Acute paracoccidioidomycosis worsened by immunosuppressive therapy due to a misdiagnosis of Crohn's disease.

Paracoccidioidomycosis (PCM) is a systemic mycosis endemic in Latin America, mostly in Brazil. The involvement of the gastrointestinal tract is uncommon and usually associated with the acute form. Recently, a cluster of acute PCM cases has been described in Rio de Janeiro, Brazil. We report a 42-year-old male, resident of Rio de Janeiro, presenting chronic diarrhea and abdominal pain in the past 3 years, previously diagnosed as Chron´s disease. When immunosuppressive therapy was prescribed, the patient evolved with worsening of the previous symptoms in addition to odynophagia, 20 kg-weight loss, disseminated skin lesions, diffuse lymphadenopathy and adrenal insufficiency. Histopathological and mycological examination of a skin lesion were compatible with PCM. Itraconazole was prescribed in high doses (400 mg/day). After seven months of treatment, the patient presented with acute abdominal pain which led to an emergent appendectomy, revealing the presence of the fungus. After 24 months, the patient reached clinical cure and recovered from adrenal insufficiency. We emphasize the importance of PCM as a differential diagnosis in patients with chronic diarrhea. The risk of fungal infections should be considered prior to initiating immunosupressive therapies, particularly in endemic areas. Author summary: Paracoccidioidomycosis is a systemic mycosis caused by inhalation of fungi belonging to the genus Paracoccidioides. It is endemic in Latin America, mainly affects rural workers and is still a neglected disease. In most cases, it affects multiple organs at the same time, mainly lungs, skin and mucosa of the upper aerodigestive tract, while involvement of the gastrointestinal tract is rare. We report a case misdiagnosed as inflammatory bowel disease (Crohn´s disease). The immunosuppressive therapy led to the worsening of existing symptoms, to the involvement of other organs and then the correct diagnosis of PCM was revealed. The reported case demonstrates the importance of early diagnosis of this mycosis and the risk of starting immunosuppressive therapy in these patients. Furthermore, the place of residence and period in which the patient presented the disease coincides with recent changes in the epidemiology of the disease in the state of Rio de Janeiro, Brazil. [ABSTRACT FROM AUTHOR]