Chronic Paracoccidioidomycosis of the Intestine as Single Organ Involvement Points to an Alternative Pathogenesis of the Mycosis

Current knowledge on the natural history of paracoccidioidomycosis states that the chronic form of the disease results from reactivation of quiescent foci established years or decades before during the primary lung infection. Once reactivated, the fungi can disseminate to virtually any organ or system. We present herein two chronic paracoccidioidomycosis patients with a single organ involvement that points to an alternative pathogenesis of the mycosis. These patients suggest that the chronic form may also arise from reactivation of foci not confined to the lungs, due to the early dissemination of yeast cells during the primary infection.     

Pathology of the human pulmonary paracoccidioidomycosis

Lungs of twelve patients with chronic paracoccidioidomycosis (Pb) were studied in an attempt to understand the pathogenesis of the pulmonary disease. Ribbons of the lung parenchyma including the hilar region and directed towards apical, basal and lateral regions were subdivided into sections from the hilar, intermediate and peripheral segments. The following histopathological reactions directly or indirectly related to P. brasiliensis were described and analysed in relation to the number of slides studied and the pulmonary region involved: (1) pneumonic reaction; (2) early granulomatous formation; (3) mature and healed granulomata; (4) mixed pattern (early and mature granuloma in the same pulmonary area visualized in the slide); (5) pulmonary fibrosis.It was concluded that chronic pulmonary Pb is a recurrent disease affecting equally both lungs. Fibrosis was connected mainly with the progressive evolution of the granulomata towards cicatrization and to a lesser degree probably to a direct induction by the fungi. Based chiefly on the tendency of the fibrosis to run around bronchi and to make up septa interconnecting bronchi and vessels it was hipothesized that these findings were the result of a previous chronic specific lymphangitis by the fungi. Hilar fibrosis would be the result of this lymphangitis and/or of the progression of the specific granulomatous reaction seen in the hilar lymph nodes.Non specific forms of arteritis and areas of destructive emphysema related to granulomatous inflammation and fibrosis were described. Three cases developed pulmonary hypertension.     

Virulence of Paracoccidioides brasiliensis: The influence of in vitro passage and storage

Stability of virulence in P. brasiliensis isolates was studied with respect to the in vitro culture history and methods used for storage. Virulence in yeast-form P. brasiliensis isolates was tested in a chronic pulmonary murine model of paracoccidioidomycosis where progression of disease was quantitated in terms of colony forming units recoverable from lungs. Four isolates of P. brasiliensis, including recently isolated from patients or experimental animals, caused chronic progressive disease. Two isolates with a history of subculturing showed attenuation by causing resolving but chronic disease. An attenuated isolate became avirulent subsequent to 15 more years of subculturing. These findings suggest that virulence of P. brasiliensis can be attenuated or lost subsequent to cycles of subculturing over long periods. Our data suggest that the use of fresh P. brasiliensis isolates may be needed to provide reproducible virulence for experimental systems.Abbreviations ATCC American Type Culture Collection - CFU colony-forming units - LD Lethal dose - MMv-M modified McVeigh Morton - PMN polymorphonuclear neutrophil     

Steroid hormones in the adrenal venous effluents in idiopathic hirsutism under basal and stimulated conditions

Steroid hormone concentrations in the peripheral blood and the adrenal veins were measured in the basal state and after ACTH stimulation in 5 patients with idiopathic hirsutism. The basal concentrations of the steroids in the adrenal veins of the patients with idiopathic hirsutism were not significantly different from a control group of 5 patients catheterized for investigation of pheochromocytoma. Following ACTH stimulation, the concentrations of the steroids in the adrenal veins were also not significantly different in the hirsute and the control groups except for the concentrations of DHA and DHAS which were higher in the patients with idiopathic hirsutism. 17-hydroxyprogesterone (17-OHP) concentrations after ACTH stimulation were lower in the hirsute group compared to the control population. It is concluded that patients with idiopathic hirsutism have a defect in the biosynthesis of cortisol proximal to the action of the 11 beta- and 21-hydroxylase enzymes, deficiencies of which have been previously considered to be the usual causes of hirsutism due to an adrenocortical abnormality. The lower 17-OHP concentrations in the hirsute group can be explained on the basis of deficiency of substrate for the action of the 17-hydroxylating enzyme, consequent to the postulated deficiency of 3 beta-hydroxysteroid dehydrogenase.     

