CASE REPORT 154 DECEMBER 2014, Vol. 15,No. 4 (alkaline phosphatase(alkaline 227U/L;aspartate transaminase 107 C-reactive protein level (114 mg/L) and elevated liver enzymes 8.5 g/dL) with marked neutrophilia (17.5 × 10 a few hours. The patient anaemic was also (haemoglobin of smear,blood was which reported to treating the clinician within initiation date and ART regimen were unavailable. ofµL. Details her travel history, date of HIVdiagnosis, ART coccal antigencoccal test was negative, but (1,3)-β-D-glucan serum the The patient within 12hof died ­ admission. crypto Aserum undetectable and her CD4 and fluconazole. Onadmission, her HIV-1 was load viral meropenem, trimethoprim-sulphamethoxazole high-dose antimicrobialspectrum therapy on admission, including were noted on her face.patient The was prescribed broad- and skin lesions resembling of those molluscum contagiosum On physical examination, she had marked hepatosplenomegaly, casualty and immediately transferred to intensive the care unit. March A 37-year-old woman was admitted to aprivate hospital in Case C Corcoran, C traveller , N PGovender in areturning HIV-infected (Penicillium) marneffei Disseminated fatal Talaromyces REPORT CASE 3 2 1 Corresponding author: NPGovender ([email protected]) author: Corresponding Ampath National Reference Laboratory, Pretoria, South Africa School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa the differentialthe travel diagnosis unless a history is obtained. S Afr JHIVMed 2014;15(4):154-155.DOI:10.7196/SAJHIVMED.1087 more common among HIV-infected patients with aCD4 .fungal In southerncontext, the African where systemic opportunistic are infections fungal such as 5 days. The clinical features of HIV-associated disseminated penicilliosis overlap withthose of and endemic deep microscopy, and dimorphic were -like a thermally , confirmed bodies observed as T. marneffei, was cultured after smear.peripheral blood antigen test cryptococcal was negative. Aserum cultures Blood positive flagged after 2 days; ondirect hospital infulminant shock septic and within 12hof died admission. Intracellular on were yeast-like the bodies observed woman South African experienced had who travelled to mainland The China. 37-year-old woman was admitted to a private We of report acase disseminated fatal Talaromyces (Penicillium) marneffei infection in an HIV-infected, antiretroviral treatment- Laboratory Johannesburg, Service, South Africa National Institute for Communicable Diseases (Centre for Opportunistic, Tropical and Hospital Infections), National Health Intracellular on were peripheral yeast-like the bodies observed

2014 infulminant shock. septic She was intubated in 3 MBChB, MMed had travelled to mainland China. (SA)woman South African experienced who HIV-infected antiretroviral treatment (ART)- myces (Penicillium) marneffei infection inan We of report acase disseminated fatal Talaro­ 1,2 MB BCh, MMed, REMagobo, MBBCh, MSc; SAJHIVMED + T-lymphocyte count was 20cells/ 9 /L), an elevated 1 MSc; TGZulu, MSc;

U/L). U/L). + count of infection <100cells/µL, this is not likely considered to be in weight loss, skinpapules with central necrosis, respiratory histoplasmosisas cryptococcosis, and emmonsiosis; fever, ofwith those tuberculosis and infections fungal deep such features of HIV-associated disseminated overlap penicilliosis this thermally dimorphic thermally this fungus is endemic. opportunistic of infection inparts Asia, South-East where T. marneffei is third the most common AIDS-defining with with agar 1A), and (Fig. had microscopic characteristics consistent turned orange, with ared pigment into that readily the diffused The colonySouth Africa). was initially grey-green and then Products (DMP), National (NHLS), Health Laboratory Service a filamentous mould on Sabouraud agar (Diagnostic Media and molecular identification. At 25 National Institute for Communicable for Diseases phenotypic was cultured after 5 days. The isolate was referred to the microscopy, and were yeast-like afungus bodies observed, laboratorythe were as positive after flagged 2days. Ondirect cultures infection.fungal Blood that submitted had been to level was elevated (112pg/mL),inkeeping with a systemic fungus was as identified recently the renamed dimorphic thermally after amplification using and primers, ITS1 ITS4 and isolate the region(ITS) RNA of ribosomal fungal the gene was sequenced, at 37° strated on brain-heart infusion agar after 12 days (DMP, NHLS) The potentially fatal systemic infection caused by T. C (Fig. 1B).Aportion ofC (Fig. internal the spacer transcribed

