Biliary Paracoccidioidomycosis: An Unusual Infection Simulating Malignant Neoplasm
Klaus Steinbrück
, Reinaldo Fernandes
Corresponding author
Hepatobiliary Surgery, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, Brazil
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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Ann Hepatol. 2019;18:250-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 286 "formatos" => array:3 [ "EPUB" => 18 "HTML" => 200 "PDF" => 68 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "250" "paginaFinal" => "257" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 998 "Ancho" => 1000 "Tamanyo" => 90089 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Superior mesenteric venogram demonstrating a patent superior mesenteric vein with a moderate sized peristomal varix and nidus.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "John Romano, Charles V. Welden, Jordan Orr, Brendan McGuire, Mohamed Shoreibah" "autores" => array:5 [ 0 => array:2 [ "nombre" => "John" "apellidos" => "Romano" ] 1 => array:2 [ "nombre" => "Charles V." "apellidos" => "Welden" ] 2 => array:2 [ "nombre" => "Jordan" "apellidos" => "Orr" ] 3 => array:2 [ "nombre" => "Brendan" "apellidos" => "McGuire" ] 4 => array:2 [ "nombre" => "Mohamed" "apellidos" => "Shoreibah" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119303321?idApp=UINPBA00004N" "url" => "/16652681/0000001800000001/v2_201907270857/S1665268119303321/v2_201907270857/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "titulo" => "Biliary Paracoccidioidomycosis: An Unusual Infection Simulating Malignant Neoplasm" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "258" "paginaFinal" => "262" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Klaus Steinbrück, Reinaldo Fernandes" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Klaus" "apellidos" => "Steinbrück" "email" => array:1 [ 0 => "steinbruck@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:2 [ "nombre" => "Reinaldo" "apellidos" => "Fernandes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hepatobiliary Surgery, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, Brazil" "identificador" => "aff1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0015" "etiqueta" => "<span class="elsevierStyleBold">Figure 2.A.</span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1657 "Ancho" => 1863 "Tamanyo" => 468473 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Patient 1: area of granuloma containing fungal spherical elements (arrow) compatible with P. brasiliensis, H&E stain x400. B. Patient 2: fungal structures with budding affecting lymph node, Grocott’s methenamine silver stain x400. C and D. Patient 3 and 4: fungal structure with characteristic “Mickey Mouse” and “steering wheel” budding, respectively, Grocott’s methenamine silver stain x400.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Introduction</span><p id="p0010" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis (PCM) is one of the most important deep mycoses in Latin America<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> and was originally described by Adolfo Lutz in 1908.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a> The etiologic agent is the dimorphic fungus <span class="elsevierStyleItalic">Paracoccidioides brasiliensis.</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> It presents itself in two major forms: subacute (3-5% of cases), affecting mostly children and young adults, frequently compromising the reticuloendothelial system,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1,3</span></a> and chronic (90% of cases), involving predominantly adult males, normally affecting lungs, lymph nodes and skin.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1,3</span></a> Identification of the fungus in the affected tissue (paracoccidioidal granuloma) or culture of exudate establishes diagnosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> Herein we describe four cases of PCM simulating cholangiocarcinoma.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Case Report</span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Patient 1</span><p id="p0015" class="elsevierStylePara elsevierViewall">A 53-year-old man, from the rural area of Rio de Janeiro, Brazil, was admitted with a three-month history of jaundice, pruritus, acholic stools, choluria and weight loss of 10 kg. He denied fever. Physical examination revealed a painful and palpable left liver lobe in the epigastrium. No peripheral lymphadenopathy was detected. Anemia and elevated liver enzymes and bilirubin were present (<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>). Tumor markers (CEA and CA19-9) were normal. Thorax X-ray was normal. Abdominal ultrasonography showed hepatomegaly, intrahepatic left bile duct dilatation without perihilar linphadenomegaly and an empty gallbladder. MRI confirmed left bile duct dilatation without extrinsic compression (<a class="elsevierStyleCrossRef" href="#f0010">Figure 1A</a>).