PMC7669275_01
Skin lesions caused by the spread of P. lutzii: a) Larger ulcer covered by crusts on the forehead and minor lesions on the root of the nose, zygomatic region and extremities of the labial commissure; b) Ulcers on the nape, back and left shoulder; c) Lesions at different stages on the shoulder and right arm; d) Forearm showing nodule and ulcers presenting with high and erythematous edges; e) Lesion with ulcerative crust on the distal phalanx of the middle finger of the left hand; f) Lower limbs showing several different lesions ranging from papular to small nodules with central ulceration.
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f1
The lesions were generally circular and had a diameter between 0.5 and 1.5 cm, but the frontal region of the face presented with an ulcer of approximately 3.0 x 1.5 cm ( Figure 1 ).
PMC7669275_02
Posteroanterior chest radiography (a) lateral position chest radiography (b) after 40 days of antifungal treatment: extensive bilateral interstitial and alveolar opacities, predominating in the middle thirds and bases of the lungs; c) chest computed tomography: ground-glass and reticular diffuse opacities through the lungs, micronodules, bronchiectasis and cardiomegaly; d) computed tomography of the abdomen: very enlarged adrenals with hypodense areas.
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f2
The radiological pattern of the lungs had worsened ( Figure 2 ). A chest CT scan showed thickened bronchi walls, some with dilation, lungs with a diffuse pattern that looked like micronodules, ground-glass opacities and cardiomegaly ( Figure 2 ).
Histopathological examination of a transbronchial biopsy (HE staining): a) Vascular remodeling: dense adventitious and low cell layer; b) Vascular remodeling: exuberant thickening of the intima layer associated with endothelial hyperplasia; c) Bronchial remodeling: intense deposition of the extracellular matrix in the bronchial structures, low cell mucosa, with distortion of the architecture of the bronchial smooth muscle layer associated with thickening of the basement membrane, slight histiocytic anthracotic pigmentation (lower right quadrant) and secondary lymphatic dilation; d) Histiocytic black anthracotic pigmentation with a lymphatic distribution in the bronchovascular axis; e) Mild lymphoplasmacytic bronchitis associated with an architectural distortion of the bronchial remodeling and anthracotic pigmentation in histiocytes.
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Histological examination of tissues obtained by bronchoscopy revealed lymphoplasmacytic infiltrates associated with bronchial and vascular remodeling, aside from distortion of the tissue architecture ( Figure 3 ).