Penicillum marneffei presenting as a pneumonia and obstructive airway disease exacerbation.
Chaaban S, and Thavarajah K. Penicillum marneffei presenting as a pneumonia and obstructive airway disease exacerbation. Am J Respir Crit Care Med 2017; 195.
Am J Respir Crit Care Med
Penicillum marneffei, a pathogenic thermally dimorphic fungi causing pulmonary infection, was initially described in HIV-infected patients. The incidence rate has decreased with improved diagnostic testing for HIV and availability of highly active anti-retroviral therapy. Recently, the emergence of this pathogen in patients with underlying primary or secondary immunosuppression has been described. We share a case of Penicillum species causing infection in a patient with previously controlled IgG deficiency. Case presentation: A 52 year old female patient with history of prior tobacco use, chronic obstructive pulmonary disease, asthma, allergic rhinitis, prior eosinophilic pneumonia, and IgG deficiency on subcutaneous IgG replacement presented to the emergency department with worsening shortness of breath, cough, subjective fevers and night sweats. Of note, the patient had suffered recurrent obstructive airways disease exacerbations over the preceding three months and was treated with chronic intermittent steroids and antibiotics with partial improvement. Her physical examination revealed new hypoxia and wheezing. Her workup was notable for a normal white count, an absolute eosinophil count of 300 cells/microL, no lymphopenia, normal IgG levels, a CD4 count of 700 cell/ul, and a negative HIV ELISA. Computed Tomography (CT) of the chest showed bilateral bronchial wall thickening, tree-in-bud opacities, and ground glass opacities. Bronchoscopy revealed purulent secretions emerging from the right upper lobe. Her bronchoalveolar lavage cultures initially grew 100,000 Streptococcus colonies for which the patient was treated with levofloxacin for 14 days with mild improvement in symptoms. Fungal cultures subsequently grew Penicillum species. She was prescribed itraconazole with improvement in dyspnea, cough and low grade fevers over the following week. Chest CT four weeks later showed resolution of the radiographic abnormalities. Discussion: Penicillium marneffei infection has been reported in 15 cases of non-HIV-infected patients with autoimmune disease. The predisposing factor may be either the underlying autoimmune disease or its treatment. Infection occurs when patients receive treatment with T lymphocyte depleting drugs such as steroids, cyclosporine, azathioprine, tacrolimus and mycophenolate mofetil. Our patient received intermittent courses of steroids for management of obstructive airways disease exacerbations, which likely increased her susceptibility to infection with Penicillium species. We present this case to draw heightened awareness of this serious infection in iatrogenically immunosuppressed patients.