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Penicilliosis and Sporotrichosis inIndia
Penicilliosis and Sporotrichosis inIndia
Khuraijam Ranjana DeviRegional Institute of Medical Sciences, Imphal,
ManipurINDIA
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Penicillium marneffei andSporothrix schenckii
An important dimorphic fungi which are endemic ingeographic area of India
Sp. schenckii – known pathogen for a long time havingbeen detected from India in 1932 from Assam.
P. marneffei was implicated to be a fungal pathogen in1998
In India, both fungal agents – 1st reported from NE India High mortality with penicilliosis High morbidity with sporotrichosis
An important dimorphic fungi which are endemic ingeographic area of India
Sp. schenckii – known pathogen for a long time havingbeen detected from India in 1932 from Assam.
P. marneffei was implicated to be a fungal pathogen in1998
In India, both fungal agents – 1st reported from NE India High mortality with penicilliosis High morbidity with sporotrichosis
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Penicilliosis caused by Penicillium marneffei -recently Talaromyces
Now a well established fungal opportunisticpathogen among HIV infected patients. 1956 – 1st detected from liver of a bamboo rat-
rickettsial disease in Vietnam Implicated as human pathogen in 1973 in a pt of
Hodgkin’s disease 1985 : USA- AIDS associated pathogen Till 1990 – very rare disease but Later on – an alarming increase in no of cases
Now a well established fungal opportunisticpathogen among HIV infected patients. 1956 – 1st detected from liver of a bamboo rat-
rickettsial disease in Vietnam Implicated as human pathogen in 1973 in a pt of
Hodgkin’s disease 1985 : USA- AIDS associated pathogen Till 1990 – very rare disease but Later on – an alarming increase in no of cases
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Importedcases ……
ENDEMICITY of Penicilliosis
Importedcases ……
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Role of bamboo rats
4 species of bamboo rats- Cannomys badius,- Rhizomys pruinosus- R. sinensis &- R. sumatrensis
are known carriers of P.marneffei
Disease endemicitycorresponds to distribution ofthe bamboo rats
4 species of bamboo rats- Cannomys badius,- Rhizomys pruinosus- R. sinensis &- R. sumatrensis
are known carriers of P.marneffei
Disease endemicitycorresponds to distribution ofthe bamboo rats
Cannomys badius in NE India
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Indian scenario
• Manipur, early 1998 AIDSpatients with molluscumcontagiosum like lesion on faceand upper trunk- highmortality
• Manipur is one of the high HIVinfection prevalent state ofIndia
• Manipur, early 1998 AIDSpatients with molluscumcontagiosum like lesion on faceand upper trunk- highmortality
• Manipur is one of the high HIVinfection prevalent state ofIndia
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Giemsa stained direct smear
• Tissues
Culture in SDA
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Unusually - high mortality
First confirmed case unfortunately succumbed to penicilliosis
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J Clin Microbiology, Aug. 1999 vol 37 no 8, 2699- 2702.
Indigenous Disseminated Penicillium marneffei Infection inthe state of Manipur, India: Report of Four AutochthonousCases.
P. Narendra Singh, K. Ranjana, Y. Indiver Singh, K. Priyokumar Singh, S. SurchandraSharma, M. Kulachandra, Y. Nabakumar, A. Chakrabarti, A A Padhye, L.Kaufmanand L. Ajello
Indigenous Disseminated Penicillium marneffei Infection inthe state of Manipur, India: Report of Four AutochthonousCases.
P. Narendra Singh, K. Ranjana, Y. Indiver Singh, K. Priyokumar Singh, S. SurchandraSharma, M. Kulachandra, Y. Nabakumar, A. Chakrabarti, A A Padhye, L.Kaufmanand L. Ajello
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By next year, over a period of 19 months (April 1998- 0ctober 1999).
