Paracoccidioides brasiliensis habitat: far beyond armadillo burrows?

Paracoccidioides spp. isolation from environmental samples is rare and hardly reproducible. Molecular techniques have facilitated the fungal detection. However, it can be still difficult. Some strategies to enhance the capacity of DNA detection have been adopted, including the analysis of soil samples belonging to the habitat of animals from which Paracoccidioides spp. have already been isolated, notably armadillo burrows. To date, the detection of Paracoccidioides spp. has not yet been reported from outbreak hotspots. Clusters and outbreaks of acute paracoccidioidomycosis (PCM), usually a more severe clinical form, have currently occurred in urban areas being associated to climate changes, deforestation, and great constructions. These occurrences potentially signalise the fungus' environmental niche, a riddle not yet solved. The authors performed an environmental investigation in a deeply disturbed area, after a highway construction in Rio de Janeiro, Brazil, where a recent outbreak of acute PCM occurred. Specific DNA sequences of Paracoccidioides brasiliensis were detected in shallow soil samples around the highway, reinforcing the association between the road construction and this PCM outbreak.

Perfil sorológico dos pacientes com suspeita clínica de paracoccidiodomicose avaliados pelo Instituto Adolfo Lutz no ano de 2016 / Serological profile of patients with clinical suspicion of paracoccidiodomycosis evaluated by Instituto Adolfo Lutz in 2016

Oitenta porcento dos casos de paracoccidioidomicose (PMC) ocorrem no Brasil. As regiões brasileiras com maior número de casos são: sul, sudeste e centro-oeste, sendo emergente no norte e nordeste. A imunodifusão dupla em gel de agarose assume grande importância no diagnóstico, por permitir o monitoramento da doença e por oferecer subsídios para levantamentos soroepidemiológicos. O objetivo deste trabalho foi de avaliar e caracterizar os pacientes atendidos no Laboratório de Imunodiagnóstico das Micoses do Instituto Adolfo Lutz de São Paulo, em 2016. Trata-se de um estudo retrospectivo realizado utilizando-se dados secundários e avaliando-se as seguintes informações: idade, sexo, procedência do pedido médico, resultado e histórico sorológico dos pacientes. Dos 1.408 pacientes, 12,8% apresentaram reatividade sorológica para Paracoccidioides brasiliensis. Destes, 42,5% não possuiam histórico sorológico, sendo considerados como casos novos da doença. A classificação dos pacientes reagentes por gênero demonstrou que 83,4% eram do sexo masculino, com razão de masculinidade de 5:1. A faixa etária variou de um (1) a 92 anos, e aproximadamente 40% dos pacientes eram da faixa etária de 41 a 60 anos. Este estudo demonstra e reforça a importância da implementação dos estudos soroepidemiológicos como ferramenta auxiliar para nortear as ações de vigilância e políticas em saúde na PCM.

Eighty percent of paracoccidioidomycosis (PMC) cases occur in Brazil. The highest numbers occur in south, southeast and center-west region, being emergent in the north and northeast areas. The double immunodiffusion in agarose gel is valuable for its diagnosis, as it allows the monitoring of the disease and offers subsidies for the seroepidemiological surveys. This study evaluated and characterized the patients attended in 2016 at the Mycoses Immunodiagnosis Laboratory of Adolfo Lutz Institute of São Paulo. This retrospective study, based on the secondary data, evaluated the information: age, sex, medical request origin, result and serological history of the patients. Of 1,408 patients, 12.8% presented positive serological reactivity for Paracoccidioides brasiliensis. Of them, 42.5% had no serological history and they were considered as new cases. The classification of reactive patients by gender showed that 83.4% were males, being the masculinity ratio of 5:1. The age range was one (1) to 92 years old, and ±40% of the patients were of age ranging from 41-60 years old. This study reinforces the importance of the implementation of the seroepidemiological studies as to guide the surveillance actions and the public health politics in PCM.

Paracoccidioidomycosis manifested by sarcoidosis-like cutaneous lesions and caused by Paracoccidioides brasiliensis sensu stricto (S1a)

Abstract: Molecular studies have shown more than one species of the genus Paracoccidioides to be the causal agent of paracoccidioidomycosis. Efforts have been made to correlate the identified species with epidemiological and clinical data of patients, aiming to determine the real meaning and impact of new species. Bearing this objective in mind, the authors report a clinical case of paracoccidioidomycosis, from São Paulo state, Brazil, that manifested as uncommon sarcoid-like cutaneous lesions and was caused by Paracoccidioides brasiliensis sensu stricto (S1a). The patient was treated with itraconazole 200mg/day for 12 months, with complete clinical remission.

