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Disseminated penicilliosis associated with HIV infection
Letters to the Editor
84
our patient m a y reflect the large n u m b e r of organisms present. With the increasing incidence of non-tuberculous mycobacterial infections, cultures of l y m p h nodes f r o m adults and children should be maintained for at least I2 weeks so as to ensure isolation of mycobacteria including M. malmoense. (We thank staff of the Public Health Laboratory Service Mycobacterium Reference Unit, Cardiff for their assistance and, in particular, D r Jenkins for advice in the management of this case.)
Bristol Royal Hospital for Sick Children St Michael's Hill Bristol BS2 8BJ, U.K. *Department of Microbiology Bristol Royal Infirmary Marlborough Street Bristol BS2 8HW, U.K.
D. Griffiths H. Humphreys* H. R. Noblett
* Author to whom correspondence should be addressed.
References I. Ellis ME. Mycobacteria other than Mycobacterium tuberculosis. Curr Opini Infect Dis I988; x : 252-27I. 2. Schroder KH, Juhlin I. Mycobacterium malmoense Sp. Nov. IntJ Syst Bacteriol I977; 27: 241-246. 3. France AJ, McLeod DT, Calder MA, Seaton MA. Mycobacterium malmoense infections in Scotland: An increasing problem. Thorax I987; 42 : 593-595. 4-White NP, Bangash H, Goel KM, Jenkins PA. Non-tuberculous mycobacterial lymphadenitis. Arch Dis Child I986; 6x: 368-37I. 5. Jenkins PA. Mycobacterium malmoense. Tubercle I985; 66: I93-I95. 6. Banks J, Jenkins PA, Smith AP. Pulmonary infection with Mycobacterium malmoense--A review of treatment and response. Tubercle ~985; 66: I97-2o3. 7. Ispahani P, Baker M. Mycobacterial culture: How long? Lancet I988; |: 305.
D i s s e m i n a t e d p e n i c i l l i o s i s a s s o c i a t e d w i t h HIV i n f e c t i o n
Accepted for publication 23 December I988 Sir, Penicillium marneffei is the only species of Penicillium which is known to be dimorphic and considered to be a true pathogenic fungus because it can affect i m m u n o c o m p e t e n t hosts. 1'2 I m m u n o c o m p r o m i s e d hosts, however, are m o r e predisposed to a disseminated f o r m of infection. A case of disseminated penicilliosis associated with H I V infection has been reported from Englandfl So et al. have also reported a case of invasive penicilliosis associated with immunodeficiency of u n d e t e r m i n e d aetiology. 4 Unfortunately, in their case H I V antibody was not studied. W e wish to report another case in a 43-year-old T h a i w o m a n who presented with intermittent fever, dry cough, chronic oropharyngeal ulcers and progressive loss of weight for 5 months. She has a history of previous blood transfusion during an operation p e r f o r m e d in the Middle East 4 years earlier. She denied intravenous drug abuse. Generalised l y m p h a d e n o p a t h y without enlargement of liver or spleen was noted. A chest X - r a y showed bilateral interstitial infiltration. Antituberculous drugs and a systemic corticosteroid were given in view of deteriorating respiratory function.
Letters to the Editor
85
A few days later, generalised erythematous papules erupted. L y m p h node and skin imprints showed numerous ellipsoidal septate yeast-like organisms. Penicillium marneffei was isolated from blood, s p u t u m and lymph nodes. In addition, H I V antibody was detected by enzyme immunoassay and confirmed by western blot technique (positive g p I 2 o , P55/63, g p 4 I , P34). In the presence of laboratory evidence for H I V infection, disseminated infection by P. marneffei is not listed as an indicator disease for reporting the acquired immunedeficiency syndrome ( A I D S ) : T h u s , we could not report this patient as having A I D S according to the revised case definition 5 issued by the Centers for Disease Control (CDC), Atlanta. Otherwise, this patient would certainly be diagnosed as having fully developed A I D S on the clinical grounds of serological evidence of H I V infection plus the disseminated fungal infection. PeniciUium marneffei is endemic in Southeast Asia, 1 as is Histoplasma capsulatum in the U.S.A. It is an example of an agent of infection in the tropics which differs from those in temperate climates. T h u s , we feel that the list of infections indicating A I D S in the presence of positive H I V serological tests should be modified accordingly in order not to miss cases for purposes of reporting. We believe that disseminated infection caused by P. marneffei should be added to the list of indicator diseases especially when applied to Southeast Asia. (We thank Dr C. Wasi of the Department of Microbiology, Siriraj Hospital, Mahidol University for confirming the presence of HIV antibody by the western blot technique.)
