ABSTRACT Paracoccidioidomycosis caused by Paracoccidioides lutzii is endemic in the Midwest of Brazil and its clinical spectrum is still little known due to the recent identification of this fungal species. A patient resident in Southeast Brazil, but who had lived for many years in the Midwest region, presented with skin injuries, chronic cough and bilateral adrenal involvement. Paracoccidioides spp. was isolated in culture from a skin lesion biopsy. This isolate was later identified as P. lutzii using gene sequencing. A favorable initial response to treatment with itraconazole was observed, but a few weeks later, the patient developed respiratory failure and worsening of lung lesions. Evaluation by computed tomography and echocardiography were suggestive of pulmonary arterial hypertension, and a bronchoscopic biopsy showed peribronchial remodeling. The patient completed the antifungal treatment but maintained the respiratory dysfunction. The reported case shows that P. lutzii can be isolated from patients in a geographic area far from the place of infection acquisition and that, as P. brasiliensis , it can cause adrenal injury and cardio-respiratory complications as a consequence of excessive necrosis and fibrosis.

Abstract Phylogenetic species of Paracoccidioides brasiliensis complex (S1a and S1b, PS2, PS3, and PS4) and Paracoccidioides lutzii are agents of paracoccidioidomycosis, an endemic fungal disease in Latin America. P. restrepiensis (PS3 genotype) was classified as monophyletic and geographically restricted to Colombia and neighboring territories. BAT (or Pb-327B) was isolated from a patient living in the southeast region of Brazil but with genotype similar to Colombian Paracoccidioides spp. strains. This study aimed to define the phylogenetic species of BAT isolate by using additional genotyping methods, as well as reviewing the epidemiological and clinical studies related to P. restrepiensis isolates. Genomic DNA of BAT isolate and reference strains of P. brasiliensis sensu stricto (S1b), P. americana (PS2), P. restrepiensis (PS3), and P. lutzii were analyzed by conventional polymerase chain reaction (PCR) of partial gp43 exon 2 loci, by PCR-RFLP technique of tub1 gene, and by sequencing of the whole gp43 exon 2 loci. Here, we show that BAT isolate belongs to P. restrepiensis species, which is an unusual identification in southeastern Brazil, where P. brasiliensis sensu stricto is the prevalent genotype. This identification has relevance for geographical distribution and propagation of the genus Paracoccidioides in South America.

Resumo A paracoccidioidomicose (PCM) é uma micose sistêmica, relacionada às atividades agrícolas, com incidência e prevalência subestimadas, pela ausência de notificação em várias Unidades da Federação (UFs). A evolução insidiosa do quadro clínico pode ter como consequência sequelas graves se o diagnóstico e o tratamento não forem instituídos precoce e adequadamente. Ao lado do complexo Paracoccidioides brasiliensis (P. brasiliensis), a descrição de nova espécie, Paracoccidioides lutzii (P. lutzii), em Rondônia, onde a doença alcançou níveis epidêmicos, bem como na região Centro-Oeste e no Pará, constituem-se em desafios para a instituição do diagnóstico e a urgente disponibilização de antígenos que tenham reatividade com os soros dos pacientes. Este consenso visa atualizar o primeiro consenso brasileiro em PCM, estabelecendo recomendações para o manejo clínico do paciente, com base nas evidências conhecidas. São apresentados dados de etiologia, epidemiologia, imunopatogenia, diagnóstico, terapêutica e sequelas, enfatizando-se o diagnóstico e a terapêutica, bem como recomendações e desafios atuais nessa área do conhecimento.

Abstract Paracoccidioidomycosis is a systemic fungal disease associated with agricultural activities. Its incidence and prevalence are underestimated because of the lack of reporting in several Brazilian states. If paracoccidiodomycosis is not diagnosed and treated early and adequately, endemic fungal infection may result in serious sequelae. In addition to the Paracoccidioides brasiliensis (P. brasiliensis) complex, the appearance of a new species, Paracoccidioides lutzii (P. lutzii), in Rondônia state, where the disease has reached epidemic levels, and in the country’s Midwest region and Pará state, are challenges to diagnosis and to the urgent availability of antigens that are reactive with patients’ sera. These guidelines aim to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. The guidelines provide data on etiology, epidemiology, immunopathogenesis, diagnosis, treatment and sequelae, with emphasis on diagnosis and treatment, as well as current recommendations and challenges in this field of knowledge.

