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Disseminated penicilliosis in a Korean human immunodeficiency virus infected patient from Laos.

Jung JY, Jo GH, Kim HS, Park MY, Shin JH, Chin BS, Bang JH, Shin HS - J. Korean Med. Sci. (2012)

Bottom Line: The patient completely recovered after being prescribed amphotericin-B and receiving antiretroviral therapy.This is the first case of penicilliosis in a Korean HIV-infected patient.It is necessary to consider P. marneffei when immunocompromised patients, with a history of visits to endemic areas, reveal respiratory disease.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Disease, Department of Internal Medicine, National Medical Center, Seoul, Korea.

ABSTRACT
Penicillium marneffei may cause life-threatening systemic fungal infection in immune-compromised patients and it is endemic in Southeast Asia. A 39-yr-old HIV-infected male, living in Laos, presented with fever, cough, and facial vesiculopapular lesions, which had been apparent for two weeks. CT scans showed bilateral micronodules on both lungs; Pneumocystis jirovecii was identified by bronchoscopic biopsy. Despite trimethoprim-sulfamethoxazole and anti-tuberculosis medications, the lung lesions progressed and the facial lesions revealed central umbilications. Biopsy of the skin lesions confirmed disseminated penicilliosis, with the culture showing P. marneffei hyphae and spores. The P. marneffei was identified by rRNA PCR. A review of the bronchoscopic biopsy indicated penicilliosis. The patient completely recovered after being prescribed amphotericin-B and receiving antiretroviral therapy. This is the first case of penicilliosis in a Korean HIV-infected patient. It is necessary to consider P. marneffei when immunocompromised patients, with a history of visits to endemic areas, reveal respiratory disease.

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Penicillium marneffei cultured at 25℃ on Sabouraud dextrose agar plate. (A) Gross findings of culture. Colonies revealed distinctive red diffusible pigment and the surface was powdery and gray-green with a white border. (B) Microscopic findings. Lactophenol cotton blue stain preparation from colony revealed metulae and conidia of Penicillium marneffei.
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Figure 2: Penicillium marneffei cultured at 25℃ on Sabouraud dextrose agar plate. (A) Gross findings of culture. Colonies revealed distinctive red diffusible pigment and the surface was powdery and gray-green with a white border. (B) Microscopic findings. Lactophenol cotton blue stain preparation from colony revealed metulae and conidia of Penicillium marneffei.

