Choroidal granuloma caused by ?Paracoccidioides brasiliensis?
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c a u s e d b y 'Paracoccidioides brasiliensis'
A clinical and angiographic study* P. P. Bonomo l, R. Belfort Jr l, J. Y. Tsunechiro ~ & O. G. Filho 2
From Department of Ophthalmology of Escola Paulista de Medicina, S6o Paulo, Brasil 2From Department of Pathology ofEscola Paulista de Medicina, S6o Paulo, Brasil
Abstract A 48 year-old-female with a choroidal granuloma presented a systemic picture of paracoccidioidomycosis proven by rhinopharyngeal biopsy. The clinical picture, the differential diagnosis and the therapeutic test are discussed. This is the first time that the fluorescein angiography is described in such cases. Resumo Paciente de 48 anos de idade com um granuloma de coroide apresentou quadro sist~mico de paracoceidioidomieose provado por bi6psia de lesao da rinofaringe. Sao discutidos os aspectos clinicos, diagn6sticos diferenciais e prova terap~utica. Esta 6 a primeira vez que se descreve a angiografia fluoresceinica num caso destes.
Paracoccidioidomycosis is a chronic granulomatous infection produced by 'Parar brasiliensis" affecting viscera, mucosa and skin. Despite its many clinical forms, there is a tendency today to believe that its main entry way into the host's body is through the respiratory tract and that its dissemination takes place through the blood or lymphatic system (1). Ocular involvement is rare in paracoccidioidomycosis, and it usually affects the lid and the conjunctiva, when present (2, 3, 9, 10). Cases of possible choroidal granuloma have been much more rarely described (4, 6). This study is justified by the investigation of the clinical and ocular angiographic aspects of a patient presenting a choroidal granuloma associated to the systemic clinical picture and a proven rhinopharyngeal lesion caused by paracoccidioidomycosis. *This study was supported by 'Centro de Estudos de Oftalmologia Moacyr E. Alvaro'.
LMS, 48 years old, female, rural worker. The patient complained of periorbital pain on the left side, starting five months before with blurred vision, and appearance of nodes in the neck, axillary and inguinal regions, and slight loss of weight.
Mycopathologia77, 37-41 (1982). 0301 486x/82/0771-0037/$1.00. 9 Dr W. Junk Publishers, The Hague. Printed in The Netherlands.
Physical examination Various cervical, axillary and inguinal nodes painless, movable, hard and smooth, with 1 cm in diameter. Ulcerated lesion in the rhinopharynx with abundant macerated material.
Ophthalmologic examination Normal right eye. The left eye presented visual acuity of hand movements at 30 cm, intra-ocular pressure of 14 mm Hg and absence of inflammatory
38 Figs. l, 2 and3. Fluorescein angiography of the gr~inuloma in the left eye before treatment.
Fig. I. Red-free photography showing choroidal mass.
Fig. 3. Late phase with central hipofluorescencein the area of the granuloma and impregnation of its borders.
Fig. 2. Capillary phase with blocked fluorescence of the fundus.
39 Figs. 4 and 5. Biopsyof rhinopharyngeallesion.
Fig. 4. Foreignbody granulomas are seen as part of the inflammation of soft tissues. There are also multinucleated giant-cells and micro-organismsidentifiedas Paracoecidioides brasiliensis (H. E. Stain, medium-powerview).
Fig. 5. With Grocott's staining the P. brasiliensis are observed much more easier (highpower view).
signs in the anterior segment. The fundus of the eye showed an oval shaped yellowish mass at the choroid level with 2 disc diameter (D.D.) in diam -~ eter. It was situated in the superior temporal region and was surrounded by pigment disorganization. A serous detachment of the retina was found over such mass, going from the peri-pappilar region to the equator, engulfing the macula (Fig. 1). No vitreous reaction was observed. The fluorescein angiography (Figs. 1, 2 and 3) evidentiated a blocked choroidal fluorescence up to the capillary phase, starting from there on a slight impregnation of the granulomatous mass, to be completed in the late phases. There was no evidence of intragranulomatous vessels.
