Letter to the Editor Whole-body magnetic resonance imaging for the evaluation of thoracic involvement in disseminated paracoccidioidomycosis Ressonância magnética de corpo inteiro na avaliação do comprometimento torácico na paracoccidioidomicose disseminada Edson Marchiori, Elisa Carvalho Ferreira, Gláucia Zanetti, Bruno Hochhegger To the Editor: Whole-body magnetic resonance imaging (MRI) revealed that he had worked for the past two is a diagnostic tool that enables the visualization years as a farm worker, taking care of animals. of the entire body and combines fast acquisition Upon physical examination, the patient times with high contrast resolution. An important presented with fever, multiple honey-colored advantage of this technique is the absence of scabs, and ulcerated lesions on the face, trunk, ionizing radiation. Thus, whole-body MRI offers a upper limbs, and perianal region. Pulmonary radiation-free alternative to radionuclide imaging auscultation findings were normal, as were those and CT for the diagnosis, staging, and monitoring of the cardiac examination, and there was no of young patients who require frequent follow-up abdominal organomegaly. examinations. Because MRI is the best method A left cervical lymph node was aspirated, and to evaluate bone marrow and soft tissues, it direct examination for fungi revealed refringent represents an ideal tool for the assessment of blastoconidia with multiple buds suggestive of P. numerous systemic diseases, especially those brasiliensis in the specimen. Blood agar culture affecting the skeletal system.(1) was also positive for P. brasiliensis. A skin biopsy Paracoccidioidomycosis, a systemic fungal specimen stained with Grocott and periodic acid- disease caused by the fungus Paracoccidioides Schiff stains revealed yeast cells with multiple brasiliensis, is endemic in Central and South buds in the form of a ship’s wheel, which is a America.(2,3) In Europe and North America, typical finding of P. brasiliensis. Serology by it is considered a rare imported disease, the double immunodiffusion techniques was positive incidence of which is expected to continue for paracoccidioidomycosis. A blood test for rising due to the increase in migration and HIV was negative. A diagnosis of the acute or international travel.(4) Given that the disease subacute so-called “juvenile” type of disseminated can affect virtually any organ, whole-body paracoccidioidomycosis was made, and the patient MRI seems to be a suitable diagnostic tool for was hospitalized for treatment. evaluating systemic manifestations of disseminated Before the necessary treatment was started, paracoccidioidomycosis, because it provides written informed consent was obtained and the a global view. The aim of the present report was to present the whole-body MRI findings patient was submitted to whole-body MRI in order of a patient with systemic manifestations of to further investigate the systemic involvement paracoccidioidomycosis, with an emphasis on of the disseminated disease. The examination lymphatic, skeletal, and pleural involvement. To revealed extensive involvement at multiple our knowledge, thoracic findings of disseminated locations throughout the body, including the paracoccidioidomycosis on whole-body MRI have subcutaneous tissue, lymph nodes, skeletal system, not been described previously. pleural cavity, and peritoneal cavity. Lymph node A 24-year-old man was referred to our enlargement was seen on whole-body MRI in facility for the diagnostic investigation of multiple lymph node chains. On a gadolinium- multiple complaints. The symptoms began enhanced volumetric interpolated breath-hold approximately 15 months prior to hospitalization examination (VIBE) sequence, the lymph nodes and mainly consisted of emaciation, fever, painful presented peripheral contrast enhancement lymphadenopathy, and crusted, ulcerated skin (Figure 1A). On a short-tau inversion-recovery lesions. The epidemiologic history of the patient (STIR) sequence, the central portions of those J Bras Pneumol. 2013;39(2):248-250 Whole-body magnetic resonance imaging for the evaluation of 249 thoracic involvement in disseminated paracoccidioidomycosis lymph nodes exhibited hyperintense signals, frequently, in the mucosa or skin.(5) Therefore, giving them a necrotic appearance. our case can be classified as the acute form of On T1-weighted images, the skeletal lesions paracoccidioidomycosis.