Paracoccidioidomycosis pathophysiology: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
m (Changes made per Mahshid's request)
 
(57 intermediate revisions by 2 users not shown)
Line 4: Line 4:


==Overview==
==Overview==
Spores of ''[[Paracoccidioides brasiliensis|Paracoccidioides spp.]]'' are commonly transmitted via the respiratory route to the human host. Following transmission, ''[[Paracoccidioides brasiliensis|Paracoccidioides spp.]]'' particles invade the terminal bronchioles and alveoli where [[granulomas]] are formed, but can be inactive for up to 40 years.<ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969  }} </ref> On microscopic histopathological analysis, a "pilot's wheel" or a "Mickey mouse ears-like" appearance is a characteristic finding of paracoccidioidomycosis (PCM).<ref>Paracoccidioidomycosis. Wikipedia.https://en.wikipedia.org/wiki/Paracoccidioidomycosis. Accessed on January 12, 2016</ref><ref name="?">Manns B.J, Baylis B.W, Urbanski S.J, Gibb A.P, Rabin H.R. Paracoccidioidomycosis: Case Report and Review. ''CID''. 1996; 23: 1026-1032 </ref><ref name="paper">Vargas J, Vargas R. Paracoccidiodomicosis. ''Rev. enferm. infecc. trop.''2009(1):49-56</ref>


==Pathopysiology==


==Pathogenesis==
=== Transmission ===
*Spores of ''Paracoccidioides spp.'' are transmitted via the respiratory route to the human host.
*Spores of ''[[Paracoccidioides brasiliensis|Paracoccidioides spp]].'' are transmitted via the respiratory route to the human host.
*Following transmission, ''Paracoccidiodes spp.'' conidia and mycelial particles invade the terminal brochioles and alveoli and convert into yeast cell <ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969  }} </ref>
*Rarely in can be transmitted via skin trauma, where the [[fungus]] attaches the skin and mucous membranes. Or via the digestive system, after consuming contaminated food.<ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969  }} </ref><ref name="paper">Vargas J, Vargas R. Paracoccidiodomicosis. ''Rev. enferm. infecc. trop.''2009(1):49-56</ref>
*"The infection can spread to other tissues via lymphatic and hematic" routes. <ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969  }} </ref>
*Following transmission, ''[[Paracoccidioides brasiliensis|Paracoccidioides spp.]]'' conidia and mycelial particles invade the terminal bronchioles and alveoli where they convert into yeast cells.<ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969  }} </ref>
*"The fungi developed mechanisms (such as adhesion to host cells), to avoid entrapment within mucus and their elimination by mucigen cilliary cells" <ref name="pmid26635779">{{cite journal| author=de Oliveira HC, Assato PA, Marcos CM, Scorzoni L, de Paula E Silva AC, Da Silva Jde F et al.| title=Paracoccidioides-host Interaction: An Overview on Recent Advances in the Paracoccidioidomycosis. | journal=Front Microbiol | year= 2015 | volume= 6 | issue=  | pages= 1319 | pmid=26635779 | doi=10.3389/fmicb.2015.01319 | pmc=PMC4658449 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26635779  }} </ref>
 
