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P162 Parinaud's Oculoglandular Syndrome as an atypical manifestation of sporotrichosis in Brazil

Abstract   Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives Inform the general practitioner about the possibilities of atypical manifestations secondary to sporotrichosis, such as ocular manifestations, unrelated to the classic finding of contiguous lymphocutaneous ulcers. Methods This is a single-center, cross-sectional, retrospective study with patients evaluated and seen from June 2018 to April 2022 at the Mycology Outpatient Clinic of Hospital Universitário Oswaldo Cruz, University of Pernambuco. All patients were evaluated by the same infectious disease physician throughout the course, from diagnosis to outpatient discharge. Scrapings and cultures were collected by the institution's specialized Mycology team. Biopsies were sent to the University Pathology Service (CIAP). Results During the 4-year period, 231 patients started their treatment for sporotrichosis following clinical, laboratory, and histopathological criteria. Of these, 9 (3,8%) had Parinaud's Oculoglandular Syndrome, unilateral granulomatous conjunctivitis associated with ipsilateral preauricular or submandibular lymphadenitis (Fig. 1). Of the 9 reported cases, 8 presented manifestations only in the conjunctiva (88%), and 1 case also presented palpebral involvement (12%). Since most patients had a late diagnosis due to the difficulty in carrying out the specific investigation of the agent by a non-specialized team, the diagnosis by scraping and culture was compromised by early treatment with antifungals, especially itraconazole. It is becoming common in the Northeast of Brazil that the association of sick cats with typical manifestations of sporotrichosis is the main epidemiological factor since our case series for infections caused by soil manipulation is low. Therefore, 55% (5/9) had a clinical-epidemiological diagnosis of sporotrichosis, with an excellent clinical response to itraconazole 200 mg/day, as well as the 4 patients with diagnoses confirmed by culture (Fig. 2). The antifungal was taken after lunch since a fatty diet interferes with improved medication absorption. All patients were instructed not to use medications with known interactions, especially proton pump inhibitors and alcohol use. Conclusion Human sporotrichosis has become endemic in Latin America in the last two decades, bringing relevant morbidity to those infected. Zoonotic transmission by direct contact with infected sick cats has been gaining ground in Northeast Brazil, creating important epidemiology when typical sporotrichosis lesions appear following contact with these animals. Lymphocutaneous sporotrichosis is known to be the most common manifestation, but there is a need for care teams working in primary and secondary care to identify atypical manifestations and expand the investigation into the possibility of fungal infections. The epidemiology of the neighborhood associated with the presence and contact with sick cats with ulcerative lesions must be considered and taken into account.

Poster session 2, September 22, 2022, 12:30 PM -1:30 PM Objectives: Inform the general practitioner about the possibilities of atypical manifestations secondary to sporotrichosis, such as ocular manifestations, unrelated to the classic finding of contiguous lymphocutaneous ulcers.
Methods: This is a single-center, cross-sectional, retrospective study with patients evaluated and seen from June 2018 to April 2022 at the Mycology Outpatient Clinic of Hospital Universitário Oswaldo Cruz, University of Pernambuco.
All patients were evaluated by the same infectious disease physician throughout the course, from diagnosis to outpatient discharge.
Scrapings and cultures were collected by the institution's specialized Mycology team. Biopsies were sent to the University Pathology Service ( CIAP ) .
Since most patients had a late diagnosis due to the difficulty in carrying out the specific investigation of the agent by a non-specialized team, the diagnosis by scraping and culture was compromised by early treatment with antifungals, especially itraconazole. It is becoming common in the Northeast of Brazil that the association of sick cats with typical manifestations of sporotrichosis is the main epidemiological factor since our case series for infections caused by soil manipulation is low. Therefore, 55% ( 5/9 ) had a clinical-epidemiological diagnosis of sporotrichosis, with an excellent clinical response to itraconazole 200 mg/day, as well as the 4 patients with diagnoses confirmed by culture ( Fig. 2 ) . The antifungal was taken after lunch since a fatty diet interferes with improved medication absorption. All patients were instructed not to use medications with known interactions, especially proton pump inhibitors and alcohol use.
Conclusion: Human sporotrichosis has become endemic in Latin America in the last two decades, bringing relevant morbidity to those infected. Zoonotic transmission by direct contact with infected sick cats has been gaining ground in Northeast Brazil, creating important epidemiology when typical sporotrichosis lesions appear following contact with these animals. Lymphocutaneous sporotrichosis is known to be the most common manifestation, but there is a need for care teams working in primary and secondary care to identify atypical manifestations and expand the investigation into the possibility of fungal infections. The epidemiology of the neighborhood associated with the presence and contact with sick cats with ulcerative lesions must be considered and taken into account. Objectives: During the COVID-19 pandemic, several cases of mucormycosis related to SARS-CoV-2 were reported. This association is still poorly studied due to its recent emergence and makes diagnosis and treatment challenging. Usually, patients who are affected by this infection are immunocompromised by corticosteroid treatment and uncontrolled diabetes mellitus, being mucormycosis a life-threatening opportunistic invasive fungal infection caused by mucoromycetes, which reaches a mortality rate of about 50%, even with treatment. Thus, this association requires as much information as possible about the pathogenesis and treatment.

P163
Methods: Here, we report two cases with conclusive diagnosis and positive evolution to mucormycosis associated with COVID-19 after corticosteroid therapy.
Results: The first case was a 68-year-old woman, hypertensive and diabetic, who was affected by SARS-CoV-2, with intense ocular pain and paralysis of extrinsic ocular muscles of the right eye and eyelid. The patient underwent CT scan of the sinuses with contrast, which showed signs on maxillary. The patient was submitted to sinusectomy with orbital decompression and the material from the surgery was sent for fungal investigation, which 20% KOH direct exam showed hyaline, sparsely-septate, broad, ribbon-like hyphae with irregular right-angle branching. Rhizopus oryzae was isolated on Sabouraud agar. Mucormycosis was diagnosed in the facial sinuses, and resolution of infection was obtained with liposomal amphotericin B. The second case was a 59-year-old woman, obesity degree 3, asthmatic and history of COVID-19, with history of abscesses in oral mucosa and palate, with drainage of brown secretion after 30 days of COVID-19 resolution. After medical discharge, the patient was evaluated by an oral and maxillofacial surgeon to solve an esthetic problem, when the material was collected for biopsy of the mucosal lesions. Histopathological exam showed aseptic thick mycelial filaments presenting right angle bifurcation, suggestive of Mucorales ( mucormycosis ) . The patient was readmitted to the hospital for mucormycosis treatment based on isavuconazole ( 200 mg, q8 as attack dose on Day 1 and 2, and 3 toward q24 ) , and treatment evolved positively with no need for surgical intervention. We conclude that the extensive use of steroids associated with diabetes is the main factor for the appearance of mucormycosis after COVID-19, but with a conclusive diagnosis and correct treatment, this infection can have a good evolution, resulting in an improvement in the patient's clinical condition, reducing the risk of death for this infection.
Conclusion: Isavuconazole appears to be a drug with a safe profile and with curative potential for mucormycosis. The possibility of oral use from the third day at its maintenance dose ( 200 mg/day ) with intravenous use in the first 48 h at a dose of 200 mg every 8 h. Diabetic patients are more prone to infection, but patients infected with SARS CoV 2 using corticosteroids have shown to be a risk group for this fungus.