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©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
Extrahepatic cholestasis associated with paracoccidioidomycosis: Challenges in the differential diagnosis of biliopancreatic neoplasia
José Sebastião dos Santos, Vitor de Moura Arrais, William José Rosseto Ferreira, Ricardo Ribeiro Correa Filho, Mariângela Ottoboni Brunaldi, Rafael Kemp, Ajith Kumar Sankanrakutty, Jorge Elias Junior, Fernando Bellissimo-Rodrigues, Roberto Martinez, Edson Zangiacomi Martinez, José Celso Ardengh
José Sebastião dos Santos, Vitor de Moura Arrais, William José Rosseto Ferreira, Ricardo Ribeiro Correa Filho, Rafael Kemp, Ajith Kumar Sankanrakutty, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Cirurgia e Anatomia, Ribeirão Preto 14049-900, São Paulo, Brazil
Mariângela Ottoboni Brunaldi, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Patologia, Ribeirão Preto 14048900, São Paulo, Brazil
Jorge Elias Junior, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Ribeirão Preto 14048900, São Paulo, Brazil
Fernando Bellissimo-Rodrigues, Edson Zangiacomi Martinez, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Medicina Social , Ribeirão Preto 14015-010, São Paulo, Brazil
Roberto Martinez, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Clínica Médica, Ribeirão Preto 14015-010, São Paulo, Brazil
José Celso Ardengh, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Cirurgia e Anatomia, Ribeirão Preto 14049-900, São Paulo, Brazil and Hospital Moriah, Serviço de Endoscopia Digestiva, São Paulo 04084-002, São Paulo, Brazil
Author contributions: dos Santos JS and Ardengh JC were the guarantors and designed the study, drafted the initial manuscript, and revised the article critically for important intellectual content; de Moura Arrais V, Rosseto Ferreira WJ, and Ribeiro Correa Filho R participated in the acquisition, analysis, and interpretation of data; Brunaldi MO participated in the interpretation of data; Kemp R, Sankanrakutty AK, Elias Junior J, Bellissimo-Rodrigues F, Martinez R, and Zangiacomi Martinez E participated in the acquisition and analysis of data.
Institutional review board statement: The study was reviewed and approved by the Research Ethics Committee of HCFMRP-USP (Approval No. 4580249).
Informed consent statement: The informed consent was waived from the patients as the study is retrospective, poses no risk to the patient’s health, and does not involve intervention or contact with them. Patient data will be anonymously compiled in a table with a password to minimize the risk of identity exposure.
Conflict-of-interest statement: The authors report no conflicts of interest.
Data sharing statement: Data can be acquired from the corresponding author.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: José Celso Ardengh, MD, MSc, PhD and FASGE Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Departamento de Cirurgia e Anatomia, Ribeirão Preto 14049-900, São Paulo, Brazil and Hospital Moriah, Serviço de Endoscopia Digestiva, São Paulo 04084-002, São Paulo, Brazil. jcelso@uol.com.br
Received: January 15, 2024
Revised: March 20, 2024
Accepted: April 19, 2024
Published online: June 15, 2024
Processing time: 151 Days and 5.9 Hours
BACKGROUND
Paracoccidioidomycosis (PCM) may involve the hepatic pedicle and peripancreatic lymph nodes, cause damage to the bile duct and manifest, exceptionally, in combination with extrahepatic cholestasis (EHC), making investigation and treatment challenging.
AIM
To investigate the management of patients with visceral PCM admitted with EHC.
METHODS
All patients diagnosed with PCM treated in a public, tertiary teaching hospital between 1982 and 2020 were retrospectively evaluated. Those also identified with EHC were allocated to two groups according to the treatment approach for the purpose of comparing clinical, laboratory, and imaging findings, resources used for etiological diagnosis, treatment results, and prognosis. Statistical analyses were performed using the linear mixed-effects model (random and fixed effects), which was adjusted using the PROC MIXED procedure of the SAS® 9.0 software, and Fisher’s exact test.
RESULTS
Of 1645 patients diagnosed with PCM, 40 (2.4%) had EHC. Of these, 20 (50.0%) lived in the rural area and 29 (72.5%) were men, with a mean age of 27.1 years (3-65 years). Jaundice as first symptom and weight loss of at least 10 kg were observed in 16 patients (40.0%), and a mass in the head of the pancreas was observed in 8 (20.0%). The etiological diagnosis was made by tissue collection during surgery in 4 cases (10.0%) and by endoscopic methods in 3 cases (7.5%). Twenty-seven patients (67.5%) received drug treatment alone (Group 1), whereas 13 (32.5%) underwent endoscopic and/or surgical procedures in combination with drug treatment (Group 2). EHC was significantly reduced in both groups (40.7% in Group 1, with a mean time of 3 months; and 38.4% in Group 2, with a mean time of 7.5 months), with no statistically significant difference between them. EHC recurrence rates, associated mainly with treatment nonadherence, were similar in both groups: 37% in Group 1 and 15.4% in Group 2. The mortality rate was 18.5% in Group 1 and 23% in Group 2, with survival estimates of 71.3% and 72.5%, respectively, with no statistically significant difference.
CONCLUSION
Although PCM-related EHC is rare, it needs to be included in the differential diagnosis of malignancies, as timely treatment can prevent hepatic and extrahepatic sequelae.
Core Tip: Paracoccidioidomycosis (PCM) associated with extrahepatic cholestasis (EHC) is a rare condition that can mimic malignant tumors. Correct diagnosis and treatment are essential to prevent unnecessary operations. Immunoelectrophoresis has proven to be a sensitive and reliable method for diagnosis and has influenced treatment decisions. We compared the results of two groups based on the treatment and/or diagnostic approach. Of 1645 patients diagnosed with PCM, 40 (2.4%) had EHC. This study is a unique contribution to the medical literature, with the largest sample size ever reported, by drawing attention to the diagnosis of PCM in patients with EHC, especially in endemic regions.