Resumen La paracoccidioidomicosis es una micosis sistémica, relacionada con las actividades agrícolas, con incidencia y prevalencia subestimadas por la ausencia de notificación en varios estados. La evolución insidiosa del cuadro clínico puede tener como consecuencia secuelas graves si el diagnóstico y el tratamiento no se establecen precoz y adecuadamente. Al lado del complejo Paracoccidioides brasiliensis (P. brasiliensis), la descripción de nueva especie, Paracoccidioides lutzii (P. lutzii) en Rondonia, donde la enfermedad alcanzó niveles epidémicos, y en la región Centro Oeste y en Pará, se constituyen en desafíos para la institución del diagnóstico y la urgente puesta a disposición de antígenos que tengan reactividad con los sueros de los pacientes. El presente consenso tiene por objeto actualizar el primer consenso brasileño en paracoccidioidomicosis, estableciendo recomendaciones para el manejo del paciente al borde del lecho, con base en las evidencias conocidas. Se presentan datos de etiología, epidemiología, inmunopatogenia, diagnóstico, terapéutica y secuelas, enfatizando el diagnóstico y terapéutica, así como recomendaciones desafíos y actuales en esta área del conocimiento.

Resumo A paracoccidioidomicose (PCM) é uma micose sistêmica, relacionada às atividades agrícolas, com incidência e prevalência subestimadas, pela ausência de notificação em várias Unidades da Federação (UFs). A evolução insidiosa do quadro clínico pode ter como consequência sequelas graves se o diagnóstico e o tratamento não forem instituídos precoce e adequadamente. Ao lado do complexo Paracoccidioides brasiliensis (P. brasiliensis), a descrição de nova espécie, Paracoccidioides lutzii (P. lutzii), em Rondônia, onde a doença alcançou níveis epidêmicos, bem como na região Centro-Oeste e no Pará, constituem-se em desafios para a instituição do diagnóstico e a urgente disponibilização de antígenos que tenham reatividade com os soros dos pacientes. Este consenso visa atualizar o primeiro consenso brasileiro em PCM, estabelecendo recomendações para o manejo clínico do paciente, com base nas evidências conhecidas. São apresentados dados de etiologia, epidemiologia, imunopatogenia, diagnóstico, terapêutica e sequelas, enfatizando-se o diagnóstico e a terapêutica, bem como recomendações e desafios atuais nessa área do conhecimento.

Abstract Paracoccidioidomycosis is a systemic fungal disease associated with agricultural activities. Its incidence and prevalence are underestimated because of the lack of reporting in several Brazilian states. If paracoccidiodomycosis is not diagnosed and treated early and adequately, endemic fungal infection may result in serious sequelae. In addition to the Paracoccidioides brasiliensis (P. brasiliensis) complex, the appearance of a new species, Paracoccidioides lutzii (P. lutzii), in Rondônia state, where the disease has reached epidemic levels, and in the country’s Midwest region and Pará state, are challenges to diagnosis and to the urgent availability of antigens that are reactive with patients’ sera. These guidelines aim to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. The guidelines provide data on etiology, epidemiology, immunopathogenesis, diagnosis, treatment and sequelae, with emphasis on diagnosis and treatment, as well as current recommendations and challenges in this field of knowledge.

Resumen La paracoccidioidomicosis es una micosis sistémica, relacionada con las actividades agrícolas, con incidencia y prevalencia subestimadas por la ausencia de notificación en varios estados. La evolución insidiosa del cuadro clínico puede tener como consecuencia secuelas graves si el diagnóstico y el tratamiento no se establecen precoz y adecuadamente. Al lado del complejo Paracoccidioides brasiliensis (P. brasiliensis), la descripción de nueva especie, Paracoccidioides lutzii (P. lutzii) en Rondonia, donde la enfermedad alcanzó niveles epidémicos, y en la región Centro Oeste y en Pará, se constituyen en desafíos para la institución del diagnóstico y la urgente puesta a disposición de antígenos que tengan reactividad con los sueros de los pacientes. El presente consenso tiene por objeto actualizar el primer consenso brasileño en paracoccidioidomicosis, estableciendo recomendaciones para el manejo del paciente al borde del lecho, con base en las evidencias conocidas. Se presentan datos de etiología, epidemiología, inmunopatogenia, diagnóstico, terapéutica y secuelas, enfatizando el diagnóstico y terapéutica, así como recomendaciones desafíos y actuales en esta área del conocimiento.

