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Penicilliosis

Author: A/Prof Felix Boon-Bin Yap, Dermatologist, University Tunku Abdul Rahman and Sunway Medical Centre, Selangor, Malaysia. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. June 2020.


What is penicilliosis?

Penicilliosis is a systemic fungal infection caused by the fungus Penicillium marneffei.

Penicilliosis

Who gets penicilliosis?

Penicilliosis is mainly seen among individuals with a compromised immune system due to human immunodeficiency virus (HIV) infection. It can sometimes be seen in individuals with other causes of immunosuppression, such as kidney transplant recipients, and very rarely in individuals with a normal immune system [1].

Penicilliosis is common in tropical countries and is occasionally seen elsewhere in returning travellers [1].

What causes penicilliosis?

Penicillium marneffei is a dimorphic fungus that can exist as either a yeast or a mould, depending on temperature.

What are the clinical features of penicilliosis?

An individual presenting with penicilliosis most commonly presents with fever, weight loss, and skin lesions. Other features may include:

  • Enlargement of the liver, spleen, and lymph nodes
  • Diarrhoea
  • Coughing [1,2].

Skin lesions

Penicilliosis most commonly affects the face and neck, but may also arise on the arms, legs, trunk, and oral mucosa.

It typically presents as papules or nodules with central necrotic umbilication or ulceration. Subcutaneous nodules, abscesses, and verrucous (warty) skin lesions may also occur [2]. Successful treatment is followed by postinflammatory hyperpigmentation and scarring.

What are the complications of penicilliosis?

Penicilliosis is a serious systemic infection which, if left untreated, will lead to death.

How is penicilliosis diagnosed?

Penicilliosis can be diagnosed presumptively by finding intracellular or extracellular yeasts in a Wright-stained touch smear of a necrotic or ulcerated skin lesion.

Histopathological examination of a skin biopsy may reveal 2–4 µm, intracellular or extracellular fungal elements.

Culture of a sample taken from the skin lesion or another affected organ (eg, bone marrow, lymph node, or pleural fluid) may reveal Penicillium marneffei, confirming the diagnosis [3].

What is the differential diagnosis of penicilliosis?

The differential diagnosis depends on the type of penicilliosis lesion.

Intracellular fungi seen on the histopathological examination might be confused with Histoplasma capsulatum infection. A ‘safety pin’ appearance (ie, cross-wall divisions) indicates penicilliosis [1].

What is the treatment for penicilliosis?

Early diagnosis and treatment are essential to cure penicilliosis. Treatment consists of the administration of systemic antifungal treatment.

  • Treatment is typically a dose of intravenous amphotericin B for at least 2 weeks as an inpatient, followed by oral itraconazole as an outpatient for at least 8 weeks [2].
  • Another antifungal, such as voriconazole, can also be used.
  • Concurrent HIV infection must be treated with highly active antiretroviral treatment (HAART).
  • Individuals infected with HIV who have a CD4 (a glycoprotein found on immune cells) count of < 100 cells/µL should receive prophylaxis with an oral antifungal (eg, itraconazole) to prevent a recurrence of penicilliosis.
  • If the CD4 count is > 100cells/µL, prophylaxis is optional [2].

What is the outcome for penicilliosis?

Detected early and with early treatment, the prognosis of penicilliosis is good with full recovery.

The recurrence rate is 4–50%.

The mortality rate ranges between 2.7% and 11.4%. Late diagnosis and treatment lead to higher mortality [2].

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References

  1. Yap FB, Thevarajah S, Asmah J. Penicillium marneffei infection in an African man. Dermatol Online J 2010; 16: 2. PubMed
  2. Wu TC, Chan JW, Ng CK, Tsang DN, Lee MP, Li PC. Clinical presentations and outcomes of Penicillium marneffei infections: A series from 1994 to 2004. Hong Kong Med J 2008; 14: 103–9. PubMed
  3. Vanittanakom N, Cooper CR Jr, Fisher MC, Sarisanthana T. Penicillium marneffei infection and recent advances in the epidemiology and molecular biology aspect. Clin Microbiol Rev 2006; 19: 95–110. DOI: 10.1128/CMR.19.1.95-110.2006. PubMed

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