Indigenous disseminated Penicillium marneffei infection in the state of Manipur, India: report of four autochthonous cases

British Association for Sexual Health and HIV national guideline for the management of Genital Molluscum in adults (2021)

This guideline offers recommendations on diagnosis, treatment regimens and health promotion principles needed for the effective management of genital molluscum, including management of the initial presentation and recurrences. The Primary focus of the guideline is on infection which affects the genital area and has a sexual mode of transmission. This is an update to the guideline previously published in this journal in 2014.

Title of Paper: First case of subcutaneous infection by Talaromyces marneffei in a renal transplant recipient from India and review of literature

Talaromyces marneffei is one of the endemic mycoses prevalent in South-East Asian region. The infection, which was once considered to be opportunistic infection in HIV-positive patients, is establishing foothold in transplant and immunocompetent population. We report a case of a 41-year-old post-renal transplant female with a travel history to Assam two years back presenting with a subcutaneous lesion on right side of scalp associated with pain and blurring of vision in right eye. Fine-needle aspiration from the scalp lesion showed yeast cells with transverse septation in cytological examination and culture grew Talaromyces marneffei, which was confirmed by sequencing of ITS region. Patient was successfully managed with oral itraconazole 200 mg twice daily for ten months without subsequent recurrence. To our knowledge, this is the first case of subcutaneous infection by T. marneffei in a renal transplant recipient from India.

Talaromyces stipitatus, a novel agent causing superficial mycosis in a diabetic patient from North India

Among millions of reported fungal species, only a few hundred species are capable of causing diseases in humans and animals that range from superficial to life-threatening infections. Both immunocompetent as well as immunocompromised patients with underlying diseases, such as AIDS, diabetes, etc., are at higher risk of acquiring fungal infections. Superficial mycoses invade the stratum corneum and the outermost layers of the skin. The aim of the present study was to study clinical symptoms, isolate and identify the causal agent in the investigated patient along with sharing insights achieved through reviewing the literature. Direct microscopy, cultural, microscopic, and molecular characterization was done to identify the recovered causal agent. Herein, we report a case of superficial mycosis that affected the left foot of a 65-year-old diabetic male who was a farmer by occupation from district Jammu, Jammu and Kashmir, India. The pathogenic fungal species was identified as Talaromyces stipitatus. To the best of our knowledge, there are no reports on T. stipitatus as a causal agent of skin infection so far. Thus, the causal agent described in the research communication constitutes a new addition to the list of pathogenic non-dermatophytes associated superficially with human skin. In-vitro antifungal activity revealed fluconazole as the most effective antifungal agent against the causal agent.

Burden of Talaromyces marneffei infection in people living with HIV/AIDS in Asia during ART era: a systematic review and meta-analysis

Background

Talaromyces marneffei (TM) is a dimorphic fungus mainly prevalent in Southeast Asian countries, which often causes disseminated life-threatening infection. TM infection often occurs in HIV/AIDS patients even in the antiretroviral therapy (ART) era. However, there has as yet, not been a systematic analysis of the prevalence of TM infection in HIV-infected populations in Asia.

Methods

In this study, we searched Pubmed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and WanFang from inception to 21 November 2018 for studies reporting TM infection in people living with HIV/AIDS (PLWHA). Our meta-analysis included studies investigating the prevalence of TM infection in PLWHA. Reviews, duplicate studies, and animal studies were excluded. A random effects model was used to estimate pooled prevalence, and meta-regression analysis was conducted to explore potential factors for heterogeneity.

Results

159,064 patients with HIV infection in 33 eligible studies were included in our meta-analysis. The pooled prevalence of TM infection in PLWHA was 3.6%. Vietnam had the highest prevalence (6.4%), followed by Thailand (3.9%), China (3.3%), India (3.2%) and Malaysia (2.1%). In China, TM infection was most prevalent in South China (15.0%), while the burden in Southwest China was not very heavy (0.3%). CD4+ T-cell counts below 200 cells/mm³ contributed to the increased risk of TM infection in PLWHA (OR 12.68, 95%CI: 9.58–16.77). However, access to ART did not significantly decrease the risk of TM infection in PLWHA.

Conclusions

The burden of TM infection in Asia is heavy, and varies from region to region. PLWHA in lower latitude areas are more likely to suffer from TM infection. Optimization of diagnostic tools and universal screening for TM in vulnerable people to ensure early case detection and prompt antifungal treatment should be considered.

