Urinalysis was unremarkable The initial chest X-ray and computed

Urinalysis was unremarkable. The initial chest X-ray and computed tomography scan findings showed diffuse

infiltrates and nodular lesions, some of them cavitates (Figure 1). Both the ECG and the echocardiogram were normal. An abdominal ultrasound revealed no adenopathies. No intestinal parasites were found in the stool test. A bronchoscopy with bronchoalveolar aspiration and lavage was carried out. Gram stain, microscopy, and culture of the aspirate were all negative. Bacterial, fungal, and mycobacterium cultures were also negative after 6 weeks. Bronchoscopy was repeated and a transbronchial lung biopsy was performed, revealing acute inflammatory interstitial pulmonary infiltrates. Serologies for Influenza A and B virus, adenovirus, respiratory syncytial BI 6727 molecular weight virus (RSV), Mycoplasma pneumoniae, Coxiella, Chlamydia, Blastomyces dermatitis, Coccidioides immitis, and Histoplasma SAHA HDAC purchase capsulatum were all negative. Other serologies including HIV, HCV, HBV, Dengue, Chagas, syphilis, and

Legionella were also negative. Serology and a molecular diagnostic technique based on real-time PCR in sputum for Paracoccidioides brasiliensis were performed. Briefly, a molecular beacon probe was used, labeled with FAM and directed at the ITS1 region of ribosomic DNA. The detection limit of the technique developed was 1 fg of fungal DNA per microliter of sample. Serology and real-time PCR were both positive. As a result of this positive finding on PCR, treatment with itraconazole (100 mg/d) was initiated. Weekly follow-up in the outpatient setting was performed. Unfortunately, SB-3CT 4 weeks later the symptoms worsened, and the patient reported continuous fever and increased dyspnea. New thoracic chest X-ray and Ga67 gammagraphy were performed, which showed progression of the infiltrates and increased uptake in the lungs. In response to these signs of clinical progression, and after excluding a bacterial or mycobacterial coinfection, treatment with

liposomal amphotericin B (200 mg/d, up to 3 g) was initiated, followed up by sulfadiazine (1 g/6 h). Tolerance to both drugs was good, except for a discrete hypokalemia (secondary to the amphotericine use) which was controlled with oral supplements. Once on these medications, clinical progress was good. The fever resolved, and the cough and thoracic pain settled. At 14th week, the patient remained well with no active pulmonary lesions, oxygen saturation of 96% on air, and normal leucocytes, platelets, ESR, and IgE on blood tests. Spirometry done at this time showed a restrictive pattern [forced vital capacity (FVC) 2.83 L (74%); forced expiratory volume in first second (FEV1) 2.36 L (77.7%); FEV1/FVC 83.70%]. Treatment was stopped after 18 months. A new spirometry revealed a total improvement [FVC 4.13 l (108.7%), FEV1 3.20 l (105.9%); FEV1/FVC 77.43%]. After 9 months of discontinuing treatment, there is no relapse.

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