Research Article: Clinical characteristics and outcome of Penicillium marneffei infection among HIV-infected patients in northern Vietnam

Date Published: August 16, 2012

Publisher: BioMed Central

Author(s): Mattias Larsson, Lien Ha Thi Nguyen, Heiman FL Wertheim, Trinh Tuyet Dao, Walter Taylor, Peter Horby, Trung Vu Nguyen, Minh Ha Thi Nguyen, Thuy Le, Kinh Van Nguyen.

http://doi.org/10.1186/1742-6405-9-24

Abstract

This study reports the clinical characteristics and outcome of HIV-associated Penicilliummarneffei infection in northern Vietnam.

We conducted a retrospective chart review of all patients with laboratory confirmed Penicilliummarneffei infection admitted to the National Hospital for Tropical Diseases in Hanoi, Vietnam, between July 2006 and September 2009.

127 patients with P. marneffei infection were identified. All were HIV-infected; median CD4+ T-cell count was 24 cells/μl (IQR:12-48); 76% were men. Common clinical features were fever (92.9%), skin lesions (82.6%), hepatomegaly (61.4%), lymphadenopathy (40.2%), weight loss (59.1%) and cough (49.6%). Concurrent opportunistic infections were present in 22.0%; half of those had tuberculosis. Initial treatment regimens were: itraconazole or ketoconazole capsule (77.2%), amphotericin B (20.5%), and fluconazole (1.6%). In-hospital mortality was 12.6% and showed no significant difference in patients treated with itraconazole (or ketoconazole) and amphotericin B (p = 0.43). Dyspnea, ascites, and increased LDH level were independent predictors of mortality. No seasonality was observed.

The clinical features, treatments and outcomes of HIV-associated P. marneffei infection in northern Vietnam are similar to those reported in other endemic regions. Dyspnea was an important predictor of mortality. More patients were treated with itraconazole than amphotericin B and no significant difference in treatment outcome was observed. It would be of clinical value to compare the efficacy of oral itraconazole and amphotericin B in a clinical trial.

Partial Text

Penicillium marneffei can cause a fatal systemic mycosis in immunosuppressed patients and is one of theleading causesof mortality in people living with Human Immunodeficiency Virus (HIV) in South-East Asia [1-3]. Penicilliosis presents primarily as a disseminated disease in HIV-infected patients with CD4+ T-cell count <100 cells/μL, involving the blood stream, skin, liver, spleen, lymph nodes, bone marrow, lung and gastrointestinal tract [2,4]. Typical umbilicated skin lesions are present in 70% of patients, facilitating early empirical antifungal therapy and resulting in better outcomes [4]. Laboratory diagnosis is made by microscopy and culture of skin lesions, blood, lymph node, or other body fluids [3].The majority of patients respond well to either amphotericin B or itraconazole treatment [2,4-6]; however no randomized controlled trials have been conducted to evaluate treatment choices for penicilliosis. P. marneffei infection was diagnosed in 127 patients, 42.5% by both blood and skin lesion culture, 29.1% by blood culture alone, and 28.3% by skin lesion culture alone. The average age was 32 years (range 21–50); the majority was male (75.6%), and 81.9% came from provinces outside of Hanoi in northern Vietnam. The reported route of HIV infection was intravenous drug use (IDU) (37.0%), commercial sex (29.9%), husband to wife (15.7%), combination of IDU and commercial sex (7.9%) and unknown (9.0%). 29.9% had been on antiretroviral therapy (ART) prior to the diagnosis of penicilliosis; the mean duration of ART was 10.8 weeks (SD 18.4). Penicilliosis accounted for 11% of all HIV-related admissions at NHTD in Hanoi during 2007 and 2008 which is higher than the 4.4% reported from the major referral hospital for infectious diseases in Ho Chi Minh City, southern Vietnam [4]. However as NHTD is a specialized tertiary hospital, and most (82%) of the cases were referred, and because other epidemiological data were lacking, it cannot be concluded that there is a difference in disease prevalence between northern and southern Vietnam. The clinical features of disseminated penicillosis are consistent with other studies including profound immunosuppression (median CD4+ T-cell count: 24 cells/μl) and high rate of co-infections with other opportunistic pathogens [2,4,6]. One third of the patients were already on ART for in average 10 days, this indicates that many patients had an ongoing P. marneffei infection that was not revealed before initiation of ART, but was probably unmasked by immune reconstitution inflammatory syndrome (IRIS) after initiation of ART, this has earlier been reported in a few case studies [8,9]. HIV, Human Immunodeficiency Virus; NHTD, National Hospital for Tropical Diseases; IDU, Intravenous drug use. The author declares that they have no competing interests NTLH - conception and design, acquisition of data, analysis and interpretation of data, has been involved in drafting the manuscript and have given final approval of the version to be published. ML - Analysis and interpretation of data, has been involved in drafting the manuscript and have given final approval of the version to be published. HFLW - conception and design, acquisition of data, interpretation of data, revising it critically for important intellectual content and have given final approval of the version to be published. DTT – Laboratory analysis and have given final approval of the version to be published. WT - conception and design, acquisition of data, revising it critically for important intellectual content and have given final approval of the version to be published. PH -conception and design, acquisition of data, interpretation of data, revising it critically for important intellectual content and have given final approval of the version to be published. NVT– Laboratory analysis and have given final approval of the version to be published. NTMH - Acquisition of data and have given final approval of the version to be published. TL - Revising it critically for important intellectual content and have given final approval of the version to be published. NVK - conception and design, acquisition of data and have given final approval of the version to be published. All authors read and approved the final manuscript.   Source: http://doi.org/10.1186/1742-6405-9-24

 

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