Paracoccidioidomycosis in the spine: case report and review of the literature / Paracoccidioidomicose na coluna vertebral: relato de caso e revisão da literatura

ABSTRACT: CONTEXT: Paracoccidioidomycosis is a systemic form of mycosis that spreads hematogenously, secondarily to reactivation of lung infection or infection at another site or to new exposure to the causative agent. Few cases of bone involvement have been reported in the literature and involvement of the spine is extremely rare. CASE REPORT: We describe a case of a 68-year-old male patient with spondylodiscitis at the levels L4-L5 caused by presence of the fungus Paracoccidioides brasiliensis, which was diagnosed through percutaneous biopsy. The patient was treated with sulfamethoxazole and trimethoprim for 36 months, with complete resolution of the symptoms. CONCLUSION: Spondylodiscitis caused by the fungus Paracoccidioides brasiliensis is uncommon. However, in patients with chronic low-back pain who live or used to live in endemic regions, this infection should be considered as a possible differential diagnosis.

RESUMO: CONTEXTO: Paracoccidioidomicose é uma micose sistêmica de disseminação hematogênica, secundária a reativação de uma infecção pulmonar ou de outro sítio, ou a uma nova exposição ao agente causador. Poucos casos de envolvimento ósseo são relatados na literatura, e o acometimento da coluna vertebral é extremamente raro. RELATO DE CASO: Descrevemos o caso de um paciente masculino de 68 anos, apresentando espondilodiscite no nível L4-L5, causada pela presença do fungo Paracoccidioides brasiliensis, diagnosticada após biópsia percutânea. O paciente foi tratado com sulfametoxazol e trimetoprim por 36 semanas, com resolução completa dos sintomas. CONCLUSÃO: A espondilodiscite causada pelo fungo Paracoccidioides brasiliensis é incomum, mas, em pacientes portadores de lombalgia crônica que viveram ou vivem em regiões endêmicas, deve ser considerada como um possível diagnóstico diferencial.

Achados ultrassonográficos osteomusculares na paracoccidioidomicose / Musculoskeletal ultrasound findings in paracoccidioidomycosis

Resumo A paracoccidioidomicose é uma infecção fúngica endêmica na América do Sul. A infecção geralmente é assintomática e afeta principalmente os tratos respiratórios superior e inferior, com dissociação clínico-radiológica. O envolvimento articular é raro, sem um padrão ou lesão radiológica específica. Apresenta-se um relato de caso de paracoccidioidomicose em que os sintomas iniciais do paciente foram rouquidão e artrite. Depois de um exame de ultrassonografia, foram feitos o diagnóstico diferencial de outras artropatias não infecciosas e a análise do material coletado, que revelou infecção pelo fungo Paracoccidioides brasiliensis.

Abstract Paracoccidioidomycosis is a fungal infection endemic to South America. The infection is usually asymptomatic and mostly affects the upper and lower respiratory tracts with clinical–radiological dissociation. Joint involvement is rare with no specific pattern or radiological injury. We report a case of paracoccidioidomycosis in which the patient's initial symptoms were hoarseness and arthritis. After an ultrasound examination, we performed the differential diagnosis of other noninfectious arthropathies and analysis of the material collected, which revealed infection with the fungus Paracoccidioides brasiliensis.

PARACOCCIDIOIDOMYCOSIS IN A RENAL TRANSPLANT RECIPIENT

Paracoccidioidomycosis (PCM) is the most common endemic mycosis in Latin America. The etiological agents, which comprise two species, Paracoccidioides brasiliensis and P. lutzii, are thermodimorphic fungi that usually affect previously healthy adults. They primarily involve the lungs and then disseminate to other organs. Such mycosis is rare in organ transplant recipients; there have been only three cases reported in literature, until now. We report a case of PCM in a renal transplant recipient with an unusual dermatological presentation.