B. Sathapatayavongs* S. Damrongkitchaiporn* P. Saengditha* S. Kiatboonsri* P. Jayanetra* t
* Department of Medicine t Department of Pathology Ramathibodi Hospital Rama VI Road Bangkok 10400, Thailand References
I. Jayanetra P, Nitiyanant P, Ajello L e t al. Penicilliosismarneffei in Thailand: Report of five human cases. Am J Trop Med Hyg 1984; 33:637-644 • 2. Deng Z, Connor DH. Progressive disseminated penicilliosis caused by Penicilliummarneffei : Report of eight cases and differentiation of the causative organism from Histoplasma capsulatum. Am J Clin Pathol I985; 84: 323-327. 3. Peto TEA, Bull R, Millard PR et al. Systemic mycosis due to Penicillium marneffei in a patient with antibody to human immunodeficiency virus. J. Infect I988; 16: 285-29o. 4- So SY, Chau PY, Jones BM et al. A case of invasive penicilliosis in Hong Kong with immunologic evaluation. Am Rev Respir Dis I985; I3I: 662-665. 5. AIDS Program, Center for Disease Control, Atlanta, U.S.A. Revision of the CDC surveillance case definition for the acquired immunedeficiency syndrome. MMWR i987; 36 (Suppl I): 3S-I5S.
I d i o s y n c r a t i c r e a c t i o n to n e b u l i s e d r i b a v i r i n in a n a r t i f i c a l l y v e n t i l a t e d neonate
Accepted for publication 20 march I989 Sir, In view of the recent debate about the use of ribavirin in the treatment of respiratory syncytial virus (RSV) infections 1 and the emphasis that has been placed on the lack of known side-effects, we wish to report on a baby who suffered an apparently idiosyncratic reaction to the drug. A healthy 3"x 5 kg female infant, delivered to a 24-year-old prima gravida at 36 weeks
84
our patient m a y reflect the large n u m b e r of organisms present. With the increasing incidence of non-tuberculous mycobacterial infections, cultures of l y m p h nodes f r o m adults and children should be maintained for at least I2 weeks so as to ensure isolation of mycobacteria including M. malmoense. (We thank staff of the Public Health Laboratory Service Mycobacterium Reference Unit, Cardiff for their assistance and, in particular, D r Jenkins for advice in the management of this case.)
Bristol Royal Hospital for Sick Children St Michael's Hill Bristol BS2 8BJ, U.K. *Department of Microbiology Bristol Royal Infirmary Marlborough Street Bristol BS2 8HW, U.K.
D. Griffiths H. Humphreys* H. R. Noblett
* Author to whom correspondence should be addressed.
References I. Ellis ME. Mycobacteria other than Mycobacterium tuberculosis. Curr Opini Infect Dis I988; x : 252-27I. 2. Schroder KH, Juhlin I. Mycobacterium malmoense Sp. Nov. IntJ Syst Bacteriol I977; 27: 241-246. 3. France AJ, McLeod DT, Calder MA, Seaton MA. Mycobacterium malmoense infections in Scotland: An increasing problem. Thorax I987; 42 : 593-595. 4-White NP, Bangash H, Goel KM, Jenkins PA. Non-tuberculous mycobacterial lymphadenitis. Arch Dis Child I986; 6x: 368-37I. 5. Jenkins PA. Mycobacterium malmoense. Tubercle I985; 66: I93-I95. 6. Banks J, Jenkins PA, Smith AP. Pulmonary infection with Mycobacterium malmoense--A review of treatment and response. Tubercle ~985; 66: I97-2o3. 7. Ispahani P, Baker M. Mycobacterial culture: How long? Lancet I988; |: 305.