</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">Two years earlier, he had been diagnosed with ganglionar PCM located in the cervical region and has been being treated since with itraconazole 200 mg/day. No history of other diseases or previous surgery was known.</p><p id="p0025" class="elsevierStylePara elsevierViewall">An early stage intrahepatic cholangiocarcinoma was suspected and the patient was referred to surgery. Left hepatectomy with common bile duct resection and Roux-en-Y biliary-enteroanastomosis reconstruction was performed. He was discharged without complications after seven days. Histopathological evaluation revealed areas of cavitation and biliary abscesses in the liver, in which fungal elements compatible with <span class="elsevierStyleItalic">P. brasiliensis</span> were present (<a class="elsevierStyleCrossRef" href="#f0015">Figure 2A</a>). After diagnosis of biliary PCM, treatment with itraconazole was resumed. One year after surgery, he developed a new episode of ganglionar PCM in the inguinal region. He is doing well, six years after hepatectomy.</p><elsevierMultimedia ident="f0015"></elsevierMultimedia></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Patient 2</span><p id="p0030" class="elsevierStylePara elsevierViewall">A 22-year-old man, from Rio de Janeiro was transferred from a primary hospital with one-month history of jaundice associated with diarrhea and a substantial weight loss of 20 kg. He denied fever or abdominal pain. No peripheral lymphadenopathy was found. No morbidities were known. No history of rural work or previous fungal disease was reported. Laboratory exams confirmed anemia and elevation of serum bilirubin as well as liver enzymes (<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>). Serology for hepatitis and HIV were negative. MRI showed an infiltrative mass inside the hepatocholedocus, with restricted diffusion, obstructing primary and secondary biliary ducts, especially in the right side (<a class="elsevierStyleCrossRef" href="#f0010">Figure 1B</a>), suggestive of extra-hepatic cholangiocarcinoma.</p><p id="p0035" class="elsevierStylePara elsevierViewall">The patient was submitted to laparotomy. The liver had some whitish lesions suggestive of secondary implants. A large quantity of lymph nodes was observed in the hepatic hilum, hepatic artery and para-aortic. A frozen section biopsy of the liver and para-aortic lymph node did not show malign neoplasia. Transcystic cholangiography showed obstruction of the passage of contrast through the distal bile duct. The illness was considered to be at an advanced stage, and surgical team decided to perform cholecystectomy, internal/external drainage of the biliary tract, lymph node excision, and biopsies. After surgery, he developed biliary fistula and pancreatitis and responded well to clinical therapy. Microscopic analysis revealed granulomatous chronic inflammatory process affecting the gallbladder, liver and lymph nodes, associated to numerous giant multinucleated cells and fungal structures compatible with <span class="elsevierStyleItalic">P. brasiliensis</span> (<a class="elsevierStyleCrossRef" href="#f0015">Figure 2B</a>). After 30 days of intravenous amphotericin B, the patient left the hospital in a generally good state, taking itraconazole orally. The biliary drain was removed after one year and, five years after surgery, the patient is doing well.