Paracoccidioidomycosis masquerading as Crohn\'s disease

PARACOCCIDIOIDOMYCOSIS MASQUERADING AS CROHN’S DISEASE

B

A

D

C A 43-year-old man presented with abdominal pain, nausea, vomiting, and weight loss (20 kg) of 8 months duration. On physical examination there was a palpable cervical lymph node and a painful, firm mass in the periumbilical region. Colonoscopy was performed and a diagnosis of Crohn’s disease was made. He was treated with corticosteroids (initially prednisone 60 mg/day) but did not improve.

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GASTROINTESTINAL ENDOSCOPY

There was a history of pharyngeal paracoccidioidomycosis that was treated 2 years ago with itraconazole. Laboratory tests were within normal limits except for an elevated sedimentation rate. Colonoscopy was repeated and this disclosed multiple, shallow ulcers with indistinct borders covered with fibrin in the ascending colon and cecum. A large ulcer was found, with indistinct margins in the

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cecum (A); in the mid-ascending colon (B); and near the hepatic flexure (C). The cecum was deformed, making it impossible to enter the terminal ileum. The colonoscopic picture was again thought to be compatible with Crohn’s disease. However, biopsies revealed paracoccidioidomycosis brasiliensis granuloma in the intestinal wall. A giant cell with fungi and multiple granules and a mother cell with multiple budding forms were found (D, arrow; methenamine silver, orig. mag. ×500). After a few

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days of treatment with oral trimethoprim-sulfamethoxazole the patient noted symptomatic improvement. Marcelo de Souza Cury, MD Bruno de Souza Ribeiro, MD Patrícia Piauilino Costa, MD Vinícius Machado de Lima, MD Sender Jankiel Mizsputen, MD Angelo Paulo Ferrari, MD São Paulo, Brazil doi:10.1067/mge.2000.104004

GASTROINTESTINAL ENDOSCOPY

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