1 T. marneffei. Nat Dip Tech;, Mdu Plooy marneffei. Phase transition to yeast the form was demon­ [1]

3 Nat Dip Tech; ° C, isolate the grew as [2] The clinical

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SAJHIVMED DECEMBER 2014, Vol. 15, No. 4 15, No. Vol. DECEMBER 2014, Samson RA, Yilmaz N, Houbraken J, et al. Phylogeny and nomenclature of of nomenclature and Phylogeny et al. J, N, Houbraken RA, Yilmaz Samson subgenus in Penicillium taxa accommodated and Talaromyces the genus 10.3114/ 2011;70(1):159-183. [http://dx.doi.org/ Mycol Stud Biverticillium. sim.2011.70.04] marneffei Penicillium T. Sirisanthana MC, Fisher N, CooperJr, CR Vanittanakom biology molecular aspects. in the epidemiology and Clin advances recent and infection Rev 2006;19(1):95-110. [http://dx.doi.org/10.1128/CMR.19.1.95-110.2006] Microbiol of outcome and Clinical et al. characteristics HF, LH, Wertheim M, Nguyen Larsson Vietnam. northern in patients HIV-infected among infection marneffei Penicillium 10.1186/1742-6405-9-24] 2012;9(1):24-29. [http://dx.doi.org/ AIDS Res Ther marneffei Penicillium P. Moss K, Adams H, G, Thaker R, Barlow C, Hajjawi Hall (IRIS) in a patient syndrome inflammatory reconstitution immune an as presenting 10.1136/bcr-2012-007555] BMJ Case Rep [http://dx.doi.org/ 2013. HIV. advanced with paediatric- cases of of Cohen A comparison al. et C, VC, Quan ST, Meiring cryptococcosis population-based detected adult-onset through and onset 10.1097/ surveillance, 2005-2007. AIDS 2012;26(18):2307-2314. [http://dx.doi.org/ QAD.0b013e3283570567] Cryptococcus AIDS-associated et al. neoformans NT, Cuc Kim TT, Chau Hong Le T, resource-limited dilemma in A therapeutic coinfection: marneffei Penicillium and 2010;51(9):e65-e68. [http://dx.doi.org/10.1086/656685] Dis Clin Infect settings. 2. 4. 3. 5. 6. 1. B References In We [4] [6] count <100 cells/µL, this infection is is this <100 cells/µL, infection count + It is possible that this patient developed an an developed this patient that possible is It This is particularly important in cases where in cases where particularly is important This [3] [5] A immune reconstitution inflammatory syndrome related to penicilliosis to related syndrome inflammatory reconstitution immune be confirmed. this cannot though initiation, ART following not likely to be considered in the unless a travel unless a travel diagnosis in the differential be to considered likely not history obtained. is involvement, lymphadenopathy and hepatosplenomegaly are most most are hepatosplenomegaly and lymphadenopathy involvement, reported. commonly fluconazole is selected as an empiric agent instead of of instead agent antifungal selected empiric is an as fluconazole itraconazole. B or amphotericin as such agents broader-spectrum the southern African context, where systemic opportunistic fungal opportunistic systemic where Africanthe context, southern HIV- among common more cryptococcosis as far such infections are a CD4 with infected patients are aware of only one previously diagnosed penicilliosis case of in SA previously one only of aware are 3 fungal Group Hazard Plooy). M du with (personal communication care also great be with should handled marneffei T. as such pathogens laboratories. in diagnostic on brain-heart marneffei (Penicillium) phase of Talaromyces and yeast agar (A), on Sabouraud marneffei (Penicillium) 1. Mould phase of Talaromyces Fig. infusion agar (pale-cream (B). colonies) mucoid