Acute Abdomen Due to Penicillium marneffei : An Indicator of HIV Infection in Manipur State

Abstract

A-28-year-old male military personnel presented with a four day history of right sided non-colicky abdominal pain radiating to the back, and associated with fever and rigor for two weeks, at Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India. The fever used to subside only on medication. He had no other gastrointestinal or urinary symptoms. He was not an intravenous drug abuser but consumed alcohol in moderate amounts regularly. There was history of significant weight loss in the recent past.On general examination, he was pyrexic with associated tachycardia. Other than pallor and non tender non matted multiple lymphadenopathy no other significant finding was present.Abdomen was diffusely tender with mild guarding and could be palpated properly only after administering analgesics (Inj. Diclofenac 75 mg i.m.). Multiple lumps were palpated in all the quadrants. The lumps were firm in consistency, tender and mobile. Liver was just palpable.Chest radiograph looked normal. His blood test showed neutrophilia (20×10 9 /l), a raised ESR of 120 and a raised C-reactive protein of 200 mg/l. The rest of the blood tests including serum amylase were in the normal range.An abdominal radiograph was non-contributory and computed tomography of the abdomen multiple enlarged mesentric lymph nodes [Table/ Fig-1]. Patient was treated conservatively and started on broad spectrum intravenous antibiotics (ceftriaxone and ofloxacin) but his condition did not improve. Cultures of blood and lymph node aspirate showed growth on 3 rd day itself which were consistent with culture characteristics of Penicillium marneffei [Table/ Fig-3].Peri oral umbilicated lesions [Table/ Fig-4] appeared in the 4 th day during the course of antifungal treatment which further described the Penicillium dissemination. Treatment was started with Amphotericin B at the dose of 0.6 mg/kg/day intravenously for two weeks followed by Anti Retroviral Therapy and itraconazole as per recommendation. The patient showed marked improvement on follow up after six months and was symptom free with CD4 cell count of 350/mm 3 . DiSCuSSiOnPenicilliosis marneffei (PM) is a disseminated and progressive fungal infection caused by Penicillium marneffei, a facultative intracellular pathogen and the only dimorphic species of the genus Penicillium ABSTRACTOpportunistic infection in HIV disease often present to clinicians in an atypical manner testing clinical acumen. Here, we report a case of Penicilliosis marneffei (PM) infection presenting to surgical emergency as acute abdomen with undiagnosed HIV status in advanced AIDS, chief complaints being prolonged fever and diffuse abdominal pain. Radiologic imaging showed non-specific mesenteric and retroperitoneal lymphadenopathy. Fine needle aspiration cytology (FNAC) of the lymph node was done and subjected to direct microscopy, gram staining and culture on Sabouraud's dextrose agar (SDA) which showed Penicillium marneffei. He was then treated with intravenous amphotericin. This case is reported for its rarity and unusual...