Disseminated Penicillium marneffei infection with IRIS.

Penicillium marneffei infection is an endemic opportunistic infection for AIDS patients that can be found in south Asia. Fever and typical skin lesions are the most commonly seen symptoms. Our case describes an AIDS patient with Immune Reconstitution Inflammatory Syndrome (IRIS) presented with liver masses and skin lesions whose blood, bone marrow and ascites culture were all identified with P. marneffei.

A 47-year-old man with HIV infection was referred to our hospital because of fever and generalized molluscum contagiosum-like skin lesions for 1 month. He had lived in Dongguan, which is located in southeastern of China, for 10 years. Antiretroviral therapy (ART) was initiated 2 weeks before admission, when the CD4+ T cell counts was 32/mm3. However, the skin lesions had spread to all over the face (figure) rapidly. On admission, the temperature was 39.2 °C, WBC was 3.61 × 109/L, with neutrophils of 88.6%, HB72 g/L, PLT 49 × 109/L; CT revealed numerous low-density opacities in the liver, large amount of ascites, and multiple lymph nodes in the abdomen (figure). The skin lesion was biopsied and cultured. Staining with Periodic Acid Schiff (PAS) stain revealed yeast-like fungi. At 25 °C, this fungus grew as mold on Sabouraud Dextrose agar and produced a red pigment spreading into the agar (figure) characteristic of Penicillium marneffei. The chylous ascites, blood and bone marrow culture later all grew P. marneffei. The patient developed acute liver failure in 3 days after admission, with ALT 176 U/L, AST 585.7 U/L, total bilirubin 4.7 mg/dL, albumin 1.9 g/dL, PT% 9%. He was diagnosed with disseminated penicilliosis and Immune Reconstitution Inflammatory Syndrome (IRIS). Intravenous fast-escalating dose amphotericin B (50 mg; 8 mg/kg body weight per day) was used (5 mg for day 1, 25 mg for day 2, 50 mg for day 3 and thereafter for the next 14 days), followed by oral itraconazole (400 mg per day). Methylprednisolone was also used for IRIS. The blood chemistry and coagulation panel all returned to normal by day 10, liver lesions resolved completely on CT scan by day 17, and the skin rashes began to subside in 3 days after 50 mg/d amphotericin B administration, which totally disappeared by day 27 (Fig. 1). He was discharged home to complete treatment with oral itraconazole. No relapse was seen during 3 months follow-up. P. marneffei infection needs to be considered in all HIV-positive patients presenting with fever and skin lesions. A travel history to southeastern of Asia assists in making a prompt diagnosis.

Fig. 1

Findings from an HIV positive man infected with Penicillium marneffei. CT scan showing liver lesions before and after treatment (A). Papular lesions resolved after treatment (B). Mold producing a red pigment on Sabouraud Dextrose agar (C). Mold stained with H.E (D).

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Conflicts of interest

We declare that we have no conflicts of interest.