KCP 814 서울아산병원 임상강사 추현희

Clinical findings 중국, 홍콩 41/M Fever, sore throat, diarrhea (O: 1mon) Past history On admission WBC: 9600/μL (Neutrophil 8764/μL, lymphocyte 470/μL) Hb: 7.0g/dL Platelet: 86K/μL CD4 + T cell: 25 cells/μL 2000년 ~ 2013년 9월 중국, 홍콩 유학생활 및 사업 귀국 Fever 10월 11월 Transfer HIV Syphilis

Rt. bronchi - RUL bronchus에서 multiple polypoid lesion 관찰되어 RUL bronchus에서 bronchial washing 및 biopsy(#6) 시행함.

Bronchial washing cytology 슬라이드입니다.

Lung, ( right upper lobe bronchus ), bronchoscopic biopsy

Lymph node, ( right supraclavicular ), needle biopsy

Lymph node, ( right supraclavicular ), needle biopsy: - Intracellular small yeast form fungi, suggestive of Histoplasmosis.

Penicillium marneffei Culture Mold form  Dimorphic fungus ? AIDS Histoplasma capsulatum Pneumocystis jirovecii Penicillium marneffei China & Hong kong - Endemic area ?

Penicillium marneffei Final diagnosis Bronchial washing, Liquid-based cytology : Penicillium marneffei

Penicillium marneffei infection in AIDS Epidemiology: endemic among HIV-positive patients in many areas in Southeast Asia, including Thailand (M/C), Vietnam, Hong Kong, Southern China, Taiwan, India, and Laos. Penicilliosis is the 3rd commonest AIDS indication disease among HIV positive patients in endemic area. Mycology: the only dimorphic fungus in the genus of Penicillium; Mycelial form at 25◦C but yeast form at 37◦C. Granular colony of P. marneffei with a characteristic red diffusible pigment on Sabouraud’s dextrose agar after 7 days incubation at 25◦C. Yeast-like colony of P. marneffei without red diffusible pigment on Sabouranud’s dextrose agar after 7 days of incubation at 35◦C 25◦C 37◦C Pathol Res Int. 2011 Feb 10;2011

Previously reported case in Korea Sex Age Clinical backgound Tavel history in endemic area Symptoms and sings Initial diagnosis Fever Diarrhea Anemia Skin lesion Other 대한신장학회지 2002; 21:680-5 M 43 Paraplegia, ESRD, CAPD No Yes Abdominal pain Peritonitis Korean J Lab Med 2010; 30:400-5 52 Hepatitis B Liver cirrhosis LT from China Immunosuppressive therapy Yes (China) Chest Discomport, Dyspnea Pneumonia J Korean Med Sci 2012;27:697-700 39 AIDS Yes (Laos) Cough Pneumocystis jirovecii pneumonia Present case 42 Yes (China -Guangzhou, Hong Kong) Hepato- splenomegaly, Lymphadenopathy Histoplasmosis

Differential diagnosis Clustered small round pathogens phagocytized by macrophages Protozoal infections Leishmaniasis Toxoplasmosis Fungal infections Histoplasmosis Pneumocystosis Penicilliosis Bacterial infections

Yeast – like fungi in AIDS patients Central transvers septum Budding instead of septated yeast cells Round cysts containing single or paired comma shaped argyrophilic foci in walls Yeast cell with simiar stained positive for GMS

KCP 814