A surprising diagnosis of paracoccidioidomycosis from routine bacterial culture of chronic finger lesions - Case report

Sep 29, 2026

Paracoccidioidomycosis is a systemic mycosis endemic to Central and South America. The case report describes an 89-year-old woman with cutaneous paracoccidioidomycosis and major comorbidities that limited first-line therapy. She presented with progressive ulcerating finger lesions unresponsive to antibiotics. Biopsy showed yeast, and routine bacterial culture grew Paracoccidioides brasiliensis within 5 days. Itraconazole was contraindicated; she was switched from sulfamethoxazole-trimethoprim due to renal dysfunction and hyperkalemia. She was started on isavuconazole, but clinical response could not be observed due to death from advanced heart disease.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Abstract

Background

Case Summary

Conclusion

| Editor’s Pick | Clinical Microbiology | Case Report A surprising diagnosis of paracoccidioidomycosis from routine bacterial culture of chronic finger lesions Nikita Jaggernauth,1 Juan Pineda-Reyes,2 Claire Zurlo,3 Devin M. Weber,1 Matthew A. Pettengill,2 Nathan P. Wiederhold,4 Connie Cañete-Gibas,4 Courtney E. Comar2 AUTHOR AFFILIATIONS See affiliation list on p. 6. ABSTRACT Background Paracoccidioidomycosis is a systemic mycosis endemic to Central and South America. Here, we describe an unusual case of an elderly female with cutaneous paracoccidioidomycosis and comorbidities limiting the use of first-line therapeutic agents. Case Summary An 89-year-old female with a past medical history of advanced systolic heart failure presented with decompensated heart failure along with chronic, progressive ulcerating lesions involving multiple fingers, unresponsive to antibiotic therapy. A biopsy showed evidence of yeast on pathology and samples grew Paracoccidioides brasiliensis within 5 days on routine bacterial culture. Further history revealed that she lived in Trinidad and Tobago for periods during her childhood and had visited Ecuador for 2 weeks decades prior. Due to her history of advanced congestive heart failure on dobutamine and ventricular arrhythmias, first-line therapy with itraconazole was contraindicated. Sulfamethoxazole-trimethoprim was initiated; however, she developed progressive renal dysfunction and hyperkalemia attributed to sulfamethoxazole-trimethoprim, necessitating a change in therapy. The patient was ultimately started onisavuconazole, which has been shown to be effective in the treatment of Paracoccidioidesin a small phase 3 trial. Unfortunately, we were unable to observe clinical response toisavuconazole in our patient due to her demise in the setting of advanced heart disease. Conclusion This case highlights the variable nature of paracoccidioidomycosis, with our patient having a prolonged latency prior to development of clinical signs and symptoms, an unusual diagnosis by growth in routine bacterial culture, and the need for further research in alternative therapeutic options. KEYWORDS fungal infections, endemic mycoses P aracoccidioidomycosis is a mycosis caused by the thermally dimorphic fungi, Paracoccidioides species, endemic to Central and South America with rare cases reported in the United States (US) . Diagnostic options for Paracoccidioides infections are limited in the US, primarily relying on culture or histopathologic findings. Here, we present a case of paracoccidioidomycosis diagnosed by growth of the yeast form in bacterial culture in an elderly patient with chronic, cutaneous lesions who had a remote travel history with no sustained endemic exposure. CASE PRESENTATION An 89-year-old female with a history of cardiac amyloidosis complicated by advanced systolic heart failure, on prolonged intravenous inotropes, secondary to cardiac Editor Nicholas M. Moore, Rush University Medical Center, Chicago, Illinois, USA Address correspondence to Courtney E. Comar, [courtney.comar@jefferson.edu](courtney.comar@jefferson.edu). N. P.W. has received research support to UT Health San Antonio from Basilea, bioMerieux, Bruker, F2G, Mycovia, Elion Therapeutics (formerly Sfunga amyloidosis, presented with an 8-week history of painful ulcerative lesions on multiple fingers. The patient noted a 1-year history of intermittent ulcers involving multiple fingers with spontaneous resolution. Eight weeks prior to admission, she noted the onset of painful nodules involving multiple fingers, which ulcerated over time. She denied preceding trauma, erythema, purulence, fever, or chills. At her long-term care facility, she received daily wound care and a 2-week course of empiric vancomycin and cefepime with some transient improvement. Of note, the patient was born in New York City, grew up in Trinidad and Tobago, andover her lifetime, spent time between the United States, Trinidad and

FAQs

How was paracoccidioidomycosis diagnosed in this patient?

A biopsy showed yeast on pathology, and Paracoccidioides brasiliensis grew within 5 days on routine bacterial culture. Initial stains on pathology did not show organisms.

Why was first-line itraconazole therapy not used?

Itraconazole was contraindicated due to the patient’s advanced congestive heart failure on dobutamine and ventricular arrhythmias.

What treatment changes occurred after antibiotics and initial therapy?

Sulfamethoxazole-trimethoprim was started but led to progressive renal dysfunction and hyperkalemia, prompting a change. The patient was ultimately started on isavuconazole, though clinical response could not be assessed after her demise.

Sep 29, 2026

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