Paracoccidioides brasiliensis AND Paracoccidioides lutzii, A SECRET LOVE AFFAIR / Paracoccidioides brasiliensis e Paracoccidioides lutzii, um caso secreto de amor

SUMMARYTo commemorate Prof. Carlos da Silva Lacaz's centennial anniversary, the authors have written a brief account of a few, out of hundreds, biological, ecological, molecular and phylogenetic studies that led to the arrival of Paracoccidioides lutzii, hidden for more than a century within Paracoccidioides brasiliensis. Lacaz's permanent interest in this fungus, and particularly his conviction on the benefits that research on paracoccidioidomycosis would bring to patients, were pivotal in the development of the field.

RESUMOPara comemorar o centenário de aniversário do Prof. Dr. Carlos da Silva Lacaz, os autores fazem um breve relato dos estudos sobre a biologia, ecologia e filogenia molecular que culminaram na revelação da espécie Paracoccidioides lutzii, que havia permanecido escondida por mais de um século ao lado de Paracoccidioides brasiliensis. O professor Lacaz exerceu papel central no desenvolvimento desta área do conhecimento, pois manteve interesse permanente nas pesquisas deste fungo e da paracoccidioidomicose, visando principalmente proporcionar benefícios aos pacientes acometidos por esta micose.

Validation and clinical application of a nested PCR for paracoccidioidomycosis diagnosis in clinical samples from Colombian patients

Paracoccidioidomycosis is a systemic and endemic mycosis, restricted to tropical and subtropical areas of Latin America. The infection is caused by the thermal dimorphic fungus Paracoccidioides brasiliensisand Paracoccidioides lutzii. The diagnosis of paracoccidioidomycosis is usually performed by microscopic examination, culture and immunodiagnostic tests to respiratory specimens, body fluids and/or biopsies; however these methods require laboratory personnel with experience and several days to produce a result. In the present study, we have validated and evaluated a nested PCR assay targeting the gene encoding the Paracoccidioides gp43membrane protein in 191 clinical samples: 115 samples from patients with proven infections other than paracoccidioidomycosis, 51 samples as negative controls, and 25 samples from patients diagnosed with paracoccidioidomycosis. Additionally, the specificity of the nested PCR assay was also evaluated using purified DNA isolated from cultures of different microorganisms (n= 35) previously identified by culture and/or sequencing. The results showed that in our hands, this nested PCR assay for gp43 protein showed specificity and sensitivity rates of 100%. The optimized nested PCR conditions in our laboratory allowed detection down to 1 fg of P. brasiliensisDNA.

Paracoccidioidomycosis in southern Rio Grande do Sul: a retrospective study of histopathologically diagnosed cases

Paracoccidioidomycosis (PCM) is a systemic mycosis caused by the fungus Paracoccidioides brasiliensis and is endemic to Brazil. The aim of this study was to perform a retrospective analysis of the PCM cases in the countryside south of Rio Grande do Sul, Brazil. The files from four histopathology laboratories located in the city of Pelotas were obtained, and all of the epidemiological and clinical data from the PCM diagnosed cases were collected for analysis. A total of 123 PCM cases diagnosed between 1966 and 2009 were selected. Of these patients, 104 (84.5%) were male, and 17 were female. The patients ranged from 02 to 92 years of age. Fifty-two cases (41.9%) were obtained from the oral pathology laboratory, and the remaining 71 cases (58.1%) were obtained from the three general pathology laboratories. Of all of the patients studied, 65.2% lived in rural zones and worked in agriculture or other related fields. Data on the evolution of this disease was available for 43 cases, and the time frame ranged from 20 to 2920 days (mean = 572.3 days). An accurate diagnosis performed in less than 30 days only occurred in 21% of the cases. PCM is endemic to the countryside of Rio Grande do Sul. Therefore, it is recommended that PCM be included as a differential diagnosis, mainly for individuals between 30 and 60 years of age, living in rural zones and who have respiratory signs and associated-oropharyngeal lesions.

Paracoccidioides brasiliensis infection in dogs from Western Brazilian Amazon / Infecção por Paracoccidioides brasiliensis em cães da Amazônia Ocidental Brasileira

The objective of the study was to evaluate Paracoccidioides brasiliensis infection in urban dogs from the municipality of Monte Negro, Rondonia, Western Brazilian Amazon. The serum samples (n=126) were analyzed by indirect ELISA and the immunodiffusion test using P. brasiliensis gp43 and exoantigen as antigens, respectively. A positivity of 54.8% was observed only in the ELISA test and no statistical difference was observed in the seroprevalence in relation to age or sex. This is the first paracoccidioidomycosis survey carried out with dogs from the Western Brazilian Amazon. The higher positivity rates of P. brasiliensis infection observed in this study suggest that veterinarians must be alert to detect new cases of natural disease in dogs living in paracoccidioidomycosis endemic areas.

