Disseminated Penicillium marneffei infection in human immunodeficiency virus-infected children.

ABSTRACT

Disseminated infection with the fungus Penicillium marneffei is one of the most common opportunistic infections in human immunodeficiency virus (HIV) disease in northern Thailand. We report the clinical, laboratory and therapeutic features of 21 human immunodeficiency virus-infected children with disseminated P. marneffei who were prospectively followed. Significant clinical and laboratory features included generalized lymphadenopathy (90%), hepatomegaly (90%), body temperature > 38.5 degrees C (81%), papular skin lesions with central umbilication (67%), splenomegaly (67%), failure to thrive (52%), severe anemia (hemoglobin < 60 g/liter) (43%) and thrombocytopenia (platelet count < 0.5 x 10(11)/liter) (21%). The response rate in patients who were treated with appropriate antifungal therapy (amphotericin B, fluconazole or ketoconazole) was 82%. No relapse was observed in patients given ketoconazole prophylactically. Skin lesions, usually papules with central necrotic umbilication, provide the most significant clue to the diagnosis. Early diagnosis based on finding P. marneffei in the skin smear or lymph node provides the basis for prompt administration of antifungal therapy and improved outcome.

ABSTRACT

PIP This report describes the epidemiology of Penicillium marneffei infections among HIV infected children who were seen at Chiang Mai University Hospital, Thailand, between April 1989 and January 1995. HIV infections among children 18 months old and older were determined by both enzyme-linked immunosorbent assay and particle agglutination tests. Confirmation of HIV infection was made among younger children by signs and symptoms and repeated reactive serum tests. Diagnosis of P. marneffei infection was determined by isolation of the organism from clinical blood or tissue specimens. Antifungal agents were administered and improvement was recorded. There were 23 cases of P. marneffei among the 362 children diagnosed with HIV infection during the study period. One case was a non-HIV infected girl and another was a thalassemic patient who had received an HIV infected blood transfusion. The remaining 21 children acquired the infection perinatally. All mothers of the 21 children had acquired the HIV infection as prostitutes or from husbands who used prostitutes. All 21 children had clinical cases of HIV infection at the onset of the P. marneffei infection. The median time of presentation was 32 months. Fever was a primary symptom. 67% had skin lesions and most lesions were on the face and extremities. Other laboratory findings are reported. 9 of the 21 children had other HIV-related opportunistic infections diagnosed at the same time as the diagnosis of P. marneffei. There were 4 cases of Salmonella bacteremia, 2 cases of cryptosporidiosis, 1 case of Pseudomonas aeruginosa bacteremia, 1 case of Pneumocystis carinii and cytomegalovirus pneumonia, and 1 case of nontyphoid Salmonella bacteremia and herpes zoster. All 7 culture-proved patients who did not receive antifungal therapy died. 9 culture-proved and 3 other cases responded to antifungal treatment. Findings suggest that P. marneffei infection should be included as another AIDS-defining illness. The case fatality rate of patients with P. marneffei infection was very high, mostly due to late diagnosis.