Blood groups and HLA antigens in paracoccidioidomycosis

The frequencies of blood groups, Rh and HLA antigens were studied in a series of patients with paracoccidioidomycosis as well as in control subjects. Statistical analysis of the results showed that only 2 antigens (HLA-A9 and HLA-B13) had a significantly increased frequency among patients with paracoccidioidomycosis compared with healthy controls. Among patients with paracoccidioidomycosis antigen HLA-A9 was significantly more prevalent in progressive pulmonary forms of the disease than in patients with extra pulmonary involvement. These observations suggest that HLA-A9 may influence susceptibility to the mycosis as well as its course.     

Treatment of hyperandrogenic states in women

Hyperandrogenic states have to be treated according to their etiology. But, idiopathic hirsutism represents the majority of observed cases. Its pathophysiology is still under discussion. The ovary and/or adrenal origin has led to various treatments with corticoids or combined estrogen-progestogen preparations. However, practical problems are different. After ruling out a tumoral process or mild congenital adrenal hyperplasia, a rational and efficient treatment must be proposed. It has now become possible with the use of both antiandrogen and antigonadotropin drugs. Cyproterone acetate is the best therapeutic agent because of its antiandrogen, antigonadotropin and progestogen properties. Because of its antiestrogen effects, cyproterone acetate must be used in combination with estrogens as a substitutive therapy to permit regular bleeding.     

Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism.

Polycystic ovaries were defined with ultrasound imaging in a series of 173 women who presented to a gynaecological endocrine clinic with anovulation or hirsutism. Polycystic ovaries were found in 26% of women with amenorrhoea, 87% with oligomenorrhoea, and 92% with idiopathic hirsutism--that is, hirsutism but with regular menstrual cycles. Fewer than half the anovulatory patients with polycystic ovaries were hirsute, but in 93% of cases there was at least one endocrine abnormality to support the diagnosis of polycystic ovaries--that is, raised serum concentrations of luteinising hormone, raised luteinising hormone: follicle stimulating hormone ratio, or raised serum concentrations of testosterone or androstenedione. This study shows that polycystic ovaries, as defined by pelvic ultrasound, are very common in anovulatory women (57% of cases) and are not necessarily associated with hirsutism or a raised serum luteinising hormone concentration. Most women with hirsutism and regular menses have polycystic ovaries so that the term "idiopathic" hirsutism no longer seems appropriate.     

Production of pro- and anti-inflammatory cytokines by monocytes from patients with paracoccidioidomycosis

Monocytes and macrophages can produce a large repertoire of cytokines and participate in the pathogenesis of granulomatous diseases. We investigated the production of pro- and anti-inflammatory cytokines by monocytes from patients with active paracoccidioidomycosis. Peripheral blood monocytes from 37 patients and 29 healthy controls were cultivated with or without 10 microg/ml of lipopolysaccharide (LPS) for 18 h at 37 degrees C, and the cytokine levels were determined in the culture supernatants by enzyme immunoassay. The results showed that the endogenous levels of tumor necrosis factor alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6, IL-8, IL-10 and transforming growth factor beta detected in the supernatant of patient monocytes cultivated without stimulus were significantly higher than those produced by healthy controls. These data demonstrated that monocytes from patients with active paracoccidioidomycosis produce high levels of cytokines with both inflammatory and anti-inflammatory activities. However, patient monocytes produced significantly lower TNF-alpha and IL-6 levels in response to LPS when compared to normal subjects, suggesting an impairment in their capacity to produce these cytokines after LPS stimulation. Concentrations of IL-1beta, IL-8 and IL-10 in cultures stimulated with LPS were higher in patients than in controls. These results suggest that an imbalance in the production of pro- and anti-inflammatory cytokines might be associated with the pathogenesis of paracoccidioidomycosis.     

Allelic variation in the serotonin transporter (5HTT) gene contributes to idiopathic pulmonary hypertension in children

Pulmonary hypertension is a potentially lethal condition, which affects adults and children alike. Genetic factors are implicated in the causation of primary pulmonary hypertension. We investigate the role of polymorphism in the 5HTT gene in the etiology of pulmonary hypertension in children aged 1-18.8 years. We have tested the hypothesis that the 5HTT gene does contribute to the pathogenesis of this disease in children by comparing the allelic frequencies of both the long and short variants between children with idiopathic pulmonary hypertension and pulmonary hypertension secondary to underlying pulmonary disease. We found that homozygosity for the long variant of 5HTT was highly associated with idiopathic pulmonary hypertension in children, suggesting perhaps a more important role for 5HTT gene function in the pathogenesis of early onset disease.     