Re-drawing the Maps for Endemic Mycoses

Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within specific geographic areas of known endemicity. However, over the past few decades, there have been increasingly frequent reports of infections due to endemic fungi in areas previously thought to be “non-endemic.” There are numerous potential reasons for this shift such as increased use of immune suppressive medications, improved diagnostic tests, increased disease recognition, and global factors such as migration, increased travel, and climate change. Regardless of the causes, it has become evident that our previous understanding of endemic regions for these fungal diseases needs to evolve. The epidemiology of the newly described Emergomyces is incomplete; our understanding of it continues to evolve. This review will focus on the evidence underlying the established areas of endemicity for these mycoses as well as new data and reports from medical literature that support the re-thinking these geographic boundaries. Updating the endemic fungi maps would inform clinical practice and global surveillance of these diseases.

Talaromyces marneffei Outside Endemic Areas in India: an Emerging Infection with Atypical Clinical Presentations and Review of Published Reports from India

Talaromycosis is a disseminated disease caused by Talaromyces (Penicillium) marneffei, mainly seen in acquired immunodeficiency syndrome (AIDS) patients. Its distribution is restricted to southeast Asian countries; a small pocket of endemicity exists in the northeast Indian state of Manipur. Here, we present a series of five cases presenting to our tertiary care hospital, originating from non-endemic states neighboring Manipur. In addition to the geographical distinction, a variety of unique features were noted in our cases, including human immunodeficiency virus (HIV)-negative hosts, the absence of typical skin lesions, presentation as pneumonia and generalized lymphadenopathy. Our series highlights the importance of distinguishing this disease from histoplasmosis and tuberculosis, both endemic in India.

Morphology and multigene phylogeny of Talaromycesamyrossmaniae, a new synnematous species belonging to the section Trachyspermi from India

A new Talaromyces species, T.amyrossmaniae, isolated from decaying fruit and litter of Terminalia bellerica, is described and illustrated. On the natural substrate, the new species produces determinate synnemata, with a well-defined, vivid orange red to orange red cylindrical stipe, and a greyish green capitulum. Conidiophores are typically biverticillate, or sometimes have subterminal branches, with acerose phialides that produce globose to subglobose, smooth to slightly roughened conidia. Multigene phylogenetic analyses based on the internal transcribed spacer region (ITS), and partial sequences of β-tubulin (BenA), calmodulin (CaM), and DNA directed RNA polymerase second large subunit (RPB2) genes, along with morphological characterization, revealed that these isolates are distinct and form a unique lineage of Talaromyces in section Trachyspermi, closely allied to T.aerius, T.albobiverticillius, T.heiheensis, T.erythromellis, and T.solicola. The new species T.amyrossmaniae is the first species in section Trachyspermi with determinate synnemata.

Pancytopenia and cutaneous cryptococcosis as an indicator disease of acquired immune deficiency syndrome

We present a case of pancytopenia and cutaneous cryptococcosis in a young girl with no complaints of fever, headache and vomiting. Fine-needle aspiration cytology and further investigation for pancytopenia revealed presence of Cryptococcus in skin and bone marrow aspirates. Fungal cultures of the skin aspirates, blood and bone marrow confirmed cryptococcal infection. Counselling and human immunodeficiency virus (HIV) test revealed the status of the patient to be retropositive. Although meningitis is the commonest manifestation of cryptococcosis among HIV-infected patients, rare cutaneous manifestation with pancytopenia but with no meningeal signs indicate the HIV status in an endemic area of penicilliosis, Manipur.

Acute Abdomen Due to Penicillium marneffei: An Indicator of HIV Infection in Manipur State

Opportunistic infection in HIV disease often present to clinicians in an atypical manner testing clinical acumen. Here, we report a case of Penicilliosis marneffei (PM) infection presenting to surgical emergency as acute abdomen with undiagnosed HIV status in advanced AIDS, chief complaints being prolonged fever and diffuse abdominal pain. Radiologic imaging showed non-specific mesenteric and retroperitoneal lymphadenopathy. Fine needle aspiration cytology (FNAC) of the lymph node was done and subjected to direct microscopy, gram staining and culture on Sabouraud's dextrose agar (SDA) which showed Penicillium marneffei. He was then treated with intravenous amphotericin. This case is reported for its rarity and unusual presentation to sensitise clinicians and microbiologists to consider PM as an aetiology in acute abdomen in high risk individuals, more so, in patients from north-east India.

Emerging systemic fungal infections

Systemic mycoses are a heterogeneous group of infections caused by different species of fungi that mainly affect individuals with primary or secondary alterations of immunity. In recent years, there has been an increase in the incidence of infections related to migration, AIDS, and other causes of immunosuppression, such as solid organ and bone marrow transplantation; oncological, hematological, and autoimmune diseases; and the use of new drugs. In this paper, we outline the microbiological and epidemiological characteristics of 3 fungi: Aspergillus spp, Fusarium spp, and Penicillium spp. We describe the clinical manifestations of disease with emphasis on those that should alert the dermatologist to make an early diagnosis. We detail the various tools for early diagnosis, prevention, and the epidemiology of different antifungals available for treatment and their mechanism of action and therapeutic efficacy.

Penicillinosis in a HIV-positive individual

Penicillium marneffei is a dimorphic fungus, which can cause fatal infection in HIV-infected patients. The aim of this article is to report a rare case of penicillinosis in an HIV-positive patient from a nonendemic area such as Paonta Sahib, Himachal Pradesh. The patient presented with nonhealing painful ulcer on tongue, chest pain, cough, and chronic diarrhea. Diagnosis was made possible through blood investigations and culture reports of saliva and blood samples.

Penicillinosis in a HIV-positive individual

Penicillium marneffei is a dimorphic fungus, which can cause fatal infection in HIV-infected patients. The aim of this article is to report a rare case of penicillinosis in an HIV-positive patient from a nonendemic area such as Paonta Sahib, Himachal Pradesh. The patient presented with nonhealing painful ulcer on tongue, chest pain, cough, and chronic diarrhea. Diagnosis was made possible through blood investigations and culture reports of saliva and blood samples.

The spectrum of clinical and pathological manifestations of AIDS in a consecutive series of 236 autopsied cases in mumbai, India

The HIV epidemic in the Asian subcontinent has a significant impact on India. The AIDS associated pathology has not been well evaluated in a representative study hence very little is known about the spectrum of HIV/AIDS associated diseases in Indian subcontinent. To determine the important postmortem findings in HIV infected individuals in Mumbai, autopsy study was carried out. The patient population included patients with AIDS who died at the tertiary care hospital over a 20 year period from 1988 to 2007. A total of 236 (182; 77% males and 54; 23%) females) patients with AIDS were autopsied. The main risk factor for HIV transmission was heterosexual contact (226 patients; 96%) and 223/236 (94%) patients died of HIV-related diseases. Tuberculosis was the prime cause of death in 149 (63%) patients, followed by bacterial pneumonia 33 (14%), cryptococcosis 18 (8%), toxoplasmosis of brain 15 (6%), pneumocystis jiroveci (PCJ) 1 (0.5%) and Non-Hodgkin's lymphoma 7 (3%) cases. The major underlying pathologies are either preventable or treatable conditions. There is an urgent need for attention towards the diagnosis, issue of therapy, and care of HIV disease in developing countries. Reducing mortality in patients with AIDS from infections must be highest public health policy in India.

Penicillium marneffei Infection in AIDS

Penicillium marneffei is a dimorphic fungus which is endemic in Southeast Asia. It is an opportunistic pathogen which has emerged to become an AIDS-defining illness in the endemic areas. Early diagnosis with prompt initiation of treatment is crucial for its management. Prompt diagnosis can often be established through careful cytological and histological examination of clinical specimens although microbiological culture remains the gold standard for its diagnosis. Standard antifungal treatment for AIDS patients with penicilliosis is well established. Highly active antiretroviral therapy should be started early together with the antifungal treatment. Special attention should be paid to potential drug interaction between antiretroviral and antifungal treatments. Secondary prophylaxis may be discontinued with a low risk of relapse of the infection once the immune dysfunction has improved.

Clinical profile of HIV/AIDS-infected patients admitted to a new specialist unit in Dhaka, Bangladesh--a low-prevalence country for HIV

This paper describes the clinical features of a series of patients admitted to the specialist HIV/AIDS unit (Jagori) of the Dhaka Hospital, ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) during May 2008-February 2010. Data were collected from a review of documents and electronic case-records and collation of laboratory results with respect to CD4 counts. One hundred and nine patients were admitted during this period. Their mean age was 33.4 years, and 62% were male. On admission, the mean CD4 count +/- standard deviation (SD) was 244 +/- 245 (range 2-1,549). The death rate was 12%. The patients were classified as World Health Organization clinical stage 1: 23%, stage 2: 30%, stage 3: 23%, and stage 4: 24% during the admission. The commonest diagnosis recorded was tuberculosis (TB) (23%), which was also the commonest cause of death (38%). Even for those clinicians with limited experience of managing AIDS cases, the commonest problem encountered in this patient group was TB, reflecting the continued high burden of TB on health services in Bangladesh. Additional challenges to managing TB/HIV co-infection include atypical presentations in HIV-infected persons and the complex drug interaction with antiretroviral therapy.

Endemic fungal infections in the Asia-Pacific region

Endemic mycoses are important fungal infections in their respective habitats. In the Asia-Pacific region, an accurate epidemiological picture of endemic mycoses is elusive; few epidemiological surveys have been performed, and limited laboratory facilities and experience with fungal infections have further hampered recognition of infection. However, pockets of endemicity do indeed exist, and endemic fungal infections can have a significant impact on public health. This article reviews the most common endemic mycoses in the Asia-Pacific region: histoplasmosis, penicilliosis, and sporotrichosis. Blastomycosis, which has been infrequently reported within the region, is also briefly discussed. Certain areas of the Asia-Pacific region are endemic for histoplasmosis; however, the ecologic niche for this infection remains unclear. Penicilliosis is restricted to Southeast and Eastern Asia, whereas sporotrichosis is encountered in tropical areas of the Asia-Pacific region linked to environmental reservoirs distinct from those seen in the Western world. Before the advent of acquired immune deficiency syndrome (AIDS), histoplasmosis and penicilliosis were only occasionally reported; however, the incidence of both mycoses has increased with the rise in the incidence of AIDS. Comprehensive studies are needed to fully assess the areas of endemicity and the impact of endemic mycoses in the Asia-Pacific region.

Characterization of an MPLP6, a gene coding for a yeast phase specific, antigenic mannoprotein in Penicillium marneffei

A gene encoding an antigenic mannoprotein of Penicillium marneffei, MPLP6, was isolated by an antibody screening approach and characterized. The polypeptide chain containing deduced 220 amino acids has a predicted molecular mass of 24 kDa. It has high similarity to Mp1p, the first mannoprotein antigen isolated from P. marneffei. The polypeptide sequence presents the property of cell wall mannoproteins by containing a putative N-terminal signal peptide and potential O-linked glycosylation sites. However, absence of a GPI-anchored signal sequence suggested that this protein is secreted. The MPLP6 transcript was present specifically in the pathogenic yeast form. The transcript was completely absent in the mold phase and conidia. The fusion protein produced in E. coli was Western immunoblotted with P. marneffei-infected human sera and 95% of the patients' sera were positive in the assay. None of the sera obtained from patients with aspergillosis, tuberculosis, histoplasmosis or cryptococcosis tested positive. These results suggest that Mplp6 can be used as a marker in a serodiagnostic assay.

Engagement of Penicillium marneffei conidia with multiple pattern recognition receptors on human monocytes

P. marneffei is a thermal dimorphic fungus which causes penicilliosis, an opportunistic infection in immunocompromised patients in South and Southeast Asia. Little is known about the innate immune response to P. marneffei infection. Therefore, the initial response of macrophages to P. marneffei conidia was evaluated by us. Adhesion between monocytes from healthy humans and fungal conidia was examined and found to be specifically inhibited by MAbs against PRR, such as MR, (TLR)1, TLR2, TLR4, TLR6, CD14, CD11a, CD11b, and CD18. To study the consequences of these interactions, cytokines were also examined by ELISA. Binding of P. marneffei conidia to monocytes was significantly inhibited, in a dose-dependent manner, by MAbs against MR, TLR1, TLR2, TLR4, TLR6, CD14, CD11b and CD18. When monocytes were co-cultured with the conidia, there was an increase in the amount of surface CD40 and CD86 expression, together with TNF-alpha and IL-1beta production, compared to unstimulated controls. In assays containing anti-TLR4 or anti-CD14 antibody, reduction in the amount of TNF-alpha released by monocytes stimulated with P. marneffei conidia was detected. In addition, it was found that production of TNF-alpha and IL-1beta from adherent peripheral blood monocytes was partially impaired when heat-inactivated autologous serum, in place of untreated autologous serum, was added to the assay. These results demonstrate that various PRR on human monocytes participate in the initial recognition of P. marneffei conidia, and the engagement of PRR could partly initiate proinflammatory cytokine production.

Cavitary pulmonary disease

A pulmonary cavity is a gas-filled area of the lung in the center of a nodule or area of consolidation and may be clinically observed by use of plain chest radiography or computed tomography. Cavities are present in a wide variety of infectious and noninfectious processes. This review discusses the differential diagnosis of pathological processes associated with lung cavities, focusing on infections associated with lung cavities. The goal is to provide the clinician and clinical microbiologist with an overview of the diseases most commonly associated with lung cavities, with attention to the epidemiology and clinical characteristics of the host.

Penicillium marneffei infection and recent advances in the epidemiology and molecular biology aspects

Penicillium marneffei infection is an important emerging public health problem, especially among patients infected with human immunodeficiency virus in the areas of endemicity in southeast Asia, India, and China. Within these regions, P. marneffei infection is regarded as an AIDS-defining illness, and the severity of the disease depends on the immunological status of the infected individual. Early diagnosis by serologic and molecular assay-based methods have been developed and are proving to be important in diagnosing infection. The occurrence of natural reservoirs and the molecular epidemiology of P. marneffei have been studied; however, the natural history and mode of transmission of the organism remain unclear. Soil exposure, especially during the rainy season, has been suggested to be a critical risk factor. Using a highly discriminatory molecular technique, multilocus microsatellite typing, to characterize this fungus, several isolates from bamboo rats and humans were shown to share identical multilocus genotypes. These data suggest either that transmission of P. marneffei may occur from rodents to humans or that rodents and humans are coinfected from common environmental sources. These putative natural cycles of P. marneffei infection need further investigation. Studies on the fungal genetics of P. marneffei have been focused on the characterization of genetic determinants that may play important roles in asexual development, mycelial-to-yeast phase transition, and the expression of antigenic determinants. Molecular studies have identified several genes involved in germination, hyphal development, conidiogenesis, and yeast cell polarity. A number of functionally important genes, such as the malate synthase- and catalase-peroxidase protein-encoding genes, have been identified as being upregulated in the yeast phase. Future investigations pertaining to the roles of these genes in host-fungus interactions may provide the key knowledge to understanding the pathogenicity of P. marneffei.

Chondroitin sulfate B and heparin mediate adhesion of Penicillium marneffei conidia to host extracellular matrices

Penicilliosis is a disseminated infection in immunocompromised individuals caused by the dimorphic fungus, Penicillium marneffei. Very little is known about its route of infection, however, it is thought that initial infection occurs through inhalation of conidia. We investigated the role played by various extracellular matrix glycosaminoglycans (GAGs) in the initial adherence of P. marneffei conidia using a direct adhesion assay. GAGs were further used to block the binding of fungal spores to human lung epithelial cells and highly sulfated GAGs were tested for their inhibitory effects owing to their degree of sulfation. Our results demonstrated high levels of conidial adhesion to chondroitin sulfate B, heparin and highly sulfated chitosan (CP-3). No direct adherence was observed to immobilized chondroitin sulfate (CS) A, CSC, CSD and hyaluronic acid, as well as chitosans with low sulfate content. The results suggested that P. marneffei conidia bind to iduronic acid (IdoA) of the polysaccharide chains. Involvement of negatively charged sulfate groups in adhesion was also indicated. Furthermore, significant inhibition of conidial adherence to A549 cells was observed in the presence of CSB, heparan sulfate (HS), heparin and CP-3. It was further demonstrated that GAGs can affect the adhesion of conidia to fibronectin and laminin, glycoproteins that have previously been implicated as adhesive receptors for fungal conidia. CSB and HS could partially inhibit the adhesion of fungal conidia to laminin and fibronectin implying that conidia can weakly interact with the IdoA GAG-binding domain(s) of these molecules. The data indicated that, in addition to fibronectin and laminin, IdoA-containing GAGs may play an important role in fungal adherence to the surface of human lung epithelium.

Varied clinical manifestations of Penicillium marneffei in patients with human immunodeficiency virus: a report from south India

Penicillium marneffei is a dimorphic fungus endemic to northeast India. This is the first report of penicilliosis from a hospital in south India. Three patients with diverse clinical manifestations who presented to a tertiary care hospital are described. High index of clinical suspicion and knowledge of 'local' microbiology is paramount in early diagnosis and timely treatment.

Isolation and characterization of a catalase-peroxidase gene from the pathogenic fungus,Penicillium marneffei

Penicillium marneffei is a facultative intracellular pathogen that causes common opportunistic infection in AIDS patients in Southeast Asian countries. The pathogen can usually survive and replicate inside the phagosome of macrophages, and is also found extracellularly in blood smears or host tissue. Surviving within the alveolar macrophage is a primary key to the success of P. marneffei invasion. However, the mechanism of survival under oxidative stress in this environment has not been elucidated. An antigenic catalase-peroxidase protein-encoding gene (cpeA) was isolated by antibody screening of a cDNA library derived from the yeast phase of P. marneffei. DNA sequence analysis of this gene revealed an open reading frame encoding a 748 amino acid polypeptide with a predicted molecular mass of 82.4 kDa. The deduced amino acid sequence was 45-69% identical to that of catalase-peroxidases from many bacteria and fungi. Potential iron regulated binding elements and conserved active sites for peroxidases were found in the peptide sequence. Southern blot analysis showed that the P. marneffei genome contained a single copy of the cpeA. This gene displayed a high level of expression, specifically being induced when the temperature was shifted to 37 degrees C, the condition whereby the pathogenic yeast phase of P. marneffei is formed. The high expression of the cpeA mRNA transcripts at 37 degrees C may contribute to the survival of this dimorphic fungus in host cells.

Role of Cannomys badius as a natural animal host of Penicillium marneffei in India

Infection by Penicillium marneffei in human immunodeficiency virus-positive patients in India has recently been described; the aim of our study was to survey wild rodents and their associated environment in order to identify the natural populations of this fungus. Surveys recovered P. marneffei from the internal organs of 10 (9.1%) of 110 bamboo rats (Cannomys badius) examined from Manipur state, India, an area endemic for penicilliosis marneffei. Identification of the isolates was based on a detailed study of their morphological characteristics, in vitro conversion to fission yeast form, and exoantigen tests. Multilocus microsatellite typing (MLMT) of the isolates revealed five genotypes. No genotypes were shared between sample sites, and all bamboo rats were infected with a single genotype within sample sites, demonstrating spatial genetic heterogeneity. One MLMT genotype was identical to that seen in a human isolate, suggesting that either coinfection from a common source or host-to-host transmission had occurred. This demonstrates the utility of an MLMT-based approach to elucidating the epidemiology of P. marneffei.

Disseminated Penicillium marneffei infection among HIV-infected patients in Manipur state, India

OBJECTIVE

To further describe the clinical and epidemiological characteristics of Penicillium marneffei infection in human immunodeficiency virus (HIV) infected patients in India.

METHODS

In continuation of our earlier report of four autochthonous cases of P. marneffei infection in HIV infected patients from Manipur, a northeastern state of India, we studied additional 46 cases of penicilliosis marneffei from the same area over a period of 19 months (April 1998-October 1999). Clinical, microbiological features, and therapeutic responses were analyzed in 36 of the 46 patients as ten patients were lost to follow-up.

RESULTS

Of the 198 HIV positive patients attending the J. N. Medical Hospital, Imphal, Manipur state during the period mentioned, 46 (25%) had P. marneffei disseminated infection. Of the 36 patients analyzed 31 (86%) were intravenous drug abusers, 1 had multiple sex partners, and 3 females acquired HIV infection from their respective spouses. A 9-year-old child acquired HIV infection by vertical transmission. The common clinical symptoms included fever (97%), weight loss (100%), weakness (86%), anemia (86%), and characteristic skin lesions (81%). Presumptive diagnosis was made by microscopic examination of Wright's-stained smears of fine needle aspirated material from skin lesions and lymph nodes showing numerous intracellular and extracellular, oval, elongated, yeast-like cells dividing by fission. The etiologic agent P. marneffei was isolated in culture from clinical materials in 10 cases when isolation was attempted. All patients were treated with oral itraconazole. All, except one patient, responded favorably to treatment within 7 days.

CONCLUSION

Thus, the present cases further confirm the endemicity of penicilliosis marneffei in Manipur and resemble the epidemiology and clinical course of patients from other parts of south-east Asia.