Male, 56 years old, rural worker monteador, smoker.
It begins three months before the consultation with fever, cough, expectoration and dyspnea.
She received amoxicillin with partial improvement.
One month later, the symptoms worsened, adding general repercussion.
On examination, erythema multiforme on the face, trunk and limbs; respiratory failure; and diffuse dry crackling rales.
Chest radiography and HRCT showed extensive bilateral fibrotic pulmonary involvement, cavities with sprouts inside and mediastinal adenopathies with necrosis.
Axial CT of the abdomen showed enlarged adrenal glands.
It is caused by prolonged respiratory symptoms, fever, with general repercussion, and bilateral fibrotic pulmonary involvement, with multiple cavities and nodules: pulmonary tuberculosis or deep mycosis of the adult, chronic form of cavitary disease, with extensive glass content.
The mediastinal adenopatic involvement with necrosis and adrenal necrosis is compatible with these lesions.
As for the deep mycoses, given the clinical presentation imaging, the patient's history and in our environment, it is suggested that this entity is due to mycosis or histoplasmosis, both endemic mycoses.
As a differential diagnosis systemic vasculitis is suggested, and as Churg-Strauss disease given the type of cutaneous involvement that was not typical of the proposed deep mycoses, or Wegener's lung disease.
Laboratory studies were as follows: hemoglobin, 10.2 g/dL; platelets, 563,000/mm3; white blood cells, 9,400 positive/mm3; eosinophils, 3%; VES, 130 mm/h; normal bronchial blood cell culture; negative anti-HIV, negative antibodies
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Given the diagnostic difficulty and the persistence of symptoms under empirical treatment for nonspecific germs, it is decided to refer the patient to a referral center where the fibrobronchrony with BAL is repeated.
Direct mycological examination of fresh yeasts revealed abundant multibacillary yeasts with the morphological characteristics of P. brasiliensis.
Direct mycological examination with Giemsa and Gomori staining revealed yeasts of P. brasiliensis and H. capsulatum.
In Sabouraud medium cultures maintained at 28oC for 4 weeks, P. brasiliensis and H. capsulatum grew.
In serology with double diffusion, antibodies against P. brasiliensis and H. capsulatum were detected.
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The patient presented asthenia and dizziness with hypotension, and cortico-adrenal insufficiency was suggested, which was confirmed by orthostatic adrenocorticotropic hormone (HHH) curve and elevated basal ACTH.
Treatment with amphotericin B showed improvement after one month, followed by itraconazole six months after which it was stable, with residual fibrotic sequelae.