D i s s e m i n a t e d p e n i c i l l i o s i s a s s o c i a t e d w i t h HIV i n f e c t i o n
Accepted for publication 23 December I988 Sir, Penicillium marneffei is the only species of Penicillium which is known to be dimorphic and considered to be a true pathogenic fungus because it can affect i m m u n o c o m p e t e n t hosts. 1'2 I m m u n o c o m p r o m i s e d hosts, however, are m o r e predisposed to a disseminated f o r m of infection. A case of disseminated penicilliosis associated with H I V infection has been reported from Englandfl So et al. have also reported a case of invasive penicilliosis associated with immunodeficiency of u n d e t e r m i n e d aetiology. 4 Unfortunately, in their case H I V antibody was not studied. W e wish to report another case in a 43-year-old T h a i w o m a n who presented with intermittent fever, dry cough, chronic oropharyngeal ulcers and progressive loss of weight for 5 months. She has a history of previous blood transfusion during an operation p e r f o r m e d in the Middle East 4 years earlier. She denied intravenous drug abuse. Generalised l y m p h a d e n o p a t h y without enlargement of liver or spleen was noted. A chest X - r a y showed bilateral interstitial infiltration. Antituberculous drugs and a systemic corticosteroid were given in view of deteriorating respiratory function.
Letters to the Editor
85
A few days later, generalised erythematous papules erupted. L y m p h node and skin imprints showed numerous ellipsoidal septate yeast-like organisms. Penicillium marneffei was isolated from blood, s p u t u m and lymph nodes. In addition, H I V antibody was detected by enzyme immunoassay and confirmed by western blot technique (positive g p I 2 o , P55/63, g p 4 I , P34). In the presence of laboratory evidence for H I V infection, disseminated infection by P. marneffei is not listed as an indicator disease for reporting the acquired immunedeficiency syndrome ( A I D S ) : T h u s , we could not report this patient as having A I D S according to the revised case definition 5 issued by the Centers for Disease Control (CDC), Atlanta. Otherwise, this patient would certainly be diagnosed as having fully developed A I D S on the clinical grounds of serological evidence of H I V infection plus the disseminated fungal infection. PeniciUium marneffei is endemic in Southeast Asia, 1 as is Histoplasma capsulatum in the U.S.A. It is an example of an agent of infection in the tropics which differs from those in temperate climates. T h u s , we feel that the list of infections indicating A I D S in the presence of positive H I V serological tests should be modified accordingly in order not to miss cases for purposes of reporting. We believe that disseminated infection caused by P. marneffei should be added to the list of indicator diseases especially when applied to Southeast Asia. (We thank Dr C. Wasi of the Department of Microbiology, Siriraj Hospital, Mahidol University for confirming the presence of HIV antibody by the western blot technique.)
B. Sathapatayavongs* S. Damrongkitchaiporn* P. Saengditha* S. Kiatboonsri* P. Jayanetra* t
* Department of Medicine t Department of Pathology Ramathibodi Hospital Rama VI Road Bangkok 10400, Thailand References
I. Jayanetra P, Nitiyanant P, Ajello L e t al. Penicilliosismarneffei in Thailand: Report of five human cases. Am J Trop Med Hyg 1984; 33:637-644 • 2. Deng Z, Connor DH. Progressive disseminated penicilliosis caused by Penicilliummarneffei : Report of eight cases and differentiation of the causative organism from Histoplasma capsulatum. Am J Clin Pathol I985; 84: 323-327. 3. Peto TEA, Bull R, Millard PR et al. Systemic mycosis due to Penicillium marneffei in a patient with antibody to human immunodeficiency virus. J. Infect I988; 16: 285-29o. 4- So SY, Chau PY, Jones BM et al. A case of invasive penicilliosis in Hong Kong with immunologic evaluation. Am Rev Respir Dis I985; I3I: 662-665. 5. AIDS Program, Center for Disease Control, Atlanta, U.S.A. Revision of the CDC surveillance case definition for the acquired immunedeficiency syndrome. MMWR i987; 36 (Suppl I): 3S-I5S.
I d i o s y n c r a t i c r e a c t i o n to n e b u l i s e d r i b a v i r i n in a n a r t i f i c a l l y v e n t i l a t e d neonate
Accepted for publication 20 march I989 Sir, In view of the recent debate about the use of ribavirin in the treatment of respiratory syncytial virus (RSV) infections 1 and the emphasis that has been placed on the lack of known side-effects, we wish to report on a baby who suffered an apparently idiosyncratic reaction to the drug. A healthy 3"x 5 kg female infant, delivered to a 24-year-old prima gravida at 36 weeks