Abstract Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis ( P. brasiliensis ) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii ( P. lutzii ), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients’ sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

BACKGROUND Fluorescence in situ hybridisation (FISH) associated with Tyramide Signal Amplification (TSA) using oligonucleotides labeled with non-radioactive fluorophores is a promising technique for detection and differentiation of fungal species in environmental or clinical samples, being suitable for microorganisms which are difficult or even impossible to culture. OBJECTIVE In this study, we aimed to standardise an in situ hybridisation technique for the differentiation between the pathogenic species Paracoccidioides brasiliensis and Paracoccidioides lutzii, by using species-specific DNA probes targeting the internal transcribed spacer-1 (ITS-1) of the rRNA gene. METHODS Yeast and mycelial phase of each Paracoccidioides species, were tested by two different detection/differentiation techniques: TSA-FISH for P. brasiliensis with HRP (Horseradish Peroxidase) linked to the probe 5’ end; and FISH for P. lutzii with the fluorophore TEXAS RED-X® also linked to the probe 5’ end. After testing different protocols, the optimised procedure for both techniques was accomplished without cross-positivity with other pathogenic fungi. FINDINGS The in silico and in vitro tests show no reaction with controls, like Candida and Cryptococcus (in silico) and Histoplasma capsulatum and Aspergillus spp. (in vitro). For both phases (mycelial and yeast) the in situ hybridisation showed dots of hybridisation, with no cross-reaction between them, with a lower signal for Texas Red probe than HRP-TSA probe. The dots of hybridisation was confirmed with genetic material marked with 4’,6-diamidino-2-phenylindole (DAPI), visualised in a different filter (WU) on fluorescent microscopic. MAIN CONCLUSION Our results indicated that TSA-FISH and/or FISH are suitable for in situ detection and differentiation of Paracoccidioides species. This approach has the potential for future application in clinical samples for the improvement of paracoccidioidomycosis patients prognosis.

RESUMOPara comemorar o centenário de aniversário do Prof. Dr. Carlos da Silva Lacaz, os autores fazem um breve relato dos estudos sobre a biologia, ecologia e filogenia molecular que culminaram na revelação da espécie Paracoccidioides lutzii, que havia permanecido escondida por mais de um século ao lado de Paracoccidioides brasiliensis. O professor Lacaz exerceu papel central no desenvolvimento desta área do conhecimento, pois manteve interesse permanente nas pesquisas deste fungo e da paracoccidioidomicose, visando principalmente proporcionar benefícios aos pacientes acometidos por esta micose.

SUMMARYTo commemorate Prof. Carlos da Silva Lacaz's centennial anniversary, the authors have written a brief account of a few, out of hundreds, biological, ecological, molecular and phylogenetic studies that led to the arrival of Paracoccidioides lutzii, hidden for more than a century within Paracoccidioides brasiliensis. Lacaz's permanent interest in this fungus, and particularly his conviction on the benefits that research on paracoccidioidomycosis would bring to patients, were pivotal in the development of the field.

Over the last decades, there have been important changes in the epidemiology of Candida infections. In recent years, Candida species have emerged as important causes of invasive infections mainly among immunocompromised patients. This study analyzed Candida spp. isolates and compared the frequency and biofilm production of different species among the different sources of isolation: blood, urine, vulvovaginal secretions and peritoneal dialysis fluid. Biofilm production was quantified in 327 Candida isolates obtained from patients attended at a Brazilian tertiary public hospital (Botucatu, Sao Paulo). C. albicans ALS3 gene polymorphism was also evaluated by determining the number of repeated motifs in the central domain. Of the 198 total biofilm-positive isolates, 72 and 126 were considered as low and high biofilm producers, respectively. Biofilm production by C. albicans was significantly lower than that by non-albicans isolates and was most frequently observed in C. tropicalis. Biofilm production was more frequent among bloodstream isolates than other clinical sources,in urine, the isolates displayed a peculiar distribution by presenting two distinct peaks, one containing biofilm-negative isolates and the other containing isolates with intense biofilm production. The numbers of tandem-repeat copies per allele were not associated with biofilm production, suggesting the evolvement of other genetic determinants.

We aimed to evaluate whether the occurrence of cryptic species of Paracoccidioides brasiliensis, S1, PS2, PS3 and Paracoccidioides lutzii, has implications in the immunodiagnosis of paracoccidioidomycosis (PCM). Small quantities of the antigen gp43 were found in culture filtrates of P. lutzii strains and this molecule appeared to be more variable within P. lutzii because the synonymous-nonsynonymous mutation rate was lower, indicating an evolutionary process different from that of the remaining genotypes. The production of gp43 also varied between isolates belonging to the same species, indicating that speciation events are important, but not sufficient to fully explain the diversity in the production of this antigen. The culture filtrate antigen AgEpm83, which was obtained from a PS3 isolate, showed large quantities of gp43 and reactivity by immunodiffusion assays, similar to the standard antigen (AgB-339) from an S1 isolate. Furthermore, AgEpm83 was capable of serologically differentiating five serum samples from patients from the Botucatu and Jundiaí regions. These patients had confirmed PCM but, were non-reactive to the standard antigen, thus demonstrating an alternative for serological diagnosis in regions in which S1 and PS2 occur. We also emphasise that it is not advisable to use a single antigen preparation to diagnose PCM, a disease that is caused by highly diverse pathogens.