42 more cases
the clinical and epidemiological characteristics of Penicilliummarneffei infection in 46 HIV infected patients of India
Journal of lnfection (2002) 45: 268-271doi:10.1053/jinf.2002.1062. available online at http://www.idealibrary.comDisseminated Penicillium marneffei Infection among HIV-Infected Patients in Manipur State, IndiaK. H. Ranjana, K. Prlyokumar, Th. J. Singh, Ch. C. Gupta, L. Sharmlla, P. N. Singh and A. ChakrabartiDepartments of Microbiology and Medicine, J. N. Medical Hospital, Imphal 795001, Manipur, India and Department ofMedical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
42 more cases
the clinical and epidemiological characteristics of Penicilliummarneffei infection in 46 HIV infected patients of India
Journal of lnfection (2002) 45: 268-271doi:10.1053/jinf.2002.1062. available online at http://www.idealibrary.comDisseminated Penicillium marneffei Infection among HIV-Infected Patients in Manipur State, IndiaK. H. Ranjana, K. Prlyokumar, Th. J. Singh, Ch. C. Gupta, L. Sharmlla, P. N. Singh and A. ChakrabartiDepartments of Microbiology and Medicine, J. N. Medical Hospital, Imphal 795001, Manipur, India and Department ofMedical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Clinical presentations in 36 HIV-infected patients of Manipur with P. marneffeiinfection.
Symptoms Number or cases (%)
Fever 35 (97)Weight loss 36 (100)Weakness 31 (86)Diarrhea 8 (22)Skin lesions 29 (81)Anemia 31 (86)Hepatosplenomegaly 14 (39)Lymphadenopathy 12 (33)
No respiratory symptoms
Clinical presentations in 36 HIV-infected patients of Manipur with P. marneffeiinfection.
Symptoms Number or cases (%)
Fever 35 (97)Weight loss 36 (100)Weakness 31 (86)Diarrhea 8 (22)Skin lesions 29 (81)Anemia 31 (86)Hepatosplenomegaly 14 (39)Lymphadenopathy 12 (33)
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inapparent lesion
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Interesting cases:
5 cases of acute abdomen admitted in Emergency apparently healthy looking, not previously diagnosed to
be HIV infected. USG/CT - mesenteric/retroperitoneal lymphadenitis. USG-FNAC showing bunch of yeast cells. Treated, counseled for HIV testing, followed by ART. All cases responded well to antifungal drugs.
5 cases of acute abdomen admitted in Emergency apparently healthy looking, not previously diagnosed to
be HIV infected. USG/CT - mesenteric/retroperitoneal lymphadenitis. USG-FNAC showing bunch of yeast cells. Treated, counseled for HIV testing, followed by ART. All cases responded well to antifungal drugs.
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? Cases from other states of IndiaYES
• Inhabitants of Manipur, Assam ,Mizoram, Meghalaya
• Because of the geographical location• Distribution of the bamboo rat –
Cannomys badius
North east India
YES
• Inhabitants of Manipur, Assam ,Mizoram, Meghalaya
• Because of the geographical location• Distribution of the bamboo rat –
Cannomys badius
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MYANMARINDIA
MANIPUR
CHINA
GEOGRAPHICAL DISTRIBUTION OF CANNOMYS BADIUS
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Red pigments diffused in the culture media
Remember:Not all Penicillium with diffused red pigment are P. marneffeithere are other species of Penicillium that produce pigments
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1 2
Colony morphology on SDA of P. marneffei (1)and Penicillium purpurogenum (2) whichproduce red pigments similar with P.marneffei. Colony morphology of P. marneffei(3) incubate at 37°C.
3
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Current scenario
Drastic decrease in no of cases because of provisionof free ART since April 2004 and better supportivecare of HIV infected patients and hence betterimmune status of affected personsMost of HIV infected pt on ART has a CD4 count
above 200 cells / cu mm
Drastic decrease in no of cases because of provisionof free ART since April 2004 and better supportivecare of HIV infected patients and hence betterimmune status of affected personsMost of HIV infected pt on ART has a CD4 count
above 200 cells / cu mm
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Clin Microbiol Rev. 2006 Jan; 19(1): 95–110.Penicillium marneffei Infection and Recent Advances in the Epidemiology and Molecular Biology AspectsNongnuch Vanittanakom, Chester R. Cooper, Jr., Matthew C. Fisher, and Thira Sirisanthana.
Fig 1: Temporal emergence of HIV (antenatal data, 1990 to 2000; UNAIDS/WHO working group report, 2003)and P. marneffei-associated penicilliosis (1985 to 2001; Maharaj Hospital, Chiang Mai) for the Chiang Mairegion, northern Thailand.
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Presently---
• Environmental sampling – conventional• Virulence markers – enzymes• AST
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Extracellular enzymes activity assay
1 2 3
Non marneffei Penicillium spp. activity of protease (1)and cellulase (2). Extracellular protease assay ofP. marneffei (3 & 4). Arrow indicates zone of enzymehydrolysis.