A pivotal role of cytosolic phospholipase A(2) in bleomycin-induced pulmonary fibrosis

Pulmonary fibrosis is an interstitial disorder of the lung parenchyma whose mechanism is poorly understood. Potential mechanisms include the infiltration of inflammatory cells to the lungs and the generation of pro-inflammatory mediators. In particular, idiopathic pulmonary fibrosis is a progressive and fatal form of the disorder characterized by alveolar inflammation, fibroblast proliferation and collagen deposition. Here, we investigated the role of cytosolic phospholipase A(2) (cPLA(2)) in pulmonary fibrosis using cPLA(2)-null mutant mice, as cPLA(2) is a key enzyme in the generation of pro-inflammatory eicosanoids. Disruption of the gene encoding cPLA(2) (Pla2g4a) attenuated IPF and inflammation induced by bleomycin administration. Bleomycin-induced overproduction of thromboxanes and leukotrienes in lung was significantly reduced in cPLA(2)-null mice. Our data suggest that cPLA(2) has an important role in the pathogenesis of pulmonary fibrosis. The inhibition of cPLA(2)-initiated pathways might provide a novel therapeutic approach to pulmonary fibrosis, for which no pharmaceutical agents are currently available.     

Is plasma 5 alpha-androstane 3 alpha, 17 beta-diol glucuronide a biochemical marker of hirsutism in women?

We investigated whether plasma androstanediol glucuronide (ADG) levels reflect the increased androgenicity in women with idiopathic hirsutism (n = 24) or hirsutism associated with polycystic ovary syndrome (n = 10). We also evaluated whether ADG levels parallel the clinical evolution of the hirsutism during a combined treatment, with cyproteroneacetate (2 mg) and ethinylestradiol (35 micrograms), of women with moderate idiopathic hirsutism. Finally, we investigated if there is evidence for increased conversion of precursors to ADG in hirsutism, by comparing the ADG levels, measured by RIA, to ADG levels obtained by applying the conversion rates of precursors obtained in non-hirsute women. ADG levels were increased in less than half of the patients with mild hirsutism. The clinical cure of hirsutism, which was obtained by the treatment in majority of patients, was accompanied by a significant decrease of plasma ADG levels, but a similar decrease was also observed in the 5 patients who did not respond to treatment. The data show that, although there is evidence for increased conversion of precursors to plasma ADG in mildly hirsute women, the latter is not a reliable parameter of androgenicity. Our data suggest, moreover, that treatment with cyproterone acetate and ethinylestradiol decreases 5 alpha-reductase activity, as indicated by the more important decrease in ADG levels than in the precursors.     

Hirsutism: common clinical problem or index of serious disease?

Hirsutism is a clinical condition commonly encountered in the practice of primary care medicine. The etiology and the age of the patient when it occurs vary widely. Causes range from a basic illness or condition (drug exposure, smoking, idiopathic, and obesity) to complex and serious diseases (Cushing's syndrome, neoplasms, congenital adrenal hyperplasia, insulin-resistance syndromes, hyperprolactinemia, polycystic ovary syndrome, and hyperthecosis). Hirsutism may appear in childhood as well as in older persons. Some drugs (oral contraceptives, L-thyroxine, danazol, and diazoxide), tobacco smoke, some syndromes (polycystic ovary syndrome, obesity, insulin resistance, hyperprolactinemia, hyperthecosis, congenital adrenal hyperplasia, and idiopathic), and some neoplasms (adrenal or ovarian) may lead to hirsutism. The most frequently defined "causes" of hirsutism are polycystic ovary syndrome and idiopathic hirsutism. In hirsutism of gradual onset, hyperprolactinemia, insulin-resistance syndromes, hyperthecosis, polycystic ovary syndrome, and idiopathic hirsutism may be responsible. Cushing's syndrome, neoplasms, and congenital adrenal hyperplasia should be suspected if there has been rapid onset.     

Chronic pulmonary paracoccidioidomycosis in the state of Rio Grande do Sul,Brazil

Since 1942, when paracoccidioidomycosis was first identified in the state of Rio Grande do Sul, paracoccidioidal pulmonary lesions became a great concern to physicians. The present study focuses on 53 patients diagnosed over a seven-year period who presented paracoccidioidal lesions circumscribed to the lungs. These patients presented clinical and radiological features that simulated several pulmonary infectious and non-infectious conditions. Four unusual cases are briefly discussed. A sequence of laboratorial tests should be established for the diagnosis of pulmonary paracoccidioidomycosis. This revised version was published online in June 2006 with corrections to the Cover Date.     

