Biological Health Hazard – Fatal Paracoccidiodomycosis: Rio de Janeiro, Brazil

PARACOCCIDIODOMYCOSIS – BRAZIL: (RIO DE JANEIRO) CONSTRUCTION-RELATED
**********************
Published Date: 2017-10-12 17:04:29
Subject: PRO/EDR> Paracoccidiodomycosis – Brazil: (RJ) construction-related
Archive Number: 20171012.5376808

Date: Thu 12 Oct 2017
Source: Emerg Infect Dis Volume 23, Number 11–November 2017 [edited]

Paracoccidioidomycosis after Highway Construction, Rio de Janeiro, Brazil
————————————————————————–
Paracoccidioidomycosis is the major systemic mycosis in Latin America and the leading fungal cause of death in immunocompetent persons in Brazil (1,2). Paracoccidioidomycosis is a neglected disease whose prevalence and incidence rates are underestimated because of lack of mandatory reporting. Infection follows inhalation of _Paracoccidioides spp._ conidia in the soil (3,4) and can progress to disease, typically manifested in 1 of 2 clinical forms. The 1st form is chronic (adult type), which accounts for ≈80 percent of paracoccidioidomycosis cases, mostly in rural workers who show fungal endogenous reactivation in the lungs and other organs later in life. The 2nd form is acute/subacute (juvenile type), which occurs primarily in young patients and is more severe because of progressive reticuloendothelial involvement, which results in high rates of complications, including death (5).

There have been reports of _Paracoccidioides spp._ infections after disturbances of soil that resulted in aerial dispersion of fungal propagules. Native indigenous populations in Latin America changed their ancient livelihood practices to cultivate coffee after deforestation of the Amazon rainforest, which resulted in paracoccidioidomycosis infections (6,7). In addition, climate changes related to the El Niño events, such as a high rainfall index followed by increased storage of water by soil and higher humidity, have been shown to occur before an increase of acute/subacute paracoccidioidomycosis cases (8).

We report an outbreak of paracoccidioidomycosis after deforestation and massive earth removal during construction of a highway in Rio de Janeiro, Brazil. The study protocol was approved by the Evandro Chagas National Institute of Infectious Diseases Research Ethics Committee (register CAAE 42590515.0.0000.5262).

The Evandro Chagas National Institute of Infectious Diseases in Rio de Janeiro is a reference center for paracoccidioidomycosis. This disease is endemic to the state of Rio de Janeiro (5). During 1988-2015, the annual average number of acute/subacute cases of paracoccidioidomycosis at this institution was 2.3 cases/year for this state and 1.4 cases/year for Baixada Fluminense, a region composed of 12 municipalities in the metropolitan area of Rio de Janeiro (Figure [for figure and tables, see original URL – Mod.LL). However, during December 2015-December 2016, a total of 8 cases were diagnosed at this center, all from Baixada Fluminense, a rate ≈5.7 times higher than that expected for this period. The most recent (2016) census in Brazil estimated that there were 968 680 persons <30 years of age living in the affected municipalities (9).

Case definition was based on clinical and laboratory criteria: reticuloendothelial involvement in young patients; laboratory test results confirming the presence of multibudding yeast-like _Paracoccidioides_ cells by direct microscopy or histopathologic analysis; fungal isolation in culture; or a positive serologic result for paracoccidioidomycosis (3). Data for the 8 case-patients (4 males and 4 females) are provided (Technical Appendix[PDF – 138 KB – 1 page] Table 1). Mean age was 22 (range 10-28) years. Median time for diagnosis was 7 (range 4-16) months. Predominant clinical manifestations were cervical lymph node enlargement (100 percent), hepatomegaly (25 percent), and splenomegaly (25 perent). Serious complications occurred in 5 patients: adrenal insufficiency (3 patients); cholestasis (1 patient), esophageal fistula (1 patient), and acute upper airway obstruction (1 patient). A 19-year-old patient died because of complications of paracoccidioidomycosis.

The Raphael de Almeida Magalhães Highway, also known as Arco Metropolitano, is a new highway in the study region (Figure). During its construction (2008-2014), large areas were deforested and massive amounts of earth were removed, which resulted in discovery of 62 archeological sites through 2012 (10). Two thirds of this highway (97 km) was constructed during 2012-2014. The highway was complete for one year before the number of new cases of paracoccidioidomycosis increased. Residence of patients was 0.1 km-16.6 km from construction areas. The increase in the number of acute/subacute cases of paracoccidioidomycosis, with temporal and geographic relationships to this construction, suggests a possible new risk for outbreaks of paracoccidioidomycosis.

Other hypotheses for this cluster are clearing of forests, soil humidity, and the El Niño phenomenon (3,8). It is noteworthy that the highway crosses a native Atlantic forest area. Moreover, over several months in 2013, this region had high rainfall indexes (Technical Appendix[PDF – 138 KB – 1 page] Table 2), which presumably contributed to retention of moisture in the soil. A previous study showed that soil humidity favors sporulation and dispersal of _Paracoccidioides spp._ (3). Also, a high-intensity El Niño phenomenon occurred during May 2015-March 2016.

