A 36-year-old black man presented to his dermatologist in May 1996 complain
ing of mucosal lesions in the mouth, as well as perforation of the hard pal
ate. The lesions had started approximately 7 months before and had worsened
gradually. Other complaints included odynophagia, dysphagia, mild dyspnea,
and dry cough. The patient was in good general health, but reported a 3 kg
weight loss over the previous semester. The hard and soft palate presented
erythematous ulcers with a finely granulated base and irregular, but clear
ly defined margins. A perforation (diameter, 0.5 cm) of the hard palate was
seen in the center of the ulcerated region (Fig. 1). Direct examination of
10% KOH cleared specimens showed typical double-walled, multiple budding y
east structures. Paracoccidioidomycosis (PCM) serologic reactions tested po
sitive for double immunodiffusion (DI), complement fixation (CF) 1:256 and
counterimmunoelectrophoresis (CIE) 1.128. Hematoxylin and eosin-stained sec
tions of oral lesions showed an ulcer covered by a fibrous leukocytic crust
, with a lymphoplasmacytic infiltrate, as well as multinuclear giant cells
containing round bodies with a double membrane. Gomori-Grocott staining sho
wed budding and blastoconidia suggestive of PCM. Lung computed tomography (
CT) exhibited findings consistent with pulmonary PCM. Diagnosis of the chro
nic multifocal form of PCM with oral and pulmonary manifestations was estab
lished. Drug therapy was initiated with ketoconazole (KCZ) 200 mg twice dai
ly, which led to clinical cure in approximately 2 months. Serum antibody va
lues rose 30 days after institution of therapy (CIE 1 :256; CF 1:512), peak
ing at day 60 (CIE 1:1024; CF 1:1024). Three months later the daily dose wa
s reduced to 200 mg and titers declined slowly. The diameter of the perfora
tion remained unchanged (Fig. 2). The hard palate perforation was corrected
with a palatoplasty 27 months after initiation of drug therapy (Fig. 3). K
CZ was discontinued when serologic cure was achieved after 34 months of tre
atment (DI weakly positive; CIE 1:8; CF not measurable). The patient was di
scharged 46 months after the first visit.