O objetivo deste estudo foi avaliar a infecção por Paracoccidioides brasiliensis em cães urbanos do município de Monte Negro, Rondônia, Amazônia Ocidental Brasileira. As amostras de soro (n=126) foram analisadas por meio dos testes de ELISA indireto e imunodifusão utilizando gp43 de P. brasiliensis e exoantígeno como antígenos, respectivamente. Uma positividade de 54,8% foi observada apé isso mesmoenas no teste de ELISA e nenhuma diferença estatística foi observada na soroprevalência em relação ao sexo ou à idade. Este é o primeiro estudo epidemiológico de paracoccidioidomicose realizado com cães da Amazônia Ocidental Brasileira. A alta positividade de infecção por P. brasiliensis observada neste estudo sugere que os veterinários devem estar atentos para detectar a doença natural em cães de áreas endêmicas para paracoccidioidomicose.

Vasculite de pequenos vasos como primeira manifestação clínica de paracoccidiodomicose: relato de caso / Small vessel vasculitis as first manifestation of paracoccidioidomycosis: case report

A paracoccidioidomicose é uma doença sistêmica causada pela inalação de conídios do Paracoccidioides brasiliensis, um fungo dimórfico que acomete, inicialmente, a via respiratória, disseminando-se, principalmente por vias linfáticas e hematogênicas, para diversos órgãos e sistemas, podendo ser fatal na ausência de diagnóstico e tratamento adequados. Os autores têm por objetivo relatar um caso de paciente que apresentou, como manifestação inicial da doença, uma vasculite de pequenos vasos, sendo esta uma forma clínica atípica, com uma única descrição na literatura.

Paracoccidioidomycosis is a systemic disease caused by inhalation of conidia of Paracoccidioides brasiliensis, a dimorphic fungus that initially affects the airway, spreading by lymphatic and hematogenous routes to various organs and systems, and that can be fatal if the diagnosis and treatment are not correct. The authors describe a patient who presents small vessel vasculitis as an initial manifestation of the disease, which is an atypical clinical form with a single description in the literature.

A semi-nested PCR assay for molecular detection of Paracoccidioides brasiliensis in tissue samples / Semi-nested PCR para a detecção molecular de Paracoccidioides brasiliensis em amostras de tecido

INTRODUCTION: Paracoccidioidomycosis is a systemic infection caused by Paracoccidioides brasiliensis. METHODS: In this study, a semi-nested PCR for paracoccidioidomycosis diagnosis was developed. The primers ITS1 and ITS4 were used in the first reaction, while the primers MJ03 and ITS1 primer were used in the second reaction. The semi-nested PCR was used to investigate biopsies of five patients with oral lesions that resembled paracoccidioidomycosis. RESULTS: The semi-nested PCR was positive for four samples and negative for a sample from a patient later diagnosed with leishmaniasis. CONCLUSIONS: The new semi-nested PCR describe is useful for paracoccidioidomycosis diagnosis.

INTRODUÇÃO: A paracoccidioidomicose é uma infecção sistêmica causada pelo Paracoccidioides brasiliensis. MÉTODOS: Neste estudo, uma semi-nested PCR foi desenvolvida para o diagnóstico da paracoccidioidomicose. Os oligonucleotídeos iniciadores ITS1 e ITS4 foram usados na primeira reação, enquanto os oligonucleotídeos iniciadores MJ03 e ITS1 foram usados na segunda reação. A semi-nested PCR foi usada para investigar biopsias de cinco pacientes com lesões orais que se assemelhavam a paracoccidioidomicose. RESULTADOS: A semi-nested PCR foi positiva para quatro amostras e negativa para a amostra de um paciente, posteriormente diagnosticado com leishmaniose. CONCLUSÕES: A semi-nested PCR descrita aqui é útil para o diagnóstico da paracoccidioidomicose.