Ketoconazole in the treatment of experimental murine paracoccidioidomycosis

In a murine model of chronic disseminated paracoccidioidomycosis (strain 18; intravenous route), Ketoconazole (200 mg/kg in 0.2% agar) was given daily by gavage in three different schedules. Continuous treatment from an early stage of infection (day 3) up to week 20 was the most effective protocol, leading to remission of histopathological lesions and of both humoral and cellular anti-P. brasiliensis immune response, and clearance of the fungus in lungs; only 1 treated animal at week 20 showed pulmonary granulomas, although less extensive than control mice. Continuous treatment from early stage up to week 8, followed by a 16 week-period of drug discontinuity, caused remission of lesions in all but 3 treated mice which showed active pulmonary paracoccidioidomycosis similar to controls (14.2% of unresponsiveness to treatment). The continuous Ketoconazole protocol since a late stage of infection (week 4) up to week 20 produced a slower remission of lesions and immune response when compared with the first drug schedule. In this model of paracoccidioidomycosis, Ketoconazole showed no detectable side-effects and was a very effective drug especially in a prolonged administration protocol from an early stage of infection.     

ras和c-erbB癌基因在特发性肺间质纤维化中的表达

采用原位分子杂交技术和免疫组织化学方法,对８例临床与肺组织学确诊的特发性肺间质纤维化（ＩＰＦ）病人的肺活检组织及７例正常肺组织进行了ｒａｓ和ｃ－ｅｒｂＢ癌基因及其产物的检测。结果：ｒａｓ癌基因产物Ｐ２１在６／８例ＩＰＦ肺组织中呈阳性反应;５／８例ＩＰＦ肺组织ｃ－ｅｒｂＢ－２显免疫阳性反应,而在７例正常肺组织Ｐ２１及ｃ－ｅｒｂＢ－２均无明显表达,原位杂交结果显示ＩＰＦ肺组织没有明显ｒａｓ和ｃ－ｅｒｂＢ癌基因的ＤＮＡ扩增提示ＩＰＦ的病变过程与ｒａｓ和ｃ－ｅｒｂＢ癌蛋白表达增强有关     

The relationship between FV Leiden and pulmonary embolism

A recent review article suggested that idiopathic pulmonary fibrosis (IPF) is a disease that is associated more with abnormal wound healing than with inflammation. Data derived from transgenic and gene transfer rodent models suggest that lung inflammation may be a necessary but insufficient component of IPF, and that at some point in the natural history of the disease IPF becomes no longer dependent on the inflammatory response for propagation. Altered microenvironment and involvement of epithelial cell/mesenchymal cell interaction are the most likely contributors to the pathogenesis of this chronic progressive disorder.     

Urinary pregnanetriol and delta 5-pregnentriol in women with idiopathic hirsutism

Urinary pregnanetriol and delta 5-pregnenetriol were determined in 90 normal women and in 90 women with idiopathic hirsutism of comparable age group. When group Student's "t"-test was carried out, the mean steroid excretion values in hirsute women were found to be significant with delta 5-pregnenetriol more significant than pregnanetriol. Of the 90 women with hirsutism, 8 patients had pregnanetriol and delta 5-pregnenetriol values higher than normal. When, on the basis of these elevated values, the women were sent for a thorough gynaecological investigation, they were found to have the polycystic ovary syndrome. After wedge resection, the diagnosis was confirmed and the urinary excretion of pregnanetriol and delta 5-pregnenetriol came down to a normal level. This study shows that, in the case of women with idiopathic hirsutism suspected of any ovarian disorder, the measurement of these two steroids could be of diagnostic importance.     

The pathogenesis of COPD and IPF: Distinct horns of the same devil?

New paradigms have been recently proposed in the pathogenesis of both chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF), evidencing surprising similarities between these deadly diseases, despite their obvious clinical, radiological and pathologic differences. There is growing evidence supporting a "double hit" pathogenic model where in both COPD and IPF the cumulative action of an accelerated senescence of pulmonary parenchyma (determined by either telomere dysfunction and/or a variety of genetic predisposing factors), and the noxious activity of cigarette smoke-induced oxidative damage are able to severely compromise the regenerative potential of two pulmonary precursor cell compartments (alveolar epithelial precursors in IPF, mesenchymal precursor cells in COPD/emphysema). The consequent divergent derangement of signalling pathways involved in lung tissue renewal (mainly Wnt and Notch), can eventually lead to the distinct abnormal tissue remodelling and functional impairment that characterise the alveolar parenchyma in these diseases (irreversible fibrosis and bronchiolar honeycombing in IPF, emphysema and airway chronic inflammation in COPD).