Mentions: A 39-yr-old male patient visited the emergency room on May 24, 2010 with fever, cough, and multiple papules that had been on his face for two weeks. He had been managing a farm in Laos for four years. He was told that he had been infected with HIV and miliary tuberculosis was suspected after a chest computed tomography (CT) scan at a hospital in Thailand. The patient denied any history of homosexual contact. Upon arrival at the emergency room, his mental status was alert and the diffuse vesiculopapular lesions were easily observed on face. His vital signs were: blood pressure of 151/90 mmHg, a body temperature of 37.1℃, a heart rate of 116 beats per minute, and a respiration rate of 27 breaths per minute. His oxygen saturation was 90% and arterial blood gas analysis revealed pH 7.46, PaCO2 34 mmHg, PaO2 55 mmHg, and HCO3 24 mM on room air. His breathing sounds were coarse with crackles in the bilateral lung field. Upon laboratory examination, his complete blood cell counts were: white blood cell count 4,100/µL (neutrophil 92.0%, lymphocytes 4.8%), hemoglobin 11.4 g/dL, and platelet 134,000/µL, while erythrocyte sedimentation rate and C-reactive protein were 114 mm/hr and 90 mg/L, respectively. Peripheral CD4+ T lymphocyte count and HIV-RNA viral load were 7 cells/µL and 457,392 copies/mL. A chest X-ray revealed diffuse reticulonodular opacities in the entire lung field. Chest CT scans revealed bilaterally distributed micronodules and consolidation with a ground-glass opacity pattern on a dependent portion of his lungs (Fig. 1A). Suspecting tuberculosis, anti-tuberculosis medications of isoniazid, rifampin, ethambutol, and pyrazinamide were started. In addition, the results of the trans-bronchoscopic lung biopsy were initially reported as Pneumocystis jirovecii and trimethoprim-sulfamethoxazole was added to his regimen. One week after admission, vesiculopapular facial lesions exhibited central hemorrhagic changes (Fig. 1B) and spread to the neck, trunk, and upper extremities. A skin biopsy was performed, which revealed massive dermatophytosis and fungal abscess. Deoxycholate amphotericin-B (0.7 mg/kg) was started and antiretroviral therapy (ART) with abacavir, lamivudine, and efavirenz was also implemented for the treatment of HIV infection. Considering the typical skin lesions and fungal organisms in the biopsy, a disseminated P. marneffei infection was suspected. Fungal culture of skin tissue obtained by biopsy revealed colonies of green-gray belts with red pigmentation in Sabouraud dextrose agar plate (Fig. 2A) and mycelia was seen in the microscopic examination after staining with Lactophenol cotton blue by touching clear scotch tape to the colony (Fig. 2B). To identify the fungal species, we performed sequencing of the internal transcribed spacer (ITS) and 26S rRNA gene regions. The ITS region (including the 5.8S rRNA gene) and the 26S rRNA gene D1/D2 domains were amplified with the primer pairs of pITS-F/pITS-R and NL1/NL4, respectively (6). Sequence similarity searches were performed using basic local alignment search tool (BLAST), which revealed a complete (100%) match with P. marneffei. After 10 days of amphotericin-B administration, the patient exhibited clinical and radiological improvement. The amphotericin-B was changed to oral itraconazole at 400 mg/day after 14 days of the amphotericin-B treatment. After eight weeks, the dose of itraconazole was modified to 200 mg/day and was maintained for an additional six months. The patient continues to visit an outpatient clinic without any specific problems.


Disseminated penicilliosis in a Korean human immunodeficiency virus infected patient from Laos.

Jung JY, Jo GH, Kim HS, Park MY, Shin JH, Chin BS, Bang JH, Shin HS - J. Korean Med. Sci. (2012)

Penicillium marneffei cultured at 25℃ on Sabouraud dextrose agar plate. (A) Gross findings of culture. Colonies revealed distinctive red diffusible pigment and the surface was powdery and gray-green with a white border. (B) Microscopic findings. Lactophenol cotton blue stain preparation from colony revealed metulae and conidia of Penicillium marneffei.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3369459&req=5

