent on the injured tissue followed by low power laser emission on the region. The interaction generates free radicals and oxidation of the plasma membrane of microorganisms, providing antimicrobial and antifungal activity without harming healthy host cells [6].

The aim of this paper is to report a case of PCM with extensive oral manifestations in which aPDT was used as an adjuvant treatment to systemic pharmacological treatment, with positive results, during the patient's hospitalization in the Intensive Care Unit (ICU).

Section snippets

Case report

A 41-year-old caucasian male patient, smoker and chronic drinker for 20 years, presented with ulcerated lesions in the oral cavity for about 6 months, initially in the left buccal mucosa and progressing to the lower lip, with strong intensity painful symptoms. Due to the pain complaint in the oropharynx, the patient reported a reduction in food acceptance, leading to a weight loss of around 40 kg.

He sought medical care in his city in Paraná, Brazil, where a chest X-ray was performed, suggesting

Discussion

The reported case refers to a male individual, in his fifth decade of life, smoker and drinker, residing in an endemic area for PCM, therefore fitting into the risk group for Paracoccidioidomycosis [1,2]. The patient presented classical manifestations of the multifocal chronic form, such as pulmonary involvement, dyspnea, odynophagia, weight loss, lymphadenopathy, manifestations in the oral mucosa and changes in the level of consciousness, requiring treatment in the hospital environment as well

Ethical statement

No ethical statement will be required for this manuscript.

Financial disclose

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Danila Silvana de Alexandria Santos: Writing – original draft. Gustavo Souza Galvão: Writing – original draft, Writing – review & editing, Investigation, Methodology. Priscila Fernandes Ribas: Supervision, Methodology, Investigation, Conceptualization. Maria Paula Siqueira de Melo Peres: Conceptualization, Investigation, Methodology, Supervision. Juliana Bertoldi Franco: Writing – original draft, Supervision, Methodology, Investigation, Conceptualization.

Declaration of Competing Interest

All authors declare that they have no conflict of interest.

Acknowledgement

We would like to offer our gratitude to all the colleagues at the Department of Dentistry, Critical Care Medicine and Infectology of Clinical Hospital of Medical School of the University of São Paulo for their helpful discussion and assistance.

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