</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Patient 3</span><p id="p0040" class="elsevierStylePara elsevierViewall">A 53-year-old woman was transferred from a primary hospital from the rural area of Rio de Janeiro with a three-month history ofjaundice, pruritus, acholia, choluria and weight loss of 13 kg. At the primary hospital, she was submitted to percutaneous transhepatic cholangiography, which showed intrahepatic biliary dilatation and main bile duct blockage. An internal-external biliary drain was placed at the same time (<a class="elsevierStyleCrossRef" href="#f0010">Figure 1C</a>). Admission blood tests showed anemia and elevated serum bilirubin and canalicular enzymes (<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>). CT scan confirmed biliary dilatation above hepatic confluence and identified gallbladder with thick and infiltrated wall, compatible with cholecystitis, as well as para-aortic and celiac trunk lym-phadenomegaly. The patient was considered to have advanced illness and treatment was limited to antibiotic therapy for cholecystitis, once biliary tract was already drained. After 9 days, she presented abdominal sepsis and underwent emergency laparotomy. During surgery, choledocoduodenal fistula, cholecystitis and inflammatory pseudotumoral involvement of duodenum were identified. The emergency team opted to perform cholecystectomy, Billroth II distal gastrectomy, and mesenteric lymph node biopsy. After surgery, the patient experienced cholangitis, but responded well to antibiotics. Histopathological evaluation revealed granulomatous chronic inflammatory process with round fungal structures, compatible with <span class="elsevierStyleItalic">P. brasiliensis</span> affecting the gallbladder, gallstones, mesenteric lymph node, and stomach wall (<a class="elsevierStyleCrossRef" href="#f0010">Figure 2C</a>). The patient received amphotericin B for 30 days and was discharged 47 days after surgery taking itraconazole orally. The biliary drain was detached one year after surgery and patient is well and asymptomatic, 38 months after surgery.</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Patient 4</span><p id="p0045" class="elsevierStylePara elsevierViewall">A 48-year-old woman from Rio de Janeiro was admitted with a two-month history of abdominal pain, cholestatic jaundice and weight loss of 12 kg. She had arterial hypertension, which was under control, and had undergone a hysterectomy 10 years before, due to myomatosis. No peripheral lymphadenopathy was found. Laboratory tests confirm cholestasis (<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>). MRI showed obstruction of main bile duct next to the confluence (<a class="elsevierStyleCrossRef" href="#f0010">Figure 1D</a>). The patient was submitted to percutaneous biliary drainage and posteriorly referred to surgery.</p><p id="p0050" class="elsevierStylePara elsevierViewall">Bilateral subcostal laparotomy was performed. Hepatic pedicle had a thick tissue evocative of malignant infiltration. Lymphadenomegaly was present in the hepatic hilum, as well as celiac trunk and retropancreatic. An analysis of these lymph nodes revealed caseous material with frozen section negative for neoplasia. An inflammatory or infectious pathology was suspected. As the biliary tract was already drained, no other procedure was performed. Anatomopathological examination revealed granulomatous chronic inflammatory process with round fungal structures with budding, compatible with P. brasiliensis (<a class="elsevierStyleCrossRef" href="#f0015">Figure 2D</a>). The postoperative period was uneventful. She received amphotericin B intravenously for 30 days and completed treatment with oral itraconazole. Biliary drain was removed after 10 months. The patient is in good shape, with mild canalicular enzymes elevation 32 months after surgery.</p></span></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Discussion</span><p id="p0055" class="elsevierStylePara elsevierViewall">PCM constitutes a serious public health problem because it is potentially quite disabling, affecting people during the economically productive years, predominantly male individuals (1 female : 10-15 male).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> It is considered to be the third leading cause of death from chronic infectious disease, in Brazil.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> About 80% of the cases reported occurred in Brazil and most of the remaining ones occurred in Venezuela, Colombia and Argentina.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> In Mexico, the endemic area is located in the South between the Gulf of Mexico and the Pacific Coast.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a></p><p id="p0060" class="elsevierStylePara elsevierViewall">The pathogen agent is the dimorphic fungus <span class="elsevierStyleItalic">Paracoccidioides brasiliensis,</span> which is present in nature in filaments containing infective propagules called conidia. Once inhaled, the propagules give rise to fungi yeast forms that will constitute their parasitic form in host tissues.