*"Their effective adherence contributes to higher speed invasion of host cells, allowing for evasion of the immune system" <ref name="pmid26635779">{{cite journal| author=de Oliveira HC, Assato PA, Marcos CM, Scorzoni L, de Paula E Silva AC, Da Silva Jde F et al.| title=Paracoccidioides-host Interaction: An Overview on Recent Advances in the Paracoccidioidomycosis. | journal=Front Microbiol | year= 2015 | volume= 6 | issue=  | pages= 1319 | pmid=26635779 | doi=10.3389/fmicb.2015.01319 | pmc=PMC4658449 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26635779  }} </ref>
=== Pathogenesis ===
*The organisms response to the primo-infection is: bronchoalveolitis, which is normally asymptomatic.<ref name="paper">Vargas J, Vargas R. Paracoccidiodomicosis. ''Rev. enferm. infecc. trop.''2009(1):49-56</ref>
*Following the primary infection, [[granulomas]] may form. [[Granulomas]] can be inactive for several years.<ref name="paper">Vargas J, Vargas R. Paracoccidiodomicosis. ''Rev. enferm. infecc. trop.''2009(1):49-56</ref>
*If the infection is active or gets activated, it can spread through lymphatic and hematologic routes to other tissues such as: spleen, kidneys, adrenal glands, liver, bone, central nervous system, and airways.<ref name="pmid21738969">{{cite journal| author=Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA| title=Immunology of paracoccidioidomycosis. | journal=An Bras Dermatol | year= 2011 | volume= 86 | issue= 3 | pages= 516-24 | pmid=21738969 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21738969 }} </ref><ref name="pmid22236894">{{cite journal| author=Barreto MM, Marchiori E, Amorim VB, Zanetti G, Takayassu TC, Escuissato DL et al.| title=Thoracic paracoccidioidomycosis: radiographic and CT findings. | journal=Radiographics | year= 2012 | volume= 32 | issue= 1 | pages= 71-84 | pmid=22236894 | doi=10.1148/rg.321115052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22236894 }} </ref>  
* [[Paracoccidioides brasiliensis|''Paracoccidioides spp'']]''.'' have developed different mechanisms to avoid mucus and eradication by [[cilliary cells]].<ref name="pmid26635779">{{cite journal| author=de Oliveira HC, Assato PA, Marcos CM, Scorzoni L, de Paula E Silva AC, Da Silva Jde F et al.| title=Paracoccidioides-host Interaction: An Overview on Recent Advances in the Paracoccidioidomycosis. | journal=Front Microbiol | year= 2015 | volume= 6 | issue=  | pages= 1319 | pmid=26635779 | doi=10.3389/fmicb.2015.01319 | pmc=PMC4658449 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26635779  }} </ref>
*The powerful adherence characteristic of the species provides a rapid takeover of host cells and consequently the avoidance of the immune system.<ref name="pmid26635779">{{cite journal| author=de Oliveira HC, Assato PA, Marcos CM, Scorzoni L, de Paula E Silva AC, Da Silva Jde F et al.| title=Paracoccidioides-host Interaction: An Overview on Recent Advances in the Paracoccidioidomycosis. | journal=Front Microbiol | year= 2015 | volume= 6 | issue=  | pages= 1319 | pmid=26635779 | doi=10.3389/fmicb.2015.01319 | pmc=PMC4658449 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26635779  }} </ref>
 
==Genetics==
*The majority of patients in countries such as Colombia and Brazil, with high prevalence of PCM, had [[HLA-A9]], [[HLA-B13]], and HLA-B4 antigens.<ref name="kkk">Martinez, R.Epidemiology of Paracoccidioidomycosis. ''Rev. Inst. Med. trop. S. Paulo.'' 2015;57(19), 11-20</ref>
*Chronic PCM is associated with patients that have C4B*-00 antigen of the [[Major histocompatibility complex|class III major histocompatibility complex]].<ref name="kkk">Martinez, R.Epidemiology of Paracoccidioidomycosis. ''Rev. Inst. Med. trop. S. Paulo.'' 2015;57(19), 11-20</ref>


==Associated Conditions==
==Associated Conditions==
==== Paracoccidiodomycosis has been associated with: ====
* '''Concomitant infections'''
**The most important infectious disease that can be found concomitant with PCM is pulmonary [[tuberculosis]] ([[Tuberculosis|TB]]). [[Tuberculosis|TB]] can hold up the diagnosis of PCM, because they have similar clinical manifestations. Other infectious diseases associated with PCM because they have the same risk factors are: [[leishmaniasis]], [[leprosy]], [[Chagas disease|Chagas disease]] and [[strongyloidiasis]].<ref name="kkk">Martinez, R.Epidemiology of Paracoccidioidomycosis. ''Rev. Inst. Med. trop. S. Paulo.'' 2015;57(19), 11-20</ref>
* '''Cancer'''
**The majority of patients with [[carcinoma]] and PCM, have the same organ or adjacent tissues involved. A risk factor for [[carcinoma]] is chronic inflammation with [[squamous metaplasia]], which has been described in 33% cases of PCM in a study.<ref name="ccc">Da Silva G, Bittencourt C, De Mattos F, Da Silva J, Prolla J Severo L. Association between paracoccidioidomycosis and cancer. ''J. bras. pneumol.'' 2010;36(3), 356-362 </ref>
==== Paracoccidioidomycosis is also considered an opportunistic infection in Latin America. Associated conditions are: ====
* '''HIV/AIDS''':
**Endemic areas of ''[[Paracoccidioides brasiliensis|Paracoccidioides spp]]''. in Brazil have the majority of [[HIV AIDS|HIV/AIDS]] patients.<ref name="aaa">Brummer E, Castaneda E, Restrepo A. Paracoccidioidomycosis: An Update. 'Clin. Microbiol. Rev''.1993;Vol 6(2):89-117''</ref> Nevertheless, the incidence of [[HIV AIDS|HIV/AIDS]] and paracoccidioidomycosis is minimum, this may be because the prophylaxis ([[Trimethoprim-Sulfamethoxazole|trimethoprim-sulfamethoxazole]]) used for ''[[Pneumocystis jiroveci]]'' is the one of the possible treatments for PCM.<ref name="bbb">Amoroso A. A Man With Newly Diagnosed HIV/AIDS With Unusual Severe Opportunistic Infection and No AIDS-Defining Disease. ''CID''. 2014;58:1484-1485</ref>
* '''Cancer''':
**The majority of patients have been diagnosed at the same time (40%) or after the neoplasm diagnostic (60%). PCM is highly associated with solid organ and [[Hematological malignancies|hematologic neoplasias]].<ref name="kkk">Martinez, R.Epidemiology of Paracoccidioidomycosis. ''Rev. Inst. Med. trop. S. Paulo.'' 2015;57(19), 11-20</ref>
*'''Organ Transplantation''':
**PCM has been described in cases of [[renal transplantation]].<ref name="kkk">Martinez, R.Epidemiology of Paracoccidioidomycosis. ''Rev. Inst. Med. trop. S. Paulo.'' 2015;57(19), 11-20</ref> The small amount of cases may be because of the use of [[Trimethoprim-Sulfamethoxazole|trimethoprim-sulfamethoxazole]] as [[prophylaxis]] for ''[[Pneumocystis jiroveci]]'', which is one of the possible treatments for PCM.<ref name="ddd">Zavascki A, Bienardt J, Severo L. Paracoccidioidomycosis in organ transplant recipient: case report. ''Rev. Inst. Med. trop. S. Paulo'' 2004;46(5), 279-281 </ref>
* '''Carpal Tunnel Syndrome''':
**Only seen in Immunosupressed patients.<ref name="pmid3414040">{{cite journal| author=Lytkin MI, Petlenko VP| title=[A methodological analysis of the theory of traumatic disease]. | journal=Voen Med Zh | year= 1988 | volume=  | issue= 4 | pages= 11-4 | pmid=3414040 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3414040  }} </ref>


==Gross Pathology==
==Gross Pathology==
*[[Granulomas]] merge and form different shape [[nodules]] which can be seen macroscopically in the lungs. With time, the [[nodules]] tend to necrose and then cavitate.<ref name="pmid19608361">{{cite journal| author=Marchiori E, Valiante PM, Mano CM, Zanetti G, Escuissato DL, Souza AS et al.| title=Paracoccidioidomycosis: high-resolution computed tomography-pathologic correlation. | journal=Eur J Radiol | year= 2011 | volume= 77 | issue= 1 | pages= 80-4 | pmid=19608361 | doi=10.1016/j.ejrad.2009.06.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19608361  }} </ref>


==Microscopic Pathology==
==Microscopic Pathology==
 
* The most important microscopically characteristic is the '''“ship’s wheel”''' or '''“Mickey mouse ears'''” appereance<ref name="paper">Vargas J, Vargas R. Paracoccidiodomicosis. ''Rev. enferm. infecc. trop.''2009(1):49-56</ref>
<gallery>
Image:527_lores.jpg|Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.<ref>Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016</ref>
Image:498_lores.jpg|Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.<ref>Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016</ref>
Image:Paracoccidioidomycosis-37.jpg|This is a Lowenstein-Jensen slant culture of the fungus Paracoccidioides brasiliensis grown at 37°C.<ref>Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016</ref>
</gallery>


==References==
==References==
Line 24: Line 60:


[[Category:Fungal diseases]]
[[Category:Fungal diseases]]
[[Category:Infectious diseases]]

Latest revision as of 18:37, 18 September 2017

Paracoccidioidomycosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Paracoccidioidomycosis from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Imaging Findings

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Future or Investigational Therapies

Case Studies

Case #1

Paracoccidioidomycosis pathophysiology On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Paracoccidioidomycosis pathophysiology

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Paracoccidioidomycosis pathophysiology

CDC on Paracoccidioidomycosis pathophysiology

Paracoccidioidomycosis pathophysiology in the news

Blogs on Paracoccidioidomycosis pathophysiology

Directions to Hospitals Treating Paracoccidioidomycosis

Risk calculators and risk factors for Paracoccidioidomycosis pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Danitza Lukac

Overview

Spores of Paracoccidioides spp. are commonly transmitted via the respiratory route to the human host. Following transmission, Paracoccidioides spp. particles invade the terminal bronchioles and alveoli where granulomas are formed, but can be inactive for up to 40 years.[1] On microscopic histopathological analysis, a "pilot's wheel" or a "Mickey mouse ears-like" appearance is a characteristic finding of paracoccidioidomycosis (PCM).[2][3][4]

Pathopysiology

Transmission

  • Spores of Paracoccidioides spp. are transmitted via the respiratory route to the human host.
  • Rarely in can be transmitted via skin trauma, where the fungus attaches the skin and mucous membranes. Or via the digestive system, after consuming contaminated food.[1][4]
  • Following transmission, Paracoccidioides spp. conidia and mycelial particles invade the terminal bronchioles and alveoli where they convert into yeast cells.[1]

Pathogenesis

  • The organisms response to the primo-infection is: bronchoalveolitis, which is normally asymptomatic.[4]
  • Following the primary infection, granulomas may form. Granulomas can be inactive for several years.[4]
  • If the infection is active or gets activated, it can spread through lymphatic and hematologic routes to other tissues such as: spleen, kidneys, adrenal glands, liver, bone, central nervous system, and airways.[1][5]
  • Paracoccidioides spp. have developed different mechanisms to avoid mucus and eradication by cilliary cells.[6]
  • The powerful adherence characteristic of the species provides a rapid takeover of host cells and consequently the avoidance of the immune system.[6]

Genetics

Associated Conditions

Paracoccidiodomycosis has been associated with:

  • Concomitant infections
    • The most important infectious disease that can be found concomitant with PCM is pulmonary tuberculosis (TB). TB can hold up the diagnosis of PCM, because they have similar clinical manifestations. Other infectious diseases associated with PCM because they have the same risk factors are: leishmaniasis, leprosy, Chagas disease and strongyloidiasis.[7]
  • Cancer
    • The majority of patients with carcinoma and PCM, have the same organ or adjacent tissues involved. A risk factor for carcinoma is chronic inflammation with squamous metaplasia, which has been described in 33% cases of PCM in a study.[8]

Paracoccidioidomycosis is also considered an opportunistic infection in Latin America. Associated conditions are:

  • Carpal Tunnel Syndrome:
    • Only seen in Immunosupressed patients.[12]

Gross Pathology

  • Granulomas merge and form different shape nodules which can be seen macroscopically in the lungs. With time, the nodules tend to necrose and then cavitate.[13]

Microscopic Pathology

  • The most important microscopically characteristic is the “ship’s wheel” or “Mickey mouse ears” appereance[4]
  • Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.[14]

    Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.[14]

  • Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.[15]

    Histopathology of paracoccidioidomycosis. Budding cells of Paracoccidioides brasiliensis: ships wheel appearance. Methenamine silver stain.[15]

  • This is a Lowenstein-Jensen slant culture of the fungus Paracoccidioides brasiliensis grown at 37°C.[16]

    This is a Lowenstein-Jensen slant culture of the fungus Paracoccidioides brasiliensis grown at 37°C.[16]

References

  1. ↑ 1.0 1.1 1.2 1.3 Fortes MR, Miot HA, Kurokawa CS, Marques ME, Marques SA (2011). "Immunology of paracoccidioidomycosis". An Bras Dermatol. 86 (3): 516–24. PMID 21738969.
  2. ↑ Paracoccidioidomycosis. Wikipedia.https://en.wikipedia.org/wiki/Paracoccidioidomycosis. Accessed on January 12, 2016
  3. ↑ Manns B.J, Baylis B.W, Urbanski S.J, Gibb A.P, Rabin H.R. Paracoccidioidomycosis: Case Report and Review. CID. 1996; 23: 1026-1032
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Vargas J, Vargas R. Paracoccidiodomicosis. Rev. enferm. infecc. trop.2009(1):49-56
  5. ↑ Barreto MM, Marchiori E, Amorim VB, Zanetti G, Takayassu TC, Escuissato DL; et al. (2012). "Thoracic paracoccidioidomycosis: radiographic and CT findings". Radiographics. 32 (1): 71–84. doi:10.1148/rg.321115052. PMID 22236894.
  6. ↑ 6.0 6.1 de Oliveira HC, Assato PA, Marcos CM, Scorzoni L, de Paula E Silva AC, Da Silva Jde F; et al. (2015). "Paracoccidioides-host Interaction: An Overview on Recent Advances in the Paracoccidioidomycosis". Front Microbiol. 6: 1319. doi:10.3389/fmicb.2015.01319. PMC 4658449. PMID 26635779.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Martinez, R.Epidemiology of Paracoccidioidomycosis. Rev. Inst. Med. trop. S. Paulo. 2015;57(19), 11-20
  8. ↑ Da Silva G, Bittencourt C, De Mattos F, Da Silva J, Prolla J Severo L. Association between paracoccidioidomycosis and cancer. J. bras. pneumol. 2010;36(3), 356-362
  9. ↑ Brummer E, Castaneda E, Restrepo A. Paracoccidioidomycosis: An Update. 'Clin. Microbiol. Rev.1993;Vol 6(2):89-117
  10. ↑ Amoroso A. A Man With Newly Diagnosed HIV/AIDS With Unusual Severe Opportunistic Infection and No AIDS-Defining Disease. CID. 2014;58:1484-1485
  11. ↑ Zavascki A, Bienardt J, Severo L. Paracoccidioidomycosis in organ transplant recipient: case report. Rev. Inst. Med. trop. S. Paulo 2004;46(5), 279-281
  12. ↑ Lytkin MI, Petlenko VP (1988). "[A methodological analysis of the theory of traumatic disease]". Voen Med Zh (4): 11–4. PMID 3414040.
  13. ↑ Marchiori E, Valiante PM, Mano CM, Zanetti G, Escuissato DL, Souza AS; et al. (2011). "Paracoccidioidomycosis: high-resolution computed tomography-pathologic correlation". Eur J Radiol. 77 (1): 80–4. doi:10.1016/j.ejrad.2009.06.017. PMID 19608361.
  14. ↑ Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016
  15. ↑ Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016
  16. ↑ Paracoccidioidomycosis. CDC Public Health Image Library (PHIL).http://phil.cdc.gov/phil/details.asp. Accessed on January 20, 2016
Retrieved from "https://www.wikidoc.org/index.php?title=Paracoccidioidomycosis_pathophysiology&oldid=1358254"