Figure 2: Penicillium marneffei cultured at 25℃ on Sabouraud dextrose agar plate. (A) Gross findings of culture. Colonies revealed distinctive red diffusible pigment and the surface was powdery and gray-green with a white border. (B) Microscopic findings. Lactophenol cotton blue stain preparation from colony revealed metulae and conidia of Penicillium marneffei.
Mentions: A 39-yr-old male patient visited the emergency room on May 24, 2010 with fever, cough, and multiple papules that had been on his face for two weeks. He had been managing a farm in Laos for four years. He was told that he had been infected with HIV and miliary tuberculosis was suspected after a chest computed tomography (CT) scan at a hospital in Thailand. The patient denied any history of homosexual contact. Upon arrival at the emergency room, his mental status was alert and the diffuse vesiculopapular lesions were easily observed on face. His vital signs were: blood pressure of 151/90 mmHg, a body temperature of 37.1℃, a heart rate of 116 beats per minute, and a respiration rate of 27 breaths per minute. His oxygen saturation was 90% and arterial blood gas analysis revealed pH 7.46, PaCO2 34 mmHg, PaO2 55 mmHg, and HCO3 24 mM on room air. His breathing sounds were coarse with crackles in the bilateral lung field. Upon laboratory examination, his complete blood cell counts were: white blood cell count 4,100/µL (neutrophil 92.0%, lymphocytes 4.8%), hemoglobin 11.4 g/dL, and platelet 134,000/µL, while erythrocyte sedimentation rate and C-reactive protein were 114 mm/hr and 90 mg/L, respectively. Peripheral CD4+ T lymphocyte count and HIV-RNA viral load were 7 cells/µL and 457,392 copies/mL. A chest X-ray revealed diffuse reticulonodular opacities in the entire lung field. Chest CT scans revealed bilaterally distributed micronodules and consolidation with a ground-glass opacity pattern on a dependent portion of his lungs (Fig. 1A). Suspecting tuberculosis, anti-tuberculosis medications of isoniazid, rifampin, ethambutol, and pyrazinamide were started. In addition, the results of the trans-bronchoscopic lung biopsy were initially reported as Pneumocystis jirovecii and trimethoprim-sulfamethoxazole was added to his regimen. One week after admission, vesiculopapular facial lesions exhibited central hemorrhagic changes (Fig. 1B) and spread to the neck, trunk, and upper extremities. A skin biopsy was performed, which revealed massive dermatophytosis and fungal abscess. Deoxycholate amphotericin-B (0.7 mg/kg) was started and antiretroviral therapy (ART) with abacavir, lamivudine, and efavirenz was also implemented for the treatment of HIV infection. Considering the typical skin lesions and fungal organisms in the biopsy, a disseminated P. marneffei infection was suspected. Fungal culture of skin tissue obtained by biopsy revealed colonies of green-gray belts with red pigmentation in Sabouraud dextrose agar plate (Fig. 2A) and mycelia was seen in the microscopic examination after staining with Lactophenol cotton blue by touching clear scotch tape to the colony (Fig. 2B). To identify the fungal species, we performed sequencing of the internal transcribed spacer (ITS) and 26S rRNA gene regions. The ITS region (including the 5.8S rRNA gene) and the 26S rRNA gene D1/D2 domains were amplified with the primer pairs of pITS-F/pITS-R and NL1/NL4, respectively (6). Sequence similarity searches were performed using basic local alignment search tool (BLAST), which revealed a complete (100%) match with P. marneffei. After 10 days of amphotericin-B administration, the patient exhibited clinical and radiological improvement. The amphotericin-B was changed to oral itraconazole at 400 mg/day after 14 days of the amphotericin-B treatment. After eight weeks, the dose of itraconazole was modified to 200 mg/day and was maintained for an additional six months. The patient continues to visit an outpatient clinic without any specific problems.

Bottom Line: The patient completely recovered after being prescribed amphotericin-B and receiving antiretroviral therapy.This is the first case of penicilliosis in a Korean HIV-infected patient.It is necessary to consider P. marneffei when immunocompromised patients, with a history of visits to endemic areas, reveal respiratory disease.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Disease, Department of Internal Medicine, National Medical Center, Seoul, Korea.

ABSTRACT
Penicillium marneffei may cause life-threatening systemic fungal infection in immune-compromised patients and it is endemic in Southeast Asia. A 39-yr-old HIV-infected male, living in Laos, presented with fever, cough, and facial vesiculopapular lesions, which had been apparent for two weeks. CT scans showed bilateral micronodules on both lungs; Pneumocystis jirovecii was identified by bronchoscopic biopsy. Despite trimethoprim-sulfamethoxazole and anti-tuberculosis medications, the lung lesions progressed and the facial lesions revealed central umbilications. Biopsy of the skin lesions confirmed disseminated penicilliosis, with the culture showing P. marneffei hyphae and spores. The P. marneffei was identified by rRNA PCR. A review of the bronchoscopic biopsy indicated penicilliosis. The patient completely recovered after being prescribed amphotericin-B and receiving antiretroviral therapy. This is the first case of penicilliosis in a Korean HIV-infected patient. It is necessary to consider P. marneffei when immunocompromised patients, with a history of visits to endemic areas, reveal respiratory disease.

Show MeSH
Related in: MedlinePlus