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a></p><p id="p0065" class="elsevierStylePara elsevierViewall">The major risk factor for infection are professions or activities related to management of soil contaminated with the fungus, such as agricultural activities, earthmoving, soil preparation, gardening, and transport of plant goods. Contamination is primarily acquired in the first two-decade of life, but the presentation of clinical manifestations occurre more frequently in adults between 30 and 50 years, after reactivation of latent endogenous focus.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">Abdominal involvement in PCM is normally seen in the sub-acute form, with a wide variety of clinical manifestations, ranging from nausea, vomiting, ascites, jaundice, variable abdominal pain, hepatosplenomegaly, malabsorption syndrome, tumor mass, intestinal obstruction, peritonitis, and mesenteritis, to even acute perforative abdomen.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3,5</span></a> Jaundice usually appears at a late stage, and it is associated with more severe disease.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> It is normally caused by extrinsecal compression of the common bile duct by lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> Other causes described are intraluminar granulomatous lesion of the common bile duct (intrinsic lesion), hepatic lesion caused by blastomycotic hepatitis and pancreatic PCM. <a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">6-8</span></a></p><p id="p0075" class="elsevierStylePara elsevierViewall">In the cases reported here, the presence ofjaundice associated with other symptoms, as well as imaging exams compatible with cholangiocarcinoma, led us to this misdiagnosis. Patient 1 had a segmental intrahepatic biliary obstruction, which was probably caused by portal granulomas, as described by Brito, <span class="elsevierStyleItalic">et al.</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> Patient 2 displayed a mass causing obstruction of choledocus, compatible with intraluminar granulomatous lesion of the common bile duct. Patients 3 and 4 were misdiagnosed with Bismuth type 1 and 2 Klatskin tumor respectively. In both cases, extrinsecal compression of the common bile duct by lymph nodes and hepatic hilum inflammatory infiltration caused by PCM infection were posteriorly considered the reasons for biliary obstruction.</p><p id="p0080" class="elsevierStylePara elsevierViewall">Once the diagnostic hypothesis was cholangiocarcinoma, patients 1, 2 and 4 were submitted to intention-to-treat surgery. Patient 3 was considered to have advanced neoplasia, but underwent emergency surgery due to abdominal sepsis. Choledocoduodenal fistula was identified, which is a complication of PCM infection not yet described. In all cases, diagnosis of PCM was confirmed after anatomopathological examination of specimen. In patient 3, even the gallbladder and stomach were involved with <span class="elsevierStyleItalic">P. brasiliensis.</span></p><p id="p0085" class="elsevierStylePara elsevierViewall">After PCM was diagnosed, patients were investigated for fungal involvement of other organs, like lungs, skin, nasopharynx or lymph nodes and specific treatment was proposed. The usual therapy involves antifungal drugs, such as sulfanilamide derivatives, azole compounds and amphotericin B, which has been used in advanced cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> Patient 1 was already using itraconazole, due to a past history of ganglionar PCM, and treatment was resumed. Patients 2, 3 and 4 manifested the disease in a more advanced state and were initially treated with amphotericin B, which was changed to itraconazole after hospital discharge. Recommended dosage of itraconazole is 200 mg per day. Treatment can last up to 24 months and should not be interrupted.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> A cure for PCM patients may never be achieved because there is always a chance of later recurrence, as could be observed with patient 1.</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Conclusion</span><p id="p0090" class="elsevierStylePara elsevierViewall">The cases reported here are good examples of infectious disease mimicking a neoplasm. In the presence of obstructive jaundice and suspicion of cholangiocarcinoma, in Brazil and other endemic areas in Latin America, we should regard PCM as a differential diagnosis, particularly if the patient has a previous history of infection by <span class="elsevierStyleItalic">Paracoccidioides brasiliensis.