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Penicillium marneffei Infections Jenee Thurston, Kelly
Bees, Adam Speerstra
Courtesy of: www.doctorfungus.com
Courtesy of: http://www.hindawi.com/journals/pri/2011/764
293/fig4/
Penicillium marneffei Discovered in 1959 by G. Segratain in Paris Discovered in 1959 by G. Segratain in Paris Only known thermally dimorphic species of Penicillium Can cause penicilliosis with fever and anemia Dimorphic saprophyte of soil and decomposing organic
matter. Taxonomy Includes:
Kingdom: Fungi Phlyum: Ascomycota Class: Euascomycetes Order: Eurotiales Family: Trichocomaceae Genus: Penicillium
Geographic DistributionGeographic Distribution
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Widespread Widespread Specifically in Southeast AsiaSpecifically in Southeast Asia
o Burma (Myanmar), Cambodia, Southern China, Indonesia, Laos, Burma (Myanmar), Cambodia, Southern China, Indonesia, Laos, Malaysia, Thailand and VietnamMalaysia, Thailand and Vietnam
Cases were reported in HIV-positive patients in Australia, Cases were reported in HIV-positive patients in Australia, Europe, Japan, the UK and the U.S.. Europe, Japan, the UK and the U.S..
All, except one traveled to Southeast Asia.All, except one traveled to Southeast Asia.
Courtesy of: http://www.crownrms.com/rms/o
ffice.southeast.asia.html
Epidemiology Affects HIV-infected &
immunosuppressed patients Discovered in bamboo rats
(Rhizomys & Cannomys ) epidemiological markers and
reservoirs for human infections High mortality and morbidity
rates 10% of HIV patients in Hong
Kong affected Soil exposure, especially during
the rainy season, is a critical risk factor.
Third most common opportunistic infection (after extrapulmonary tuberculosis and cryptococcosis) in HIV-positive individuals
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Courtesy of: http://animaldiversity.ummz.umich.edu/site/accounts/pictures/Rhizomyinae.html
Life Cycle
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Thermally dimorphic Divided into three distinct phases:
1. a multicellular, filamentous (mold) vegetative form
2. asexual reproductive stage (conidiogenesis)3. a unicellular yeast-like/arthroconidial phenotype
Temperature and nutrition are key factors to determine which specific phase is displayed
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Young colonies are grown on Sabouraud glucose agar
rapid growing, flat, filamentous, and velvety, woolly, or cottony in texture
Usually appear bluish gray-green
Mature colony is reddish yellow, producing a pink or red-rose pigment that diffuses into the surrounding medium Courtesy of :http://cmr.asm.org/cgi/content/full/19/1/95
Morphologies of P marneffei under a microscope
Pathogenesis
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Pathogen found in bamboo rat feces, liver, lungs and spleen
Higher incidence during rainy season Favorable for production of
fungal spores (conidia) Airborne spores inhaled by
susceptible individuals Unclear whether people get
the disease by eating infected rats, or by inhaling fungi from their feces
Courtesy of: http://medicine.med.nyu.edu/pulmonary/node/673
Diagnosis and Histopathology Biopsy of skin lesions, lymph nodes or bone marrow The organism can also be identified on peripheral blood
smear or bone marrow aspirate Fungi shown:
spherical or oval in shape basophilic intracellular or extracellular yeastlike appearance
on Wright stain, often with clear central septation Histopathologic features include granulomatous,
suppurative, or necrotizing inflammation Polymerase chain reaction (PCR) assay is under
evaluation for rapid diagnosis of P marneffei infection
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Clinical ManifestationsClinical Manifestations
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Fever 99% Fever 99% Anemia 78% Anemia 78% Weight loss 76% Weight loss 76% Skin lesions 71% Skin lesions 71% Lymphadenopathy 58% Lymphadenopathy 58% Hepatomegaly 51% Hepatomegaly 51% Pulmonary disease/symptom 49% Pulmonary disease/symptom 49% Diarrhea 31% Diarrhea 31% Splenomegaly 16% Splenomegaly 16% Oral lesions 4% Oral lesions 4%
Clinical Manifestations cont.... Duration of symptoms before
presentation is 4 weeks. Other common manifestations:
Skin lesions, anemia, lymphadenopathy, and hepatomegaly with or without splenomegaly.
Skin lesions are present in two thirds of cases Include papular eruptions, central umbilicated
papules, acnelike lesions and folliculitis. Found on the face, trunk, and extremities. Pharyngeal and palatal lesions Subcutaneous nodules
Pulmonary symptoms (cough and dyspnea) occur in about 50% of cases.
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Courtesy of: http://www.med.cmu.ac.th/student/patho/Kamthorn/050.html
Treatment & PreventionTreatment & Prevention
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Mortality is at a 20% rate with treatment Mortality is at a 20% rate with treatment Amphotericin B with or without flucytosine, or Amphotericin B with or without flucytosine, or
itraconazoleitraconazole Ketoconazole & miconazoleKetoconazole & miconazole Newer azoles (posaconazole, ravuconazole, and Newer azoles (posaconazole, ravuconazole, and
voriconazole)voriconazole) Clinical failure rates: Clinical failure rates:
fluconazole (63.8%)fluconazole (63.8%) amphotericin B (22.8%) amphotericin B (22.8%) itraconazole (25%)itraconazole (25%)
Primary prophylaxis with itraconazole 200 mg daily can Primary prophylaxis with itraconazole 200 mg daily can prevent the occurrence of penicilliosis among patients prevent the occurrence of penicilliosis among patients with AIDS with AIDS
Case 1. Case 1.