Protein-losing enteropathy in paracoccidioidomycosis identified by scintigraphy: report of three cases

Paracoccidioidomycosis (PCM) or South American Blastomycosis is a systemic fungal infection caused by a dimorphic fungus, Paracoccidioides brasiliensis. It represents the most important systemic mycosis in South America and with higher prevalence among male inhabitants of the rural area. PCM usually affects the lungs, and rarely the intestines. The authors report three cases of PCM, treated at the University Hospital of Universidade Federal de Mato Grosso do Sul whose scintigraphy with technetium-99 labeled human albumin revead intestinal protein loss.

High molecular mass fraction in clinical isolates of Paracoccidioides brasiliensis / Fração de alta massa molecular em isolados clínicos de Paracoccidioides brasiliensis

INTRODUCTION: Different serum levels of the IgG/IgE for Paracoccidioides brasiliensis high mass molecular (hMM) fraction (~366kDa) in the acute and chronic forms of the disease have been reported. Considering the nonexistence of hMM fraction investigation involving clinical isolates of P. brasiliensis, the present study aimed to investigate the presence of the hMM fraction (~366kDa) in cell free antigens (CFA) from P. brasiliensis clinical isolates. METHODS: CFA from 10 clinical isolates and a reference strain (Pb18) were submitted to SDS-polyacrylamide gel electrophoresis (SDS-PAGE) followed by gel image capturing and densitometer analysis. Additionally, CFA from 20 isolates and Pb18 were analyzed by capture ELISA (cELISA) using polyclonal (polAb) or monoclonal (mAb) antibodies to the hMM fraction. RESULTS: The presence of the hMM component was observed in CFA of all samples analyzed by SDS-PAGE/densitometry and by cELISA. In addition, Pearson's correlation test demonstrated stronger coefficients between hMM fraction levels using pAb and mAb (R = 0.853) in cELISA. CONCLUSIONS: The soluble hMM fraction was present in all the P. brasiliensis clinical isolates analyzed and the reference strain Pb18, which could be used as a source of this antigen. The work also introduces for first time, the cELISA method for P. brasiliensis hMM fraction detection. Analysis also suggests that detection is viable using polAb or mAb and this methodology may be useful for future investigation of the soluble hMM fraction (~366kDa) in sera from PCM patients.

INTRODUÇÃO: Diferentes níveis sorológicos de IgG/IgE contra a fração de alta massa molecular (hMM) (~366kDa) de Paracoccidioides brasiliensis têm sido encontrados na PCM aguda e crônica. Considerando a inexistência de investigação sobre esta fração em isolados clínicos de P. brasiliensis, o objetivo deste estudo foi investigar a presença da fração hMM (~366kDa) no preparado livre de células (CFA) de P. brasiliensis obtidos de isolados clínicos. MÉTODOS: CFA de 10 isolados e de cepa de referência (Pb18) foram submetidas à eletroforese em gel de SDS-poliacrilamida (SDS-PAGE) seguida de captura de imagem e análise por densitometria. Adicionalmente, CFA de 20 isolados e de Pb18 foram analisados por ELISA captura (cELISA) utilizando anticorpos policlonal (polAb) ou monoclonal (mAb) para fração hMM. RESULTADOS: A presença do componente de hMM foi observada em todas as amostras analisadas por SDS-PAGE/densitometria e por cELISA. Adicionalmente, o teste de correlação de Pearson demonstrou forte relação entre os níveis de fração hMM usando pAb e mAb (R = 0.853) no cELISA. CONCLUSÕES: Conclui-se que a fração hMM está presente em todos os isolados clínicos de P. brasiliensis analisados e no isolado referencial, sugerindo a possibilidade dos mesmos serem utilizados como fonte desta fração antigênica. Este trabalho também introduz pela primeira vez o método de cELISA para detecção da fração hMM de P. brasiliensis, sugerindo que detecção utilizando anticorpos polAb ou mAb é viável e essa metodologia poderá ser útil para investigação futura desta fração solúvel (~366kDa) em soros de pacientes com PCM.

