Journal of Postgraduate Medicine
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Year : 2004  |  Volume : 50  |  Issue : 3  |  Page : 235-236  

Disseminated Penicillium marneffei infection in a Human Immunodeficiency Virus-infected individual

George M Varghese1, Gajanan Pise2, Sarojini Joy Michael3, Mary Jacob4, Renu George2,  
1 Department of Medicine and Infectious Diseases, Christian Medical College, Vellore - 632004, India
2 Department of Dermatology, Christian Medical College, Vellore - 632004, India
3 Department of Microbiology, Christian Medical College, Vellore - 632004, India
4 Department of Pathology, Christian Medical College, Vellore - 632004, India

Correspondence Address:
George M Varghese
Department of Medicine and Infectious Diseases, Christian Medical College, Vellore - 632004
India




How to cite this article:
Varghese GM, Pise G, Michael S, Jacob M, George R. Disseminated Penicillium marneffei infection in a Human Immunodeficiency Virus-infected individual.J Postgrad Med 2004;50:235-236


How to cite this URL:
Varghese GM, Pise G, Michael S, Jacob M, George R. Disseminated Penicillium marneffei infection in a Human Immunodeficiency Virus-infected individual. J Postgrad Med [serial online] 2004 [cited 2020 Apr 7 ];50:235-236
Available from: http://www.jpgmonline.com/text.asp?2004/50/3/235/12587


Full Text

Sir,

Prevention and treatment of opportunistic infections continues to be a major public health strategy among HIV-infected people in developing countries. Awareness of clinical manifestations and the cutaneous stigmata of opportunistic infections are pivotal in the diagnosis of many opportunistic infections in resource-limited areas. Increasing numbers of Penicillium marneffei infections have been documented in HIV-infected individuals from the northeastern part of India.[1] This infection has been predominantly reported from Southeast Asia where it has been reported to be the third most common illness that defines Acquired Immuno Deficiency Syndrome.[2]

We describe a patient who presented with fever, weight loss and typical umbilicated papules proven to have disseminated P. marneffei infection on histopathology and culture. A high index of suspicion in the presence of typical skin lesions can lead to early diagnosis.

A 43-year-old man from Assam presented with low-grade fever, weight loss and skin lesions. He had not previously been tested for HIV antibody or virus. On examination, he was wasted, pale with oropharyngeal candidiasis, and had multiple erythematous papules on the face, upper back and extremities. Most of the papules had a necrotic centre with scabs. Systemic examination was normal. His haemoglobin was 9.5 gm% and total white cell count was 4400/mmcu with normal differential count. The chest radiograph was normal. HIV-ELISA was reactive. Biopsy of the skin lesions revealed histiocytic granulomas with yeast-like organisms. Fungal culture grew pigment-producing fungus, Penicillium marneffei. Markers of immune suppression like CD4 counts and viral load were not done due to financial constraints. The patient showed clinical improvement with itraconazole 200 mg orally twice daily. The option of antiretroviral therapy was discussed with the patient but was deferred due to financial constraints.

Penicillium marneffei is a dimorphic fungus causing opportunistic infection, potentially life-threatening in immunocompromised individuals. P. marneffei was first isolated from a species of bamboo rat (Rhizomys sinensis) from Vietnam in 1956 and later, from other rodent species.[3] The common clinical features are fever, weight loss, anaemia, hepatosplenomegaly, and papular skin lesions.[4],[5] The typical cutaneous papules with central necrotic umbilication may be present in about 70% of patients.[4] While this a useful point, molluscum contagiosum and lesions of cryptococcosis can show similar features especially if they are inflamed or irritated. Hepatosplenomegaly, lung and bone involvement are other features of disseminated penicilliosis. Diagnosis is confirmed by fungal culture or histopathology. P. marneffei produces a distinctive red diffusible pigment and is the only dimorphic member of the genus Penicillium. As P. marneffei is an emerging pathogen, a high index of suspicion is warranted in areas which have geographic proximity to Southeast Asia, northeastern India and Bangladesh. History of travel and immigration from endemic areas are major clues to diagnosis as illustrated in this case.

In severe cases treatment with amphotericin B is necessary followed by prophylactic azole maintenance regimen. Itraconazole is an option to be considered in a less sick patient as corroborated in our case.

References

1Ranjana KH, Priyokumar K, Singh TJ, Gupta CC, Sharmila L, Singh PN, et al. Disseminated Penicillium marneffei infection among HIV-infected patients in Manipur state India. J Infect 2002;45:268-71.
2Cooper CR Jr, McGinnis MR. Pathology of Penicillium marneffei. An emerging acquired immunodeficiency syndrome-related pathogen. Arch Pathol Lab Med 1997;121:798-804.
3Chariyalertsak S, Vanittanakom P, Nelson KE, Sirisanthana T, Vanittanakorm N. Rhizomys sumatrensis and Cannomys badius, new natural animal hosts of Penicillium marneffei. J Med Vet Mycol 1996;34:10510.
4Supparatpinyo K, Khamwan C, Baosoung V, Nelson KE, Sirisanthana T. Disseminated Penicillium marneffei infection in southeast Asia. Lancet 1994;344:110-3.
5Singh PN, Ranjana K, Singh YI, Singh KP, Sharma SS, Kulachandra M, et al. Indigenous disseminated Penicillium marneffei infection in the state of Manipur, India:report of four autochthonous cases. J Clin Microbiol 1999;37:2699-702.

 
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