A surprising diagnosis of paracoccidioidomycosis from routine bacterial culture of chronic finger lesions.

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 on isavuconazole, which has been shown to be effective in the treatment of Paracoccidioides in a small phase 3 trial. Unfortunately, we were unable to observe clinical response to isavuconazole 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.