Subsidiary e x a m i n a t i o n
Hemossedimentation rate: 116 ram. Chest X-ray: nodular reticular infiltrate in the upper fields. P.P.D.: negative. Serum a n t i - M y c o b a c t e r i u m tuberculosis precipitin test: no reaction. Wassermann and VDRL: no reaction. FTA-ABS: negative. Conjunctival biopsy: slight non-specific lymphomonocytic infiltrate. Absence of granuloma. Kvein's test: negative. Biopsy of rhinopharyngeal lesion: positive for P. brasiliensis (Figs. 4 and 5).
The patient was treated with Amphotericin B and Hydrocortisone hemosuccinate. Evolution
A new examination 3 months after the treatment had begun, indicated weight gain, ganglionic regression, normalization of the pulmonary X-ray picture and healing of the rhinopharyngeal lesion. The ocular examination showed unaltered intraocular pressure and visual acuity. Absence of the serous detachtment of the retina and flattening of the yellowish mass of the choroid, with pigment disorganization and glial proliferation in the macula (Fig. 6). The fluorescein angiography showed a constant blocked fluorescence in the region occupied by the granuloma, troughout the angiogram. A transmitted fluorescence appeared surrounding the involuted granuloma and impregnated the glial proliferation zone (Figs. 7 and 8). A new P.P.D. skin test performed at that time was negative. An examination made 1 year later showed no alteration.
A sure diagnosis of choroidal granuloma caused by P. brasiliensis can be reached through the
40 Figs. 6, 7 and 8. Fluorescein angiography of the same eye 3 months after treatment.
Fig. 6. Red-free photography showing disorganization in the retinal pigment epithelium and glial proliferation in the macular zone.
Fig. 8. Late phase with persistent blocked fluorescence in the granuloma site and total impregnation with fluorescein in the macular glial proliferation area.
Fig. 7. Capillary phase with blocked fluorescence and beginning of impregnation in the macular region.
41 pathological or mycological examination of the eye lesion only. When microscopic examination of the e y e lesion is not feasible, the diagnosis can be reached only by excluding other possible causes of a choroidal granuloma (7), and a positive therapeutic test. The diagnosis of systemic paracoccidioidomycosis was reached in this case through the biopsy of the rhinopharyngeal lesion. The main other causes of a similar ocular picture have been eliminated, namely syphilis, sarcoidosis and tuberculosis 9(5). The possibility of a luetic granuloma was eliminated by the negative serological tests. Although it was clinically unlike, sarcoidosis was also set aside by the negative biopsy of the conjunctival and the Kvein's test. Tuberculosis was eliminated mainly by the negative P.P.D., maintained after treatment, and also by the serologic reactions and by the effective therapeutic response to Amphotericin B and to hydrocortisone. Since the laboratory tests proved the patient to be affected by paracoccidioidomycosis, and all other causes for a similar choroidal granuloma had been eliminatted - and since the patient positively responded to the specific treatment, the final diagnosis made was of choroidal granuloma caused by P. brasiliensis. The fluorescein angiography showed the lesion to be in the choroid itself and did not evidentiated the rich intra-granulomatous vascularization described in tuberculomas (5). It was different from the characteristic angiograms of choroidal melanomas and similar to the angiographic pictures of choroid metastatic tumors (8). In the case described by Brick (4) the initial lesion presented also retinal involvement and no laboratory or therapeutic tests were made. The case was lost to follow-up after the first ocular examination. In the case described by Dantas (6), the ocular lesion also similar to ours, presented neovascularization, which seems to be more frequent in tuber-
culosis (5). Neither of the above described the fluorescein angiographic aspects. As far as we know this is the first time in the literature that the fluorescein angiography is described in a case of choroidal granuloma caused by P. brasiliensis.
Acknowledgements We would like to thank Olga Fischman (from Department of Microbiology and Parasitology of Escola Paulista de Medicina, Sao Paulo - Brasil) that helped us in the preparation of this paper.
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