Case Presentation: Talaromycosis (formerly known as Penicilliosis) is a rare fungal disease that predominantly affects immunocompromised patients, such as those with HIV and low CD4 cell counts, from endemic regions (e.g., Southeast Asia). There have been a limited number of cases reported worldwide, with a travel-related exposure. We present a case of an immunocompetent patient residing in the southern part of the United States.The patient is a 63-year-old female with a medical history of type two diabetes mellitus and hypertension, who is originally from Thailand, but has lived in the United States since the 1970s. She initially presented at our hospital in June 2018 with dyspnea, persistent high-grade fevers, malaise, and weight loss over the preceding 4-5 months. Physical examination showed mild pallor, skin lesions and cervical lymphadenopathy. Computed tomography (CT) of the chest with contrast showed mediastinal lymphadenopathy and traces of bilateral pleural effusion. She underwent extensive workup to rule out neoplasm. Cervical lymph node biopsy had features consistent with benign reactive lymphoid hyperplasia with sinus histiocytosis or a cortical T-cell hyperplasia, but was negative for malignancy. Aspergillosis, coccidioidomycosis, histoplasmosis and HIV testing were all negative. Immunoglobulin panel and IgG subtype were within normal levels. She was treated empirically with a combination of intravenous (IV) piperacillin-tazobactam and vancomycin, and later de-escalated to oral levofloxacin, with the addition of fluconazole. She improved over the course of her hospitalization, antibiotics were discontinued, and she was discharged. Over the next several months, she was hospitalized almost monthly with a similar presentation of dyspnea, persistent high-grade fever, malaise and generalized weakness. During one such spell in early January 2019, review of bronchoscopy sample taken in June 2018 was found to be positive for Talaromyces (Penicillium) marneffei. Treatment was initiated with itraconazole; the patient responded immediately to the medication and she was sent home on itraconazole. By the end of January, she presented to the hospital this time with severe neck stiffness, right sub-mandibular swelling and fever as high as 102°F. At that point, itraconazole was discontinued and she was started on treatment with liposomal amphotericin B. She responded well to treatment and was discharged home on IV liposomal amphotericin B to complete two weeks of therapy, after which she was treated with itraconazole for a of 6-month period. She continues to follow up in clinic and has not had recurrence of the symptoms.
Discussion: This case is the first to be reported in the southern part of the United States and illustrates a very rare fungal infection occurring in an immune-competent individual living in a non-endemic area. It is unclear whether the patient contracted the disease during recent travel-related exposure or had a latent infection with an almost 40-year period between probable exposure and onset of clinical infection.
Conclusions: An understanding of the importance of early recognition of this infection is critical to clinicians, in order to appropriately diagnose, treat, and prevent serious complications related to Talaromycosis.