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Patient:Patient: Located in India Located in India 27-year-old male 27-year-old male Recently developed multiple nodules on his faceRecently developed multiple nodules on his face Other Symptoms:Other Symptoms:
fever, weight loss, anorexia, and general weakness. fever, weight loss, anorexia, and general weakness. General examination revealed multiple molluscum General examination revealed multiple molluscum
contagiosum-like papules of various sizes with contagiosum-like papules of various sizes with central umbilications mainly on his face, trunk, and central umbilications mainly on his face, trunk, and upper and lower limbsupper and lower limbs
Case 1. He was diagnosed seropositive
for HIV infection. Mild anemia, leukopenia, and a
raised erythrocyte sedimentation rate (ESR).
A chest X ray revealed bilateral patchy pneumonitis, and an ultrasonogram (USG) of the abdomen revealed mild hepatomegaly.
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Courtesy of: http://jcm.asm.org/cgi/content/full/37/8/2699
Case 1. A portion of the fine needle aspirate (FNA) when
cultured yielded a Penicillium species red diffusible pigment was produced
Giemsa-stained smears of the aspirate numerous intracellular and extracellular oval, elongated or sausage-
shaped yeast-like cells, cells divided by fission rather than by a budding process.
Three days before initiation of treatment, the patient died.
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Case 2. 29 year old Male Tay Ninh province, Vietnam Presented weight loss and a
maculopapular rash on his genitalia. No previous testing for HIV
antibody or virus. On examination, the only
momentous findings were oropharyngeal candidiasis, cervical lymphadenopathy, and the maculopapular rash on his genitalia.
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Courtesy of: http://cid.oxfordjournals.org/content/32/4/e78/F2.expansion.html
Case 2. Examination of chest and abdomen revealed no abnormalities. A chest radiograph appeared normal. Blood samples were collected for microbiological culture and
HIV testing. On the second day of hospitalization, he developed generalized
maculopapular rash with pustules and lesions with central necrotic umbilication
Results confirmed patient to be HIV positve Culture of his blood sample yielded a red pigment–producing
fungus that was subsequently identified as P. marneffei. Patient died ten hours after discharge
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ReferencesReferences
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Lindan CP, Lieu TX, Giang LT, et alLindan CP, Lieu TX, Giang LT, et al Rising HIV infection rates in Ho Chi Rising HIV infection rates in Ho Chi Minh City herald emerging AIDS epidemic in Vietnam. AIDS 1997;11(Suppl Minh City herald emerging AIDS epidemic in Vietnam. AIDS 1997;11(Suppl 1):S5-13.1):S5-13.
Remadi S, Lotfi C, Finci V, Ismail A, Rogiano D, Vassilakos P, Seemayer Remadi S, Lotfi C, Finci V, Ismail A, Rogiano D, Vassilakos P, Seemayer TA. Penicillium marneffei infection in patients infected with the human TA. Penicillium marneffei infection in patients infected with the human immunodeficiency virus. A report of two cases. Acta Cytol 1995; 39:798-802.immunodeficiency virus. A report of two cases. Acta Cytol 1995; 39:798-802.
Vanittanakom N, Cooper R, Fisher M, Sirisanthana T, Penicillium marneffei Vanittanakom N, Cooper R, Fisher M, Sirisanthana T, Penicillium marneffei Infection and Recent Advances in the Epidemiology and Molecular Biology Infection and Recent Advances in the Epidemiology and Molecular Biology Aspects. Clinical Microbiology Reviews.2006; 19:95-110Aspects. Clinical Microbiology Reviews.2006; 19:95-110
Stephenie Y. N. Wong and K. F. Wong, “Stephenie Y. N. Wong and K. F. Wong, “Penicillium marneffeiPenicillium marneffei Infection in Infection in AIDS,” AIDS,” Pathology Research InternationalPathology Research International, vol. 2011, Article ID 764293, 10 , vol. 2011, Article ID 764293, 10 pages, 2011. doi:10.4061/2011/764293pages, 2011. doi:10.4061/2011/764293
Zhoulin D, Bilbas JL, Gibson DW, Connor DHZhoulin D, Bilbas JL, Gibson DW, Connor DH Infections caused by Infections caused by Penicillium marneffei in China and Southeast Asia: review of eighteen Penicillium marneffei in China and Southeast Asia: review of eighteen published cases and report of four more Chinese cases. Rev Infect Dis published cases and report of four more Chinese cases. Rev Infect Dis 1988;10:640-7.1988;10:640-7.
Questions . 1. P. marneffei grows best in:
Dry temperature
Rainy seasons**
The cold
Heat
2. P. marneffei usually affects:
The elderly
HIV infected patients**
Infants
Women
3. P. marneffei is located in:
Southeast Asia**
Africa
South America
The Caribbean
4. All except one are common symptoms of this disease:
Cough
Fever
Lesions
Depression**
5. Which is a life cycle stage in p. marneffei?
Multicellular
Unicessulur
Aesexual
All of the above**
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