The incidence of acute paracoccidioidomycosis in the affected area after highway construction (8.25 cases/1 million persons/y, 95 percent CI 4.18-16.3 cases/1 million persons/y) was higher than that before highway construction (1.29 cases/1 million persons/y, 95 percent CI 0.74-4.03 cases/one million persons/y). More persons were probably exposed to _Paracoccidioides_ conidia, but these persons did not show progression/development of disease, did not seek medical attention, and did not have cases reported to health authorities. The chronic form of paracoccidioidomycosis will probably develop in some of these patients.

This study underscores the need for paracoccidioidomycosis surveillance, especially in the context of environmental alterations enhanced by climate change and affected by construction, deforestation, and other human interventions. Enhanced surveillance will more fully identify relative risks of different human enterprises and facilitate interventions for at-risk populations to reduce and prevent future outbreaks of paracoccidioidomycosis.

References
—————–
1. Coutinho ZF, Silva D, Lazera M, et al: Paracoccidioidomycosis mortality in Brazil (1980-1995). Cad Saude Publica. 2002;18: 1441-1454.
2. Prado M, Silva MB, Laurenti R, Travassos LR, Taborda CP: Mortality due to systemic mycoses as a primary cause of death or in association with AIDS in Brazil: a review from 1996 to 2006. Mem Inst Oswaldo Cruz. 2009;104: 513-521.
3. Shikanai-Yasuda MA, Mendes RP, Colombo AL, et al: Brazilian guidelines for the clinical management of paracoccidioidomycosis. Rev Soc Bras Med Trop. 2017;0; [Epub ahead of print]
4. Franco M, Bagagli E, Scapolio S, da Silva Lacaz C: A critical analysis of isolation of _Paracoccidioides brasiliensis_ from soil. Med Mycol. 2000;38: 185-191.
5. de Macedo PM, Almeida-Paes R, Freitas DF, et al: Acute juvenile Paracoccidioidomycosis: A 9-year cohort study in the endemic area of Rio de Janeiro, Brazil. PLoS Negl Trop Dis. 2017;11:e0005500.
6. do Valle AC, Coimbra Júnior CE, Llinares FI, Monteiro PC, Guimarães MR: [Paracoccidioidomycosis among the indian group Suruí of Rondonia, Amazonia, Brazil. A case report] [in Portuguese]. Rev Inst Med Trop Sao Paulo. 1991;33: 407-411.
7. Coimbra Júnior CE, Wanke B, Santos RV, do Valle AC, Costa RL, Zancopé-Oliveira RM: Paracoccidioidin and histoplasmin sensitivity in Tupí-Mondé Amerindian populations from Brazilian Amazonia. Ann Trop Med Parasitol. 1994;88: 197-207.
8. Barrozo LV, Benard G, Silva ME, Bagagli E, Marques SA, Mendes RP: First description of a cluster of acute/subacute paracoccidioidomycosis cases and its association with a climatic anomaly. PLoS Negl Trop Dis. 2010;4:e643.
9. Brazilian Institute of Geography and Statistics. Cities, September 12, 2016 [in Portuguese] [cited 2017 June 29]. http://cidades.ibge.gov.br/xtras/perfil.php?codmun=330170
10. Press Rio de Janeiro News. Arco Metropolitan discovers new archaeological sites, Rio de Janeiro, Brazil, April 21, 2012 [in Portuguese] [cited 2017 May 29]. http://www.rj.gov.br/web/imprensa/exibeconteudo?article-id=869952

[Authors: Francesconi do Valle AC, Marques de Macedo P, Almeida-Paes R, Romão AR, dos Santos Lazéra M, Wanke B]

—
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Paracoccidioidomycosis (also known as Brazilian blastomycosis, South American blastomycosis, Lutz-Splendore-de Almeida disease and paracoccidioidal granuloma), is a fungal infection caused by the fungus _Paracoccidioides brasiliensis_. However, paracoccidioidomycosis is caused by a different fungus than that which causes blastomycosis.

_P. brasiliensis_ is another of the dimorphic fungi that exist in the soil and environment as a mold but when spores enter the body, usually via the respiratory route, a yeast develops that is the pathologic form for humans. It is interesting that the scientific name relates it to coccidiodomycosis, but it is often called South American blastomycosis, and its presentation tends to be more similar to histoplasmosis, with either acute or chronic lung involvement or dissemination to the liver, spleen and bone marrow with or without gastrointestinal ulcers.

The infection is limited to the Latin American countries with the most important regions of endemicity in Brazil, Columbia and Venezuela.

The yeast form found in lesions in the body has a very characteristic multibudding appearance, sometimes called “pilot’s wheel budding” as shown at http://en.wikipedia.org/wiki/File:Paracoccidioides_brasiliensis_01.jpg.

In recent years, a separate species of the genus has been characterized, _P. lutzii_, which can be serologically distinguished from _P. brasiliensis_ . (Gegembauer G, Mendes Araujo L, Pereira ED, FM, et al. Serology of paracoccioidomycosis due to _Paracoccidoides lutzii_. PLoS Neglect Trop dis 2014;8:e2986). It is not clear if the pathogenicity of the 2 species differ. – Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/1650.]

See Also

2015
—-
Paracoccidioidomycosis – Argentina (northeast) 20150306.3208164
………………………………………….ll/ec/dk

Source:
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases

---