Paracoccidioidomicose em transplantados renais
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Data
2021-02-25
Autores
Shiroma, Henrique Saburó
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
Introdução: Apesar da grande quantidade de transplantados renais expostos a regiões endêmicas de paracoccidioidomicose (PCM), poucos casos foram descritos nesta população. O presente estudo teve como objetivo ampliar esta casuística e revisar a literatura sobre o assunto. Métodos: Foram incluídos, retrospectivamente, os transplantados renais com diagnóstico de PCM atendidos por um centro brasileiro, no período entre 2013 e 2020. Foi realizada busca sistemática de casos de PCM em transplantados renais na literatura. Resultados e discussão: Foram identificados cinco casos em nosso centro e 12 na literatura. Dentre os 17 casos, 64,3% eram do sexo masculino, com faixa etária média de 50 anos. Todos os indivíduos apresentaram exposição epidemiológica relevante. Metade dos doadores eram falecidos. O tempo mediano entre o transplante renal (TxR) e o diagnóstico da PCM foi de 40 meses, variando entre 3 dias e 168 meses. O esquema de manutenção da imunossupressão mais prevalente ao diagnóstico foi tacrolimo/micofenolato/prednisona (41,7%). Febre e perda ponderal ocorreram, respectivamente, em 56,3% e 75,0% dos casos. A forma clínica identificada assemelhou-se mais com a forma crônica da PCM. Contudo, o quadro respiratório esteve mais presente, houve maior acometimento de trato gastrointestinal, e o acometimento de gânglios e mucosas aerodigestivas superiores foi menos frequente. Dentre os exames diagnósticos, destacaram-se o histopatológico e o micológico direto. A pesquisa de anticorpos revelou-se positiva em apenas 26,7% dos pacientes. O padrão de imagem pulmonar mais característico foram lesões nodulares em ambos os pulmões, algumas escavadas. A terapia com sulfametoxazol/trimetoprim induziu maior proporção de efeitos adversos e falhas terapêuticas. A profilaxia pós-TxR com sulfametoxazol/trimetoprim não foi capaz de prevenir a ativação da PCM em 42,9% dos pacientes. A mortalidade geral e específica da PCM foi elevada, alcançando 35,3% e 23,5%, respectivamente. Estudos multicêntricos devem ser realizados na busca de maior número de casos de PCM em transplantados renais.
Introduction: Despite the large number of renal transplant recipients exposed to endemic regions of paracoccidioidomycosis (PCM), few cases have been described in this population. The present study aimed to expand this series and review the literature on the subject. Methods: We retrospectively included kidney transplant recipients diagnosed with PCM treated by a Brazilian center, in the period between 2013 and 2020. A systematic search for PCM cases in kidney transplant recipients was carried out in the literature. Results and discussion: Five cases were identified in our center and 12 in the literature. Among the 17 cases, 64.3% were male, with an average age of 50 years. All individuals had relevant epidemiological exposure. Half of the donors were deceased. The median time between kidney transplantation (KTx) and the diagnosis of PCM was 40 months, ranging from 3 days to 168 months. The immunosuppression maintenance scheme most prevalent at diagnosis was tacrolimus / mycophenolate / prednisone (41.7%). Fever and weight loss occurred in 56.3% and 75.0% of cases, respectively. The clinical form identified was more similar to the chronic form of PCM. However, the respiratory picture was more present, there was a greater involvement of the gastrointestinal tract, and the involvement of upper aerodigestive ganglia and mucous membranes was less frequent. Among the diagnostic exams, histopathological and direct mycological tests stood out. Antibody testing was found to be positive in only 26.7% of patients. The most characteristic pulmonary imaging pattern was nodular lesions in both lungs, some of which were hollowed out. Sulfamethoxazole / trimethoprim therapy induced a higher proportion of adverse effects and therapeutic failures. Post-KTx prophylaxis with sulfamethoxazole / trimethoprim was not able to prevent PCM activation in 42.9% of patients. The general and specific mortality of PCM was high, reaching 35.3% and 23.5%, respectively. Multicenter studies should be carried out in the search for a greater number of cases of PCM in renal transplant recipients.
Introduction: Despite the large number of renal transplant recipients exposed to endemic regions of paracoccidioidomycosis (PCM), few cases have been described in this population. The present study aimed to expand this series and review the literature on the subject. Methods: We retrospectively included kidney transplant recipients diagnosed with PCM treated by a Brazilian center, in the period between 2013 and 2020. A systematic search for PCM cases in kidney transplant recipients was carried out in the literature. Results and discussion: Five cases were identified in our center and 12 in the literature. Among the 17 cases, 64.3% were male, with an average age of 50 years. All individuals had relevant epidemiological exposure. Half of the donors were deceased. The median time between kidney transplantation (KTx) and the diagnosis of PCM was 40 months, ranging from 3 days to 168 months. The immunosuppression maintenance scheme most prevalent at diagnosis was tacrolimus / mycophenolate / prednisone (41.7%). Fever and weight loss occurred in 56.3% and 75.0% of cases, respectively. The clinical form identified was more similar to the chronic form of PCM. However, the respiratory picture was more present, there was a greater involvement of the gastrointestinal tract, and the involvement of upper aerodigestive ganglia and mucous membranes was less frequent. Among the diagnostic exams, histopathological and direct mycological tests stood out. Antibody testing was found to be positive in only 26.7% of patients. The most characteristic pulmonary imaging pattern was nodular lesions in both lungs, some of which were hollowed out. Sulfamethoxazole / trimethoprim therapy induced a higher proportion of adverse effects and therapeutic failures. Post-KTx prophylaxis with sulfamethoxazole / trimethoprim was not able to prevent PCM activation in 42.9% of patients. The general and specific mortality of PCM was high, reaching 35.3% and 23.5%, respectively. Multicenter studies should be carried out in the search for a greater number of cases of PCM in renal transplant recipients.
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Palavras-chave
Paracoccidioidomicose, Transplante renal, Imunossupressão, Paracoccidioidomycosis, Kidney transplant recipients, Immunosuppression