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Ulcerated Nodule in Patient with Talaromycosis: Re-visit a Neglected Disease in the Era of Antiretroviral Therapy

Open AccessPublished:May 11, 2022DOI:https://doi.org/10.1016/j.ijid.2022.05.014

      Highlights

      • Talaromycosis is an important opportunistic infection in patients living with HIV.
      • Molluscum-like lesions is a common skin lesion found in patients with talaromycosis.
      • Patients with cryptococcosis and histoplasmosis can also manifest similar lesions.
      • Physicians must be aware of talaromycosis in patients who lived in endemic area.
      • Returned traveler with typical skin lesion must be evaluated for talaromycosis.

      Abstract

      Talaromycosis is among common opportunistic infections in patients with AIDS living in the endemic area, although the incidence is declining in the era of antiretroviral therapy. Here, we present a case of disseminated infection in a patient who was unaware of HIV-serostatus and did not receive antiretroviral therapy.

      Keywords

      A man aged 34 years, living with HIV, presented with fever and non-itching small papules on face, trunk, and extremities. His skin lesions progress in size and numbers, and many of them turn to umbilicated, skin-colored papules and ulcerated nodules within 3 weeks (Fig 1). His CD4 cell count was 3 cells/cu.mm. Wright's staining of the skin scraping is shown in Fig 2. Hemocultures grew Talaromyces marneffei. The patient received amphotericin B followed by itraconazole. He responded well to the treatment (Fig 1) and is currently receiving antiretroviral therapy (tenofovir disoproxil fumarate/emtricitabine/ dolutegravir).
      Figure 1
      Figure 1Skin lesions on face at presentation and 16 days after antifungal therapy.
      Figure 2
      Figure 2Wright staining of skin scraping demonstrated pleomorphic yeast cell from round shape to elongated shape with occasionally-seen binary fission (Magnification: 1000x).
      Despite the wide availability of antiretroviral therapy, some patients may be unaware of their HIV-serostatus and put themselves at risk for opportunistic infections. T. marneffei is endemic in East Asia (
      • Sirisanthana T
      • Supparatpinyo K.
      Epidemiology and management of penicilliosis in human immunodeficiency virus-infected patients.
      ). Skin lesions are found in 70-80% of patients with talaromycosis; such lesions include molluscum-like lesions, papules, pustules, and nodules (
      • Lu PX
      • Zhu WK
      • Liu Y
      • Chen XC
      • Zhan NY
      • Liu JQ
      • et al.
      Acquired immunodeficiency syndrome associated disseminated Penicillium Marneffei infection: report of 8 cases.
      ;
      • Supparatpinyo K
      • Khamwan C
      • Baosoung V
      • Nelson KE
      • Sirisanthana T.
      Disseminated Penicillium marneffei infection in southeast Asia.
      ). If left untreated, molluscum-like lesions may progress to ulcerated nodules, as seen in this patient. These lesions can be found in patients with crytococcosis and histoplasmosis and must be observed in the differential diagnosis. Skin lesions are often atypical in patients with immune reconstitution inflammatory syndrome (IRIS), whether it is unmasking IRIS or paradoxical IRIS, e.g., erythematous papule, psoriasis-like, and erythema nodosum (
      • Thanh NT
      • Vinh LD
      • Liem NT
      • Shikuma C
      • Day JN
      • Thwaites G
      • et al.
      Clinical features of three patients with paradoxical immune reconstitution inflammatory syndrome associated with Talaromyces marneffei infection.
      ). The presence of skin lesions was a factor associated with initiation of early treatment (
      • Le T
      • Wolbers M
      • Chi NH
      • Quang VM
      • Chinh NT
      • Lan NP
      • et al.
      Epidemiology, seasonality, and predictors of outcome of AIDS-associated Penicillium marneffei infection in Ho Chi Minh City, VietNam.
      ;
      • Supparatpinyo K
      • Khamwan C
      • Baosoung V
      • Nelson KE
      • Sirisanthana T.
      Disseminated Penicillium marneffei infection in southeast Asia.
      ).

      Conflict of interest

      The authors have no competing interests to declare.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Ethical approval

      The patient's informed consent was obtained.

      Author contributions

      All authors had a role in taking care of this patient and proofing the final version of the manuscript.

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