A Case Report: Disseminated Talaromycosis Presenting With Umbilicated Papules in HIV Patient in Community Hospital setting

Abstract

          Disseminated Talaromycosis is a fungal infection caused by Talaromyces marneffei, commonly found in immunocompromised patients, particularly HIV-infected individuals in Southeast Asia. Delayed diagnosis may lead to increased complications and mortality, especially in community hospital settings with limited diagnostic resources. Rapid diagnosis of Disseminated Talaromycosis can be achieved through recognition of umbilicated papular skin lesions, a pathognomonic finding, combined with skin scraping and Wright stain smear as an accessible preliminary diagnostic tool in community hospital settings. Furthermore, HIV-infected patients with severe immunosuppression may present with multiple concurrent opportunistic infections, making simultaneous collection of both bacterial and fungal blood cultures critically important. This case report therefore presents an HIV-infected patient with umbilicated papular skin lesions as the presenting complaint, who was diagnosed with Disseminated Talaromycosis using skin scraping and Wright stain as a preliminary diagnostic tool in a community hospital setting.

          A 30-year-old Thai female HIV-infected patient with AIDS and a history of antiretroviral therapy non-adherence to TLD (Tenofovir/Lamivudine/Dolutegravir) for more than 3 years presented to Phra Ajarn Fun Arjaro Hospital with low-grade fever, weight loss, and umbilicated papular skin lesions on the face, extremities, and trunk. Her CD4 count on admission was 88 cells/mm³ (12.2%). Skin scraping with microscopic examination with Wright stain smear revealed yeast-form organisms with binary fission morphology, and blood fungal culture confirmed Talaromyces marneffei. Furthermore, hemocultures from 2 independent specimens yielded Salmonella typhi, confirming co-infection. Salmonella typhi bacteremia was treated with intravenous Ceftriaxone 2 gm daily for 2 weeks. Talaromycosis was treated with intravenous Amphotericin B 0.8 mg/kg/day for 2 weeks, followed by Itraconazole oral 200 mg every 8 hours for 3 days, then 200 mg every 12 hours for 10 weeks, then 200 mg daily until CD4 exceeded 100 cells/mm³. Cotrimoxazole (Trimethoprim 80 mg/Sulfamethoxazole 400 mg) 2 tabs daily was continued for opportunistic infection prophylaxis until CD4 exceeded 200 cells/mm³. Antiretroviral therapy was restarted 2 weeks after Amphotericin B initiation. At the 3-month post-discharge follow-up, the skin lesions showed significant improvement.

          Conclusion: Umbilicated papules in a severely immunocompromised patient with HIV should raise suspicion for disseminated talaromycosis. Skin scraping with Wright staining may provide rapid supportive evidence in a community hospital while confirmatory fungal culture is pending. This case also highlights the need to consider concurrent infections and to obtain appropriate bacterial and fungal cultures when clinically indicated.