Disseminated Penicillium marneffei infection in a renal-transplant recipient successfully treated with liposomal amphotericin B [5]
Journal
Transplantation
Journal Volume
76
Journal Issue
7
Date Issued
2003-10-15
Author(s)
Abstract
A 47-year-old Taiwanese man who underwent renal transplantation 33 months earlier because of end-stage renal disease secondary to chronic glomerulonephritis was admitted because of pain and swelling experienced in the right ankle since 2 months before this admission. He had been maintained on tacrolimus and prednisolone (5 mg/day) with stable graft function. Fever, dry cough, poor appetite, and weight loss developed over the 2-month period. Papulonodular skin lesions developed at the fourth toe of the right foot (Fig. 1a) and the right mouth angle (Fig. 1b), with several palpable subcutaneous masses on the lower abdomen and bilateral thighs. Osteomyelitis of the distal fibula and the right fourth metatarsal bone was diagnosed after radiographic examinations. Excisional biopsy of the subcutaneous nodules and debridement of the cutaneous and bony lesions of the toe were performed. Cultures of the blood and debrided specimens all yielded Penicillium marneffei. Liposomal amphotericin B (AmBisome) at 100 mg (2 mg/kg) daily was initiated and continued for 28 days, followed by oral itraconazole at 400 mg daily as maintenance therapy. Serum creatinine before treatment was 1.7 mg/dL and deceased to 1.4 mg/dL after 1 month of treatment. The dosage of tacrolimus was reduced during the course of itraconazole treatment because of drug interactions. Clinical and microbiologic evaluations revealed no relapse of penicilliosis or adverse effects after 1 year of itraconazole therapy. Figure 1: Papulonecrotic skin lesions at the right fourth toe (a) and at the right mouth angle (b) caused by Penicillium marneffei infection.In contrast with other fungal infections in transplantation, which usually occur within a recognized time frame after transplantation, endemic mycoses can occur at any time after transplantation (1). P. marneffei is a well-known dimorphic fungus endemic in the Southeast Asia among AIDS patients (2), but it is rarely described as an important etiology of invasive fungal infection among transplant recipients. The most common presentations of P. marneffei infection among AIDS patients were fever, papulonecrotic skin rashes, lymphadenopathy, and pulmonary infiltrates (2). Because the clinical manifestations of penicilliosis may be similar to those of tuberculosis or histoplasmosis, diagnosis and timely initiation of antifungal treatment may be delayed without histopathologic and microbiologic confirmation. Specimens of blood, bone-marrow aspirate, skin, and lymph node are the clinical specimens with highest diagnostic yields (2). After reviewing the literature, we were able to identify two other cases of disseminated P. marneffei infection in organ-transplant recipients (3). Both cases were renal-transplant recipients from our institution, with a fatal outcome, and the involved sites were blood, peritoneum, and intestine (3). Although the most effective therapy of P. marneffei infection is amphotericin B, followed by itraconazole as maintenance therapy (4), use of amphotericin B is limited by nephrotoxicity, especially in patients with chronic renal disease (5). Liposomal amphotericin B, with a better tolerability and less nephrotoxicity, has not been reported in the treatment of penicilliosis marneffei. Our present case is the first case of penicilliosis marneffei successfully treated with liposomal amphotericin B, and the renal function was maintained well after a 4-week course of treatment. In conclusion, we suggest that penicilliosis marneffei should be considered in an organ-transplant recipient who develops a disseminated infection, such as papulonecrotic skin lesions, after traveling or residing in an endemic area. Liposomal amphotericin B followed by itraconazole appears to be a good therapeutic alternative in renal-transplant recipients with penicilliosis marneffei. Jiun-Ling Wang Chien-Ching Hung Shan-Chwen Chang Chien-Ching Hung Shih-Chieh Chueh Ming-Kuen La
SDGs
Type
letter