INTRODUÇÃO: Piedra branca é micose superficial causada por fungos do gênero Trichosporon e caracterizado por nódulos firmemente aderidos à haste do pêlo. MÉTODOS: Os autores relatam casos familiares encaminhados como pediculose. Foram utilizados cultura em ágar Mycosel® e identificação molecular. RESULTADOS: Exame micológico revelou a infecção por Trichosporon spp. A identificação molecular demonstrou se tratar do Trichosporon inkin. CONCLUSÕES: Piedra branca e infecção pelo T. inkin são raramente relatados na região sudeste do Brasil. A identificação molecular é essencial para correta determinação de espécies no gênero Trichosporon.

INTRODUCTION: White piedra is a superficial mycosis caused by the genus Trichosporon and characterized by nodules on hair shaft. METHODS: The authors report a family referred to as pediculosis. Mycological culture on Mycosel® plus molecular identification was performed to precisely identify the etiology. RESULTS: A Trichosporon spp. infection was revealed. The molecular procedure identified the agent as Trichosporon inkin. CONCLUSIONS: White piedra and infection caused by T. inkin are rarely reported in Southern Brazil. The molecular tools are essentials on identifying the Trichosporon species.

INTRODUÇÃO: Infecções fúngicas na pele humana (como a esporotricose) podem se manifestar após traumatismos por peixes. O objetivo deste trabalho é procurar fungos patogênicos para o homem em peixes fluviais. MÉTODOS: Extração de arcadas dentárias Serrassalmus maculatus (piranha) e Hoplias malabaricus (traíra), ferrões de Pimelodus maculatus (mandis), raios da nadadeira dorsal de Plagioscion spp. (corvina) e Tilapia spp. para a realização do cultivo em agar Mycosel. Algumas culturas foram submetidas à extração de DNA para a identificação molecular pelo seqüenciamento da região ITS-5.8S do rDNA. RESULTADOS: As culturas mostraram que a maioria das leveduras era Candida spp. e o sequenciamento também permitiu a identificação de Phoma spp. e Yarrowia lipolytica. CONCLUSÕES: Embora a pesquisa para S. schenckii tenha sido negativa, a presença de fungos do gênero Phoma e Candida revela o potencial patogênico desta via de infecção. O gênero Phoma está envolvido em alguns casos de feohifomicoses, micoses subcutâneas causadas por fungos dematiáceos com relatos de infecções em órgãos e sistemas humanos. As estruturas traumatizantes de alguns peixes fluviais apresentam fungos patogênicos e esta pode ser uma importante via de infecção que deve ser considerada em algumas regiões do Brasil, uma vez que há um grande número de pescadores e peixes traumatogênicos.

INTRODUCTION: Fungal infections in human skin, such as sporotrichosis, can occur after fish induced trauma. This work aimed to identify fungi in freshwater fish that are pathogenic to humans. METHODS: Extraction of dental arches from Serrassalmus maculatus (piranha) and Hoplias malabaricus (wolf fish), stings from Pimelodus maculatus (mandis catfish), dorsal fin rays from Plagioscion spp. (corvina) and Tilapia spp., for culture in Mycosel agar. Some cultures were submitted to DNA extraction for molecular identification by sequencing ITS-5.8S rDNA. RESULTS: Cultures identified most yeast as Candida spp., while sequencing also permitted the identification of Phoma spp. and Yarrowia lipolytica. CONCLUSIONS: While the search for S. schenckii was negative, the presence of fungus of the genera Phoma and Candida revealed the pathogenic potential of this infection route. The genus Phoma is involved in certain forms of phaeohyphomycosis, a subcutaneous mycosis caused by dematiaceous fungi, with reports of infections in human organs and systems. Traumatizing structures of some freshwater fish present pathogenic fungi and this may be an important infection route that must be considered in some regions of Brazil, since there are a large number of a fisherman in constant contact with traumatogenic fish.

