Penicillium marneffei infection in Assam

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.

Clinical epidemiology and outcome of HIV-associated talaromycosis in Guangdong, China, during 2011-2017

OBJECTIVES

Talaromycosis is an invasive mycosis endemic to Southeast Asia. This study aimed to investigate the epidemiology, clinical features and prognostic factors of HIV-associated talaromycosis in Guangdong, China.

METHODS

We retrospectively evaluated HIV patients hospitalized with histopathology- or culture-confirmed talaromycosis between 2011 and 2017. Factors associated with poor prognosis were identified using logistic regression.

RESULTS

Overall, 1079 patients with HIV-associated talaromycosis were evaluated. Both the number and prevalence of talaromycosis among HIV admissions increased from 125 and 15.7% in 2011 to 253 and 18.8% in 2017, respectively, reflecting the increase in HIV admissions. Annual admissions peaked during the rainy season between March and August. Common clinical manifestations included fever (85.6%), peripheral lymphadenopathy (72.3%), respiratory symptoms (60.8%), weight loss (49.8%), skin lesions (44.5%) and gastrointestinal symptoms (44.3%). Common laboratory abnormalities were hypoalbuminaemia (98.6%), anaemia (95.6%), elevated aspartate aminotransferase level (AST) (76.9%), elevated alkaline phosphatase level (55.8%) and thrombocytopenia (53.7%). The median CD4 count was 9 cells/μL. Talaromyces marneffei was isolated from blood and bone marrow cultures of 66.6% and 74.5% of patients, respectively. The rate increased to 86.6% when both cultures were performed concurrently. At discharge, 14% of patients showed worsening conditions or died. Leucocytosis, thrombocytopenia, elevated AST, total bilirubin, creatinine and azole monotherapy independently predicted poor prognosis.

CONCLUSIONS

The incidence of HIV-associated talaromycosis has increased in Guangdong with the high HIV burden in China. Skin lesions were seen in less than half of patients. Induction therapy with azole alone is associated with higher mortality. Findings from this study should help to improve treatment of the disease.

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.