</span></p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Abbreviations</span><p id="p0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">•</span><p id="p0100" class="elsevierStylePara elsevierViewall">PCM: paracoccidioidomycosis.</p></li></ul></p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Conflicts of Interest</span><p id="p0105" class="elsevierStylePara elsevierViewall">The authors declares that there is no conflict of interest regarding the publication of this article.</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Supportive Foundations</span><p id="p0110" class="elsevierStylePara elsevierViewall">There was no funding source.</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Disclosure</span><p id="p0115" class="elsevierStylePara elsevierViewall">Patient 1 has been published previously as a case report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1224776" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1138842" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "s0010" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "s0015" "titulo" => "Case Report" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "s0020" "titulo" => "Patient 1" ] 1 => array:2 [ "identificador" => "s0025" "titulo" => "Patient 2" ] 2 => array:2 [ "identificador" => "s0030" "titulo" => "Patient 3" ] 3 => array:2 [ "identificador" => "s0035" "titulo" => "Patient 4" ] ] ] 4 => array:2 [ "identificador" => "s0040" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "s0045" "titulo" => "Conclusion" ] 6 => array:2 [ "identificador" => "s0050" "titulo" => "Abbreviations" ] 7 => array:2 [ "identificador" => "s0055" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "s0060" "titulo" => "Supportive Foundations" ] 9 => array:2 [ "identificador" => "s0065" "titulo" => "Disclosure" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-12" "fechaAceptado" => "2018-01-30" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1138842" "palabras" => array:4 [ 0 => "Paracoccidioidomycosis" 1 => "Cholangiocarcinoma" 2 => "Biliary tract" 3 => "Liver" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Paracoccidioidomycosis is a systemic granulomatous disease caused by the dimorphic fungus <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span> and is restricted to Latin America. It normally affects lungs, skin and lymph nodes. Abdominal organs are usually not involved. In rare cases paracoccidioidomycosis may simulate neoplasm. Herein we describe our experience with four cases of paracoccidioidomycosis mimicking cholangiocarcinoma. To the best of our knowledge, this is the largest case series on this subject produced in English. Paracoccidioidomycosis must be considered as a differential diagnosis of cholangiocarcinoma, especially in individuals who come from endemic areas.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "f0010" "etiqueta" => "<span class="elsevierStyleBold">Figure 1.A</span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1651 "Ancho" => 2074 "Tamanyo" => 255079 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Patient 1: MR T2-weighted showing an important biliary tree dilatation, mostly in left duct. B. Patient 2: MRI image showing an infiltrative mass inside the hepatocholedocus (arrow heads), C. Patient 3: Percutaneous cholangiography during biliary drain placement. Main duct blockage is evidenced (arrow heads). D. Patient 4: MR T2-weighted showing obstruction of common bile duct with upstream dilatation.</p>" ] ] 1 => array:7 [ "identificador" => "f0015" "etiqueta" => "<span class="elsevierStyleBold">Figure 2.A.</span>" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1657 "Ancho" => 1863 "Tamanyo" => 468473 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Patient 1: area of granuloma containing fungal spherical elements (arrow) compatible with P. brasiliensis, H&E stain x400. B. Patient 2: fungal structures with budding affecting lymph node, Grocott’s methenamine silver stain x400. C and D. Patient 3 and 4: fungal structure with characteristic “Mickey Mouse” and “steering wheel” budding, respectively, Grocott’s methenamine silver stain x400.