Paracoccidioidomicosis. A propósito de 4 casos / Paracoccidioidomycosis: A series of four cases

La paracoccidioidomicosis es una micosis endémica en la Argentina, cuyo agente etiológico es un hongo dimórfico saprófito, el Paracoccidioides brasiliensis. Puede manifestarse como una enfermedad localizada o diseminada; ésta última es la forma de presentación más frecuente en pediatría. Objetivo: Alertar a los médicos pediatras sobre la importancia de considerar este diagnóstico en niños con cuadros clínicos sugestivos provenientes de áreas endémicas. Población, materiales y métodos: se realizó un análisis comparativo de la presentación clínica de la enfermedad y de sus factores determinantes. Se incluyeron pacientes inmunocompetentes menores de 18 años de edad entre los años 2000 y 2010, con diagnóstico anatomopatológico y/o microbiológico de paracoccidioidomicosis. Resultados: Se identificaron 4 casos, 3 niños y 1 niña, provenientes de áreas endémicas, con una edad media de presentación de 6,5 años. Clínicamente, todos presentaron un síndrome mononucleósico y marcado compromiso del estado general, asociado a: anemia, hipergamaglobulinemia y eosinofilia severa. El tiempo de evolución al diagnóstico fue, en la mayoría de los casos, mayor a 45 días. Se arribó al diagnóstico mediante anatomía patológica y/o cultivo del hongo. Se realizó tratamiento con anfotericina EV y/o itraconazol vía oral, con buena respuesta. Conclusión: La afectación sistémica observada en la población pediátrica, así como la demora en el diagnóstico hacen indispensable su consideración entre los diagnósticos diferenciales en pacientes con cuadros clínicos compatibles provenientes de área endémica (AU)

Paracoccidioidomycosis is an endemic mycosis in Argentina, caused by Paracoccidioides brasiliensis,a saprophytic dimorphic fungus. It may manifest as a localized or disseminated disease, the latter being the most frequent presentation in children. Objective: To increase awareness among pediatricians of the importance of considering this diagnosis in children with clinical signs and symptoms coming from endemic areas. Patients, Materials, and Methods: A comparative analysis was conducted on the clinical presentation of the disease and its determining factors. Immunocompetent patients under 18 years of age with a histopathological and/or microbiological diagnosis of paracoccidioidomycosis between 2000 and 2010 were included in the study. Results: Four cases, three boys and one girl, with a mean age of 6.5 years coming from endemic areas were identified. Clinically, all children presented with a mononucleotic syndrome and marked compromise of their general state associated with: anemia, hypergammaglobulinemia, and severe eosinophilia. The time of evolution at diagnosis was more than 45 days in the majority of the cases. The diagnosis was made based on histopathology and/or culture of the fungus. Treatment consisted of IV amphotericin and/or oral itraconazole, with good response. Conclusion: Because of systemic involvement observed in the pediatric population as well as the delay in diagnosis, it is important to consider this entity in the differential diagnosis of patients with compatible signs and symptoms coming from endemic areas (AU)

Juvenile paracoccidioidomycosis in urban area: report of two cases

We present two cases of juvenile form of paracoccidioidomycosis (PCM), a systemic mycosis frequently found in rural areas, whose prognosis is poor in children and young adults. They are a 14-year-old boy and a 25-year-old woman, both residents in an urban area in São Paulo - Brazil, without any history of travelling to an endemic area. They have been admitted to the hospital due to fever, weight loss and lymphadenopathy. The diagnosis was confirmed by serologic and histopathologic study. Patients have recovered after therapy with oral itraconazole and were discharged from hospital, maintaining outpatient visits. In this article, the authors discuss the unusual presentation of PCM in an urban area.

Paracoccidioidomycosis: description of two cases autochthonous in Ceará

Paracoccidioidomycosis is endemic in most countries of Latin America. Brazil has the greatest number of cases, with no autochthonous case registered in the state of Ceará. The cases of two patients that had never gone outside the State of Ceará and lived at least some years in the municipality of Palmácia.

Simultaneous infection of human host with genetically distinct isolates of Paracoccidioides brasiliensis

This study is the first report on genetic differences between isolates of Paracoccidioides brasiliensis from a single patient. We describe a simultaneous infection with genetically distinct isolates of P. brasiliensis in a patient with chronic paracoccidioidomycosis. The clinical isolates were obtained from lesions in different anatomical sites and were characterised by random amplified polymorphic DNA (RAPD) analysis. The RAPD technique can be helpful for distinguishing between clinical isolates. Different random primers were used to characterise these clinical isolates. The RAPD patterns allowed for differentiation between isolates and the construction of a phenetic tree, which showed more than 28 percent genetic variability in this fungal species, opening new possibilities for clinical studies of P. brasiliensis. Based on these results and preliminary clinical findings, we suggest that different genotypes of P. brasiliensis might infect the same patient, inducing the active form of the disease.