Leprosy is still a worldwide public health problem. Brazil and India show the highest prevalence rates of the disease. Natural infection of armadillos Dasypus novemcinctus with Mycobacterium leprae has been reported in some regions of the United States. Identification of bacilli is difficult, particularly due to its inability to grow in vitro. The use of molecular tools represents a fast and sensitive alternative method for diagnosis of mycobacteriosis. In the present study, the diagnostic methods used were bacilloscopy, histopathology, microbiology, and PCR using specific primers for M. leprae repetitive sequences. PCR were performed using genomic DNA extracted from 138 samples of liver, spleen, lymph nodes, and skin of 44 D. novemcinctus, Euphractus sexcinctus, Cabassous unicinctus, and C. tatouay armadillos from the Middle Western region of the state of São Paulo and from the experimental station of Embrapa Pantanal, located in Pantanal da Nhecolândia of Mato Grosso do Sul state. Also, the molecular analysis of 19 samples from internal organs of other road killed species of wild animals, such as Nasua nasua (ring-tailed coati), Procyon cancrivoros (hand-skinned), Cerdocyon thous (dog-pity-bush), Cavia aperea (restless cavy), Didelphis albiventris (skunk), Sphigurrus spinosus (hedgehog), and Gallictis vittata (ferret) showed PCR negative data. None of the 157 analyzed samples had shown natural mycobacterial infection. Only the armadillo inoculated with material collected from untreated multibacillary leprosy patient presented PCR positive and its genomic sequencing revealed 100% identity with M. leprae. According to these preliminary studies, based on the used methodology, it is possible to conclude that wild mammals seem not to play an important role in the epidemiology of leprosy in the Middle Western region of the São Paulo state and in the Pantanal of Mato Grosso do Sul state.

Medical mycology has greatly benefited from the introduction of molecular techniques. New knowledge on molecular genetics has provided both theoretical and practical frameworks, permitting important advances in our understanding of several aspects of pathogenic fungi. Considering Paracoccidioides brasiliensis in particular, important eco-epidemiological aspects, such as environmental distribution and new hosts were clarified through molecular approaches. These methodologies also contributed to a better understanding about the genetic variability of this pathogen; thus, P. brasiliensis is now assumed to represent a species complex. The present review focuses on some recent findings about the current taxonomic status of P. brasiliensis, its phylogenetic and speciation processes, as well as on some practical applications for the molecular detection of this pathogen in environmental and clinical materials.

Inteins or "internal proteins" are coding sequences that are transcribed and translated with flanking sequences (exteins). After translation, the inteins are excised by an autocatalytic process and the host protein assumes its normal conformation and develops its expected function. These parasitic genetic elements have been found in important, conserved proteins in all three domains of life. Most of the eukaryotic inteins are present in the fungi kingdom and the PRP8 intein is one of the most widespread inteins, occurring in important pathogens such as Cryptococcus neoformans (varieties grubii and neoformans), Cryptococcus gattii, Histoplasma capsulatum and Paracoccidioides brasiliensis. The knowledge of conserved and non-conserved domains in inteins have opened up new opportunities for the study of population variability in pathogenic fungi, including their phylogenetic relationships and recognition or diagnoses of species. Furthermore, inteins in pathogenic fungi should also be considered a promising therapeutic drug target, since once the autocatalytic splicing is inhibited, the host protein, which is typically vital, will not be able to perform its normal function and the fungal cell will not survive or reproduce.

Paracoccidioides brasiliensis causes paracoccidioidomycosis (PCM) that is one of the most prevalent systemic human mycoses in Latin America. Armadillos show a high incidence of PCM infection and could, therefore, be a natural reservoir for this fungus. In this study were compared the virulence profiles of isolates obtained from nine-banded armadillos (Dasypus novemcinctus) (PbT1 and PbT4) and isolates from PCM patients (Pb265 and Bt83). Pathogenicity was evaluated by fungal load and analysis of colony morphology. Immunity against the fungus was tested by delayed type hypersensitivity test (DTH) and antibody quantification by ELISA. The higher virulence of PbT1 and PbT4 was suggested by higher fungal load in spleen and lungs. Armadillo isolates and Bt83 presented a cotton-like surface contrasting with the cerebriform appearance of Pb265. All isolates induced cellular and humoral immune responses in infected BALB/c mice. DTH reactions were similarly induced by the four isolates, however, a great variability was observed in specific antibody levels, being the highest ones induced by Bt83 and PbT4. The present work confirms that armadillos harbor P. brasiliensis, whose multiplication and induced immunity in experimentally infected mice are heterogeneous, resembling the behavior of isolates from human PCM. This study reinforces the possibility that armadillos play an important role in the biological cycle of this pathogen.