4
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SPOROTRICHOSISSPOROTRICHOSIS
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1st case inIndia was
reported byGhosh (1932)from Assam in
NE India
1st case inIndia was
reported byGhosh (1932)from Assam in
NE India
Ghosh LN : Anunusual case ofsporotrichosis,Ind Med Gaz,1932; 67 : 570-71.
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Sub himalayan states of North India and NE India
SPOROTRICHOSIS
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Study of Chakrabarti et al ..Kangra valley , Himachal Pradeshpopulation-based study using sporotrichin and peptido–rhabdomannan skintest antigens- the rate of skin test positivity “test” villages (as defined by
a minimum of two cases per village) - 23% to 40%In “control” villages - 6.5% to 7.6%
higher skin test positivity rate in > 55 yrs & in people engaged inhorticulture or agricultural activities
Study of Chakrabarti et al ..Kangra valley , Himachal Pradeshpopulation-based study using sporotrichin and peptido–rhabdomannan skintest antigens- the rate of skin test positivity “test” villages (as defined by
a minimum of two cases per village) - 23% to 40%In “control” villages - 6.5% to 7.6%
higher skin test positivity rate in > 55 yrs & in people engaged inhorticulture or agricultural activities
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Manipur over a period of 6 yrs (1999-2005) 73 cases 30 culture proven Females > Male Lymphocutaneous type followed by fixed cutaneous type Majority had h/o of scratches and injury All patient responded well to sat. Potasium iodide soln
In my experience -Tissue appearance – ? ? Cigar shaped yeast cells
More like any budding yeast cellsVery delicate and difficult to preserve
Manipur over a period of 6 yrs (1999-2005) 73 cases 30 culture proven Females > Male Lymphocutaneous type followed by fixed cutaneous type Majority had h/o of scratches and injury All patient responded well to sat. Potasium iodide soln
In my experience -Tissue appearance – ? ? Cigar shaped yeast cells
More like any budding yeast cellsVery delicate and difficult to preserve
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West Bengal & Sikkim
Females > Male Lymphocutaneous type followed by fixed cutaneous
type Majority had h/o of trauma Upper limb involvment – more Responded to KI soln.
West Bengal & Sikkim
Females > Male Lymphocutaneous type followed by fixed cutaneous
type Majority had h/o of trauma Upper limb involvment – more Responded to KI soln.
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Physiological characters of Sporothrix schenckii isolatesA. Ghosh, P. K. Maiti B. M. Hemashettar , V. K. Sharma and A. Chakrabarti
Mycoses 45, 449–454 (2002)
The colony morphology and physiological characteristics of 49 clinical isolatesfrom three regions (25) from north India (17) from east India and (7) southIndia were analysed in both mycelial and yeast forms.
Characteristics :Colony characters on three different media. same
Growth at 40 °C InhibitedGrowth at 40 °C Inhibited
Tolerance to osmotic pressure and salt oncentrations > yeast
Growth at different pH 3–12 - hyphal2.4 - 9.5 - yeast
Assimilation of arabinose, dextrin, raffinose, rhamnose & starch variance
Phenol oxidase + and potassium nitrate assimilation positive
Gelatinase activity and casein hydrolysis negative
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Type of lesion
Lymphocutaneoustype of lesions
Fixed localized type
Disseminated sporotrichosis Site of lesionUpper extremity
Lower extremity
Face, buttock ..
Site of lesion
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Molecular typing
• Indian clinical isolates – to be S. globosa andhomogeneous with other Asian isolates.
• North India - isolate from pulmonary sporotrichosiswas S. luriei.
• Indian clinical isolates – to be S. globosa andhomogeneous with other Asian isolates.
• North India - isolate from pulmonary sporotrichosiswas S. luriei.
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Common factors in Sub himalayan range
• Temperate climate• High humidity and• High rainfall
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In conclusionSporotrichosis Fungal pathogen that will
remain Awareness by the
dermatologist, promptmanagement
potential to cause outbreak
Penicilliosis Decreasing but need to be
alert considering IC ptsother than HIV infections,endemicity & improvedmeans of travel , clinicalsuspicion is very importantfor prompt management
Sporotrichosis Fungal pathogen that will
remain Awareness by the
dermatologist, promptmanagement
potential to cause outbreak
Penicilliosis Decreasing but need to be
alert considering IC ptsother than HIV infections,endemicity & improvedmeans of travel , clinicalsuspicion is very importantfor prompt management
Fungal pathogens where the environment and climatic conditionhave a big influence and we need to study more on the biologyand other factors that may be contributing in the prevalence ofthe disease in India
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THANKYOU