AIDS‐Associated Penicillium marneffei Infection of the Central Nervous System. Part 2

Outcomes. Three patients survived and had experienced improvement of symptoms at hospital discharge, 1 was transferred to another hospital for tuberculosis treatment after his condition deteriorated, 12 died within 24–72 h after hospital admission, and 5 were taken from the hospital to die at home, which is common practice in Vietnam. Patients taken home to die were moribund and received no further effective medical care, and all were expected to have died, giving an overall mortality of 81%. Among the 18 patients with a poor outcome, the diagnosis was not established prior to death, and no antifungal drugs were given in 12 patients. Two patients received 2 doses of itraconazole (400 mg/day) on the basis of characteristic skin lesions, 1 received 1 dose of amphotericin B on the basis of preliminary blood culture results indicating growth of yeasts, and the remaining 3 patients received 7–17 days of itraconazole or amphotericin B treatment but had concurrent comorbid conditions. The 3 patients who survived and had improvement of symptoms at hospital discharge started receiving amphotericin B within 24 h after developing CNS symptoms, on the basis of detection of unidentified yeasts from blood culture (patients 10 and 14) or positive India ink stain of CSF (patient 11), and all received a total of 14 days of amphotericin B therapy before switching to itraconazole or fluconazole.

Discussion. This report describes a new clinical syndrome associated with P. marneffei infection in HIV‐infected patients. The syndrome is characterized by an acute onset of altered mental status with confusion, agitation, or depressed consciousness in the setting of a subacute febrile illness with nonspecific constitutional symptoms. Symptoms of increased cranial pressure and signs of meningeal inflammation were notably uncommon or absent. Characteristic umbilicated skin lesions were present in only one‐half of the patients. CSF analysis varied from acellular to mild pleocytosis, with normal to mildly elevated protein levels and normal to mildly low glucose levels. CSF microscopy for P. marneffei was negative. CSF culture for P. marneffei took a mean of 4 days for identification. