Year : 2010 | Volume
: 53 | Issue : 2 | Page : 361--363
Disseminated Penicillium marneffei infection in a Myanmar refugee from Mizoram state
Neelam Sood1, Harish C Gugnani2,
1 Department of Pathology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi - 110 064, India
2 St. Theresa Medical University, St. Kitts, West Indies
B- 3 / 337 G F, Paschim Vihar, New Delhi - 110 063
A 30-year-old female, a Myanmar refugee, settled in Mizoram for last three years, reported to our hospital with respiratory symptoms and numerous characteristic skin lesions on multiple sites. Histology and culture of a biopsy from a facial skin lesion established the diagnosis of penicilliosis marneffei. This is first known case of Penicillium marneffei infection from Mizoram state, India to the best of our knowledge. It is possible that several undetected cases of the disease exist in Mizoram, and in the neighboring country, Myanmar and several such cases may be presenting in metropolitan cities.
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Sood N, Gugnani HC. Disseminated Penicillium marneffei infection in a Myanmar refugee from Mizoram state.Indian J Pathol Microbiol 2010;53:361-363
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Sood N, Gugnani HC. Disseminated Penicillium marneffei infection in a Myanmar refugee from Mizoram state. Indian J Pathol Microbiol [serial online] 2010 [cited 2022 Sep 28 ];53:361-363
Available from: https://www.ijpmonline.org/text.asp?2010/53/2/361/64350
Penicillium marneffei , the only dimorphic species of the genus Penicillium is the etiological agent of a potentially life-threatening opportunistic fungal infection in human immunodeficiency virus (HIV)-infected and other immunocompromised patients. , The disease is endemic in several regions of Southeast Asia including Thailand, Malaysia , South China, Indonesia and Vietnam. , Penicilliosis marneffei is also endemic in Manipur state in Northeast as evidenced by reports of numerous autochthonous cases from this state. , A few imported cases of P. marneffei infection have been reported from non-endemic areas of India. ,,,,,, Four species of bamboo rats have been found to serve as carriers of P. marneffei: Rhizomys sinensis, R. pruinosus, R. sumatrensis and Cannomys badius in Southeast Asia.  No case of P. marneffei infection has been described from the state of Mizoram, despite its contiguity to Manipur, and similarity in climate and the rodent fauna. Hence it is considered of interest to report here a case of P. marneffei infection in a Myanmar refugee settled in Mizoram and presenting in a metropolitan city in Northern India.
A 30-year-old female refugee from Myanmar settled in Mizoram presented to our hospital with a history of fever, cough, loss of weight and appetite and skin lesions for the last one year. Examination of the lungs revealed crepitations, and chest X-ray revealed diffuse infiltrates in both basal lung fields, indicative of patchy pneumonitis. She had numerous papulo-nodular umbilicated skin lesions (0.5-1.5 cm) with central necrotic areas and superficial ulcerations on face [Figure 1], arms and legs. She gave a history of anti-tubercular treatment without any response. The patient was tested for HIV at the VCTC (Voluntary Counseling and Testing Center) of our hospital as per guidelines of National AIDS Control Organization (NACO) using two ERS (ELISA/Rapid/Simple) tests and was found reactive. Her hemoglobin was 9.0 gm% and total leucocyte count was 5000/mm 3 Differential blood count showed polymorphs to be 60% and lymphocytes 40%. The CD4 count was 42/uL. Her chest X-ray showed bilateral pneumonitis. Hematoxylin and Eosin (HandE) stained tissue sections of a biopsy of the skin lesion showed mild hyperkeratosis of the epidermis, and diffuse inflammatory infiltrate in the dermis, entrapping dermal appendages and nerves with lymphocytes, few plasma cells, nuclear debris and areas of coagulative necrosis. No granulomas were noted. Numerous yeast-like cells were seen in the dermis and in the subcutis [Figure 2]. Tissue sections stained with Gomori silver-methenamine stain (GMS) revealed numerous round, oval, elongated, septate yeast cells multiplying by fission (fission yeast cells), characteristic of P. marneffei within histiocytes and extracellularly [Figure 3]. Culture report of the skin biopsy as well as sputum and blood showed pure growth of P. marneffei, its identification being based on gross morphological and microscopic features, distinctive red pigment and conversion of the isolate to fission yeast form when grown on brain heart infusion agar at 37ΊC. Thus a diagnosis of P. marneffei was confirmed. The patient was treated with 0.7 mg/kg amphotericin B for 14 days and later changed to itraconazole 400 mg in two divided doses for two weeks. Thereafter the patient was put on HAART. She responded well with the regression of skin lesions, and was discharged from the hospital on request one month later with advice to continue with itraconazole and HAART. She reported after one month with sudden deterioration in her condition with subsequent death.
Penicilliosis marneffei is a third most common opportunistic infection; after tuberculosis and cryptococcosis in some parts of Southeast Asia. Its occurrence in AIDS patients has increased in recent years, with 10% having penicilliosis as the primary AIDS defining illness. , This infection has been reported from non-endemic regions of India such as states of Tamil Nadu, Maharashtra , Assam, Meghalaya and Delhi. ,,,,, The case from Delhi was a patient of immune restoration syndrome and was of Manipur origin.  The lesser bamboo rat (Cannomys badius), which is a carrier of P. marneffei in Manipur occurs in other Northeastern states in India, viz. Arunachal Pradesh, Assam, Meghalaya, Mizoram and Nagaland, and as well as in the neighboring countries viz. Myanmar, Nepal and Bhutan and Bangladesh. 
Thus it is possible that these regions have endemic foci but the cases have not been reported from there. The present communication constitutes the first report of a case of P. marneffei in a refugee of Myanmar settled in Mizoram and presenting in Delhi. However we could not determine whether the patient acquired infection in Mizoram or Myanmar.
Typically, penicilliosis presents as a subacute febrile illness with pulmonary infiltration and characteristic umbilicated skin lesions resembling those of molluscum contagiosum, as in the presently described case.  The tissue reaction observed in our case is in line with that described in immunocompromised patients.  However, no granulomas were noted in this case, which have been observed by other workers. , A high index of suspicion of P. marneffei is imperative in patients with such signs and symptoms, especially if they originate from areas endemic for the disease. Further it is possible that many undiagnosed cases of P. marneffei exist in northeastern migrants in the metropolitan cities such as Delhi, Mumbai, Calcutta and Chennai. These are possibly quiescent infections, which manifest when the CD4 count falls below 100/mm 3 .
The authors are grateful to the AIDS unit of RML Hospital for performing the CD4 count on our patient. We are highly grateful to Dr. K. Chandrasekhar, NICD, Delhi, for his kind help in culturing the biopsy specimen and identification of the isolate as P. marneffei.
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