</p>" ] ] 2 => array:7 [ "identificador" => "t0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Blood test \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient 3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient 4 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alkaline phosphatase (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3,848 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">561 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">268 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2,503 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GGT (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4,402 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">463 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">481 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3,892 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AST (U/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">264 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">207 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ALT (U/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">174 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">180 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total bilirubin (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Direct bilirubin (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092118.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Admission patients’ blood tests results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0010" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consenso de paracoccidioidomicose." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Shikanai-Yasuda M.A." 1 => "Telles Filho F.Q." 2 => "Mendes R.P." 3 => "Colombo A.R." 4 => "Moretti M.A." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Soc Bras Med Trop" "fecha" => "2006" "volumen" => "39" "paginaInicial" => "297" "paginaFinal" => "310" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16906260" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0015" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Uma mycose pseudococcidica localizada na bocca e observada no Brazil. Contribuipao ao conhecimento das hyphoblastomycoses americanas." 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"autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Brito T." 1 => "de Castro R.M." 2 => "Shiroma M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Inst Med Trop" "fecha" => "1968" "volumen" => "10" "paginaInicial" => "188" "paginaFinal" => "191" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/16652681/0000001800000001/v2_201907270857/S1665268119303333/v2_201907270857/en/main.assets" "Apartado" => array:4 [ "identificador" => "77718" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/16652681/0000001800000001/v2_201907270857/S1665268119303333/v2_201907270857/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119303333?idApp=UINPBA00004N" ]
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| 2024 October | 12 | 2 | 14 |
| 2024 September | 20 | 2 | 22 |
| 2024 August | 26 | 2 | 28 |
| 2024 July | 29 | 1 | 30 |
| 2024 June | 18 | 1 | 19 |
| 2024 May | 22 | 3 | 25 |
| 2024 April | 36 | 5 | 41 |
| 2024 March | 18 | 6 | 24 |
| 2024 February | 32 | 10 | 42 |
| 2024 January | 26 | 3 | 29 |
| 2023 December | 28 | 9 | 37 |
| 2023 November | 30 | 5 | 35 |
| 2023 October | 45 | 2 | 47 |
| 2023 September | 37 | 4 | 41 |
| 2023 August | 35 | 3 | 38 |
| 2023 July | 42 | 5 | 47 |
| 2023 June | 25 | 2 | 27 |
| 2023 May | 49 | 4 | 53 |
| 2023 April | 20 | 0 | 20 |
| 2023 March | 32 | 0 | 32 |
| 2023 February | 31 | 5 | 36 |
| 2023 January | 19 | 8 | 27 |
| 2022 December | 12 | 9 | 21 |
| 2022 November | 23 | 11 | 34 |
| 2022 October | 34 | 11 | 45 |
| 2022 September | 36 | 13 | 49 |
| 2022 August | 30 | 9 | 39 |
| 2022 July | 26 | 7 | 33 |
| 2022 June | 17 | 11 | 28 |
| 2022 May | 21 | 21 | 42 |
| 2022 April | 30 | 18 | 48 |
| 2022 March | 30 | 8 | 38 |
| 2022 February | 25 | 5 | 30 |
| 2022 January | 33 | 8 | 41 |
| 2021 December | 27 | 11 | 38 |
| 2021 November | 27 | 9 | 36 |
| 2021 October | 28 | 14 | 42 |
| 2021 September | 28 | 11 | 39 |
| 2021 August | 44 | 14 | 58 |
| 2021 July | 24 | 5 | 29 |
| 2021 June | 25 | 7 | 32 |
| 2021 May | 37 | 12 | 49 |
| 2021 April | 95 | 11 | 106 |
| 2021 March | 50 | 5 | 55 |
| 2021 February | 28 | 7 | 35 |
| 2021 January | 27 | 14 | 41 |
| 2020 December | 10 | 5 | 15 |
| 2020 November | 15 | 13 | 28 |
| 2020 October | 6 | 6 | 12 |
| 2020 September | 21 | 8 | 29 |
| 2020 August | 22 | 9 | 31 |
| 2020 July | 25 | 11 | 36 |
| 2020 June | 17 | 5 | 22 |
| 2020 May | 15 | 6 | 21 |
| 2020 April | 16 | 2 | 18 |
| 2020 March | 13 | 1 | 14 |
| 2020 February | 10 | 3 | 13 |
| 2020 January | 8 | 5 | 13 |
| 2019 December | 13 | 5 | 18 |
| 2019 November | 5 | 1 | 6 |
| 2019 October | 6 | 2 | 8 |
| 2019 September | 12 | 4 | 16 |
| 2019 August | 2 | 2 | 4 |
| 2019 July | 7 | 4 | 11 |
| 2019 June | 8 | 8 | 16 |
| 2019 May | 9 | 12 | 21 |
Show all