(3) varied from hypointense to isointense, exhibiting, In the case presented here, whole-body at some sites, cortical bone destruction and an MRI showed involvement at multiple locations extensive soft tissue component. In a gadolinium- throughout the body, including the subcutaneous enhanced VIBE sequence with fat suppression, tissue, lymph nodes, skeletal system, pleural the lesions exhibited an insufflating pattern, cavity, and peritoneal cavity. Of the systemic with contrast enhancement predominantly in manifestations, we focused on the extensive the peripheral regions (Figures 1B and 2A). On thoracic skeletal involvement. Bone and joint a STIR sequence, the central portions of the infections are relatively uncommon in patients lesions presented hyperintense signals, suggestive with paracoccidioidomycosis. The lesions are of necrotic tissue. described as circumscribed, well-delineated areas Whole-body MRI with STIR sequences also of lysis, with or without a rim of sclerosis that revealed pleural and peritoneal involvement, can occur in any bone, although such lesions manifesting as pleural effusion and ascites, are usually seen in clavicles, ribs, and scapulae.(6) as evidenced by a typical hyperintense signal Although the patient had no symptoms of (Figure 2B). There were no other sites of skeletal involvement, we decided to perform involvement. whole-body MRI in order to conduct a detailed Paracoccidioidomycosis is divided into two investigation. Whole-body MRI seemed suitable polar forms, depending on its epidemiological, for the case presented here, because, in addition immunopathological, and clinical aspects.(5) The to its high contrast resolution and excellent acute or subacute form most frequently affects ability to visualize bone marrow components, the children, teenagers, and young adults and is known method has the advantage of not using ionizing as the juvenile type. It manifests as extensive radiation, making it an ideal tool for the initial involvement of the mononuclear phagocytic system, mainly in the spleen, liver, lymph nodes, evaluation and follow-up assessment of children and intestinal tract. Lung and mucosal lesions and young adults such as our patient.(7) are rare.(5) The chronic form, known as the adult In conclusion, the case presented here illustrates type, is more common, accounting for 90% of the potential of whole-body MRI as a diagnostic all cases, and predominantly affects adults over tool for evaluating systemic diseases, such as deep 30 years of age. The chronic form is more likely mycosis. This radiation-free evaluative method to be localized than is the acute form. Initially, creates images that can be used as baseline the disease is localized in the lungs, and less assessments for longitudinal monitoring. A B Figure 1 - Whole-body magnetic resonance imaging using a gadolinium-enhanced volumetric interpolated breath-hold examination sequence. In A, a scan demonstrating the enlargement of a cervical lymph node and peripheral contrast enhancement (arrows). In B, a scan in the axial plane showing insufflated lesions on the clavicle (long arrow), scapula (arrowhead), and vertebra (short arrow). J Bras Pneumol. 2013;39(2):248-250 250 Marchiori E, Ferreira EC, Zanetti G, Hochhegger B A B Figure 2 - Whole-body magnetic resonance imaging scans in the coronal plane. In A, lesions in the left humerus (arrow) with heterogeneous contrast enhancement, and axillary lymph node enlargement (arrowheads). In B, bilateral pleural effusion (arrow). Edson Marchiori References Associate Professor of Radiology, 1. Ferreira EC, Brito CC, Domingues RC, Bernardes M, Federal University of Rio de Janeiro, Marchiori E, Gasparetto EL. Whole-body MR imaging for the evaluation of McCune-albright syndrome. J Rio de Janeiro, Brazil Magn Reson Imaging. 2010;31(3):706-10. 2. Martinez R. Paracoccidioidomycosis: the dimension of the problem of a neglected disease. Rev Soc Bras Med Elisa Carvalho Ferreira Trop. 2010;43(4):480. Radiologist, Hospital de Ipanema, 3. 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Whole-body MRI in Complex, Porto Alegre, Brazil the pediatric patient. Eur J Radiol. 2009;70(3):442-51. Submitted: 10 July 2012. Accepted, after review: 30 July 2012. J Bras Pneumol. 2013;39(2):248-250