A Rare Case of Chronic Laryngitis

Abstract

INTRODUCTION: We report a case of reactivation of latent paracoccidioidomycosis. CASE PRESENTATION: A 41 year old man with a history of alcohol and tobacco use presented with dysphonia for over one year. He also complained of significant weight loss and a nonproductive cough. He denied fevers, rashes, or other symptoms. He stated he emigrated from Brazil over 10 years ago and was currently working as a landscaper. Work up revealed normal blood work with the exception of a minimally elevated C-reactive protein. Imaging of the neck and thorax revealed cervical lymphadenopathy, a paratracheal mass, multiple, bilateral cavitating lung nodules, and lower lobe fibrosis. Fiberoptic bronchoscopy was performed and noted large, diffuse mass like lesions on the vocal cords but no endobronchial lesions. Patient underwent endobronchial ultrasound with fine needle aspiration of the paratracheal mass lesion and biopsy of the vocal cord lesion. The pathology demonstrated multinucleated giant cells containing yeast with multiple daughter buds surrounding the parent form; consistent with the diagnosis of Paracoccidioidomycosis. DISCUSSION: Paracoccidioides brasiliensis lives in the soil of Central and South America, predominantly in Brazil. There, an estimated 10% of the population is affected, with the highest prevalence in male farm workers between the ages of 30 and 60. Acute infection is usually silent but in children may involve the liver, spleen, and gastrointestinal tract. However, systemic mycotic disease can develop months to years after the primary infection. This reactivation involves the lungs, oropharynx, or the laryngeal mucosa in up to 70% of patients. Patient complaints are often nonspecific including cough, dysphonia, odynophagia, and dyspnea. Blood tests are usually unrevealing. The radiographic findings can be varied and nonspecific. A few of the most common findings on chest computed tomography include parenchymal ground-glass attenuation, nodules, cavitations, and fibrosis. The gold standard for diagnosis is microscopic visualization of fungal elements on biopsy or in sputum. Infection carries a high mortality rate of up to 30%. Pulmonary sequelae can include chronic respiratory failure from fibrosis, bullae formation, emphysema, glottic and tracheal stenosis. CONCLUSIONS: With the increase in immigration from endemic areas, a rise in reported cases of Paracoccidioidomycosis is seen in nonendemic regions including the United States. Therefore, suspicion must be high in these patients.