Case of Talaromyces marneffei skin infection in an immunocompetent adult

O Sasikumari, TharaAnn Jose, S Anupama
2018 Journal of The Academy of Clinical Microbiologists  
KEYWORDS Penicillium marneffei, Talaromyces marneffei, penicilliosis, talaromycosis CASE A 45-year-old male was transferred to the emergency department (ED) following a syncopal event. He had struck his head on the ground but was found at the scene to be normotensive with normal blood sugar. Upon evaluation in the ED, the patient denied chest pain, palpitations, or shortness of breath. However, he reported a monthlong history of body aches and a mild cough. He had a history of human
more » ... ency virus (HIV) infection diagnosed in 2003 but was not on treatment until 2013, when he was diagnosed with Kaposi sarcoma of the skin and pneumocystis pneumonia. Antiretroviral therapy was subsequently initiated, but the patient had discontinued his medication 8 months prior. The patient denied any recent travel, but he had traveled to Northern Thailand approximately 18 months prior to presentation. The patient reported a slight nonproductive cough but denied chest pain or shortness of breath, though his chest X-ray showed left lower lobe consolidation consistent with pneumonia. At the time of admission, his HIV load was 136,000 copies/ml, and he had a CD4 count of 9 cells/mm 3 . Blood, urine, and stool cultures were negative for growth. Four sputum samples were obtained for bacterial culture but were rejected due to poor quality. Despite treatment with vancomycin, piperacillintazobactam, and levofloxacin, as well as prophylactic trimethoprim-sulfamethoxazole, fluconazole, and azithromycin, the patient continued to report subjective fevers. A chest computed tomography (CT) scan without contrast was obtained, and subtle opacities suggestive of bronchiolitis and a 2.5-cm mass in the left lung were appreciated. The patient underwent bronchoscopy to determine whether the mass was due to an infection or neoplasia. Cultures of the bronchoalveolar lavage fluid for bacteria and acid-fast bacilli were negative for growth. However, fungal cultures grew velvety yellow and tan-colored colonies on inhibitory mold agar (Hardy Diagnostics, Santa Maria, CA) after 3 days of incubation at 30°C (Fig. 1a) . A diffusible deep red pigment was observed after 4 days of growth. A tape preparation of the colonies showed brush-like structures typical of the genus Penicillium, i.e., hyaline, septate hyphae with conidiophores with four to five short, broad metulae, each bearing four to six phialides with oval conidia (Fig. 1b) . Because of the diffusible red pigment observed, the organism was subcultured to mycobiotic agar (Remel Thermo Scientific, Waltham, MA) and incubated at 37°C. When incubated at 37°C, the organism grew as white, dry, yeast-like colonies (Fig. 1c) . Microscopic examination of the colonies revealed oval, yeast-like cells with a central septum (Fig. 1d) . Based on the isolate's thermally dimorphic growth characteristics and diffusible red pigment, the isolate was presumptively identified as Talaromyces marneffei. Sequencing of the internal transcribed spacer (ITS) regions, ITS1 and ITS2, and the 28S rRNA gene confirmed the identification. The patient was treated with itraconazole (200 mg twice a day) for 7 months, at which time a repeat chest CT revealed complete resolution of his left lower lobe FIG 1 (a) Fungal cultures grew velvety yellow and tan-colored colonies on inhibitory mold agar (Hardy Diagnostics, Santa Maria, CA) after 3 days of incubation at 30°C. (b) Tape preparation of the colonies showing brush-like structures typical of the genus Penicillium, i.e., hyaline, septate hyphae with conidiophores with four to five short, broad metulae, each bearing four to six phialides with oval conidia. (c) When incubated at 37°C, the organism grew as white, dry, yeast-like colonies. (d) Microscopic examination of the colonies revealed oval, yeast-like cells with a central septum.
doi:10.4103/jacm.jacm_66_16 fatcat:lwtfkcmzjrgjrf72zc5zovziq4