Have a look at the dilemma post first– then test your knowledge

The correct answer is fungal infection. This was a case of Paracoccidiodes braziliensis, an endemic dimorphic fungal organism seen in South and Central America, with 60-80% of cases occuring in Brazil. The patient’s geographic location, the slow progression of symptoms, his fistulous and ulcerative lesions, and involvement of both the pulmonary and GI tracts should raise suspicion for this infectious process.

The mode of transmission of this infection is not entirely clear, but it is thought to be through water sources. The fungus causes a progressive systemic illness, with oral, GI and respiratory ulcers and fistulas progressively developing over time, along with adrenal insufficiency (which explains this patient’s eosinophilia!). It also affects the lungs, causing dyspnea and cough over time, but tends to spare the lung apices. Diagnosis is based on cultures and biopsy, with classically shows a ‘Captain’s Wheel’ or ‘Pilot’s Wheel’ appearance culture is fairly sensitive. Treatment is long term sulfa or azole therapy; both regimens are equivalent in terms of their efficacy.

Parasites can cause some of these symptoms (dyspnea with Strongyloides, ulcerating skin lesions with Leishmania) but no parasitic infection fits all of the above symptoms, when compared to Paracoccidiodes. Chagas disease, which occurs in South America/Brazil, also affects the GI tract but it specifically results in dilation of the colon and esophagus, and not ulcerative lesions like what the patient had. With respect to bacterial infections, Pinta (Treponema infection) can produce similar skin lesions, but these occur mostly in young children. Mycobacterium could present with some of the above symptoms, but the risk factors for TB were not overtly made present in this case, making it less, especially in the absence of fevers, night sweats, hemoptysis and weight loss. No viruses would classically cause the symptoms noted above, making them less likely. Autoimmune disorders such as Goodpasture’s disease and Granulomatosis with polyangitis (Wegener’s granulomatosis) can cause upper respiratory tract ulcers, but do not involve the GI tract. These disorders also tend to involve the kidneys, which was not the case in this patient (creatinine was normal). Disorders such as Lupus and RA also would usually not present this late in life initially, and generally do not cause lesions similar to what the patient had.

Hope you enjoyed figuring this case out! Feedback and comments are always welcome!