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A case of Penicillium marneffei in a US hospital

2006; Elsevier BV; Volume: 54; Issue: 4 Linguagem: Inglês

10.1016/j.jaad.2005.06.041

1097-6787

Khanh Cong Nguyen, Sarah N. Taylor, Audrey Wanger, Asra Ali, Ronald P. Rapini,

Nail Diseases and Treatments

To the Editor: A 31-year-old man with untreated HIV was hospitalized for fever, malaise, and weight loss 3 days after having arrived from a refugee camp in Thailand. He had been diagnosed with HIV 15 months earlier with a CD4 count of 70 cells/μL. His medical history was otherwise unremarkable and without medication. On admission, the patient was hypotensive, febrile, and cachectic. His face and arms had about 10 2- to 3-mm excoriated, umbilicated skin-colored papules (Fig 1). In addition, he had a palpable right supraclavicular lymph node, systolic ejection murmur, bilateral coarse breath sounds, and splenomegaly. Initial HIV RNA quantification on admission was greater than 750,000 copies/mL and his CD4 count was 8 cells/μL. The initial differential diagnosis for his umbilicated papules was molluscum contagiosum, disseminated cryptococcosis, disseminated histoplasmosis, and Penicillium marneffei infection (as a result of his past residence). Punch biopsy specimen of one lesion revealed numerous yeastlike cells in the dermis (Fig 2), whereas biopsy culture grew downy gray-white colonies surrounded by a diffusible red pigment (Fig 3). Microscopically, culture showed septate hyphae with brushlike clusters of phialides at the ends of conidiophores (Fig 4) consistent with P marneffei, which also presented in his blood and bone marrow. Subsequently, the patient received a 21-day course of intravenous liposomal amphotericin B (225 mg/d) for 14 days, followed by a course of oral itraconazole (400 mg/d) for 6 weeks. After the antifungal course, his lesions and systemic symptoms resolved. He was discharged on oral itraconazole (400 mg/d) indefinitely.Fig 3Mold colony of Penicillium marneffei showing characteristic gray-white colonies against diffusible red background.View Large Image Figure ViewerDownload (PPT)Fig 4Microscopic view of Penicillium marneffei showing paintbrushlike clusters of hyphae and conidiophores.View Large Image Figure ViewerDownload (PPT) Infection by P marneffei, characteristically found in Southeast Asia and Southern China, is considered an AIDS-defining disease in this region.1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar Signs and symptoms include weight loss, fever, anemia, lymphadenopathy, and hepatosplenomegaly. Skin lesions are typically molluscum contagiosum-like umbilicated papules, necrotic nodules, or acneiform papules1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar, 2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar (Fig 1). These occur commonly on the face and can be on the mucosa.2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar Patients have average CD4 counts of 64 cells/μL.1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar First discovered in Vietnam in 1956, P marneffei infection was isolated from the bamboo rat, Rhizomys sinensis1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar, 3Sirisanthana T. Penicillium marneffei infection in patients with AIDS.Emerg Infect Dis. 2001; 7: 561Crossref PubMed Scopus (25) Google Scholar in Northern Thailand.4Chariyalertsak S. Sirisanthana T. Supparatpinyo K. Praparattanapan J. Nelson K.E. Case-control study of risk factors for Penicillium marneffei infection in human immunodeficiency virus-infected patients in northern Thailand.Clin Infect Dis. 1997; 24: 1080-1086Crossref PubMed Scopus (99) Google Scholar Currently, P marneffei is thought to affect only human beings and the probable infection source is contaminated soil, not necessarily the rats.4Chariyalertsak S. Sirisanthana T. Supparatpinyo K. Praparattanapan J. Nelson K.E. Case-control study of risk factors for Penicillium marneffei infection in human immunodeficiency virus-infected patients in northern Thailand.Clin Infect Dis. 1997; 24: 1080-1086Crossref PubMed Scopus (99) Google Scholar P marneffei is a dimorphic fungal pathogen2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar and appears at 37°C as intracellular and extracellular yeastlike forms, similar to histoplasmosis,2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar except that there are septae that result from binary fission1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar (Fig 2). Culture at 25°C produces fluffy gray-white colonies with a diffusible red pigment on Sabouraud's glucose agar2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar (Fig 3). This mold form of P marneffei has septate hyphae with lateral and terminal conidiophores1Khongkunthian P. Isaratanan W. Samaranayake L.P. Gelderblom H.R. Reichart P.A. Case report: oro-facial manifestations of Penicillium marneffei infection in a Thai patient with AIDS.Mycoses. 2002; 45: 411-414Crossref PubMed Scopus (9) Google Scholar resembling skeleton hands or paintbrushes (Fig 4). Early treatment and lifelong prophylaxis are crucial to avoid recurrences. Currently, amphotericin B (0.6 mg/kg/d intravenously) for 2 weeks followed by itraconazole (400 mg/d orally) for 6 to 10 weeks is recommended.3Sirisanthana T. Penicillium marneffei infection in patients with AIDS.Emerg Infect Dis. 2001; 7: 561Crossref PubMed Scopus (25) Google Scholar Afterwards, patients need itraconazole (200 mg/d) orally for life.5Supparatpinyo K. Perriens J. Nelson K.E. Sirisanthana T. A controlled trial of itraconazole to prevent relapse of Penicillium marneffei infection in patients infected with the human immunodeficiency virus.N Engl J Med. 1998; 339: 1739-1743Crossref PubMed Scopus (151) Google Scholar Alternatives are voriconazole or ketoconazole.2Sobera J. Elewski B. Fungal diseases.in: Bolognia J.L. Jorizzo J.L. Rapini R.P. Dermatology. Mosby, New York2003: 1194-1198Google Scholar Although P marneffei infection rarely occurs in the United States, we still should be vigilant of regional endemic differences in our ever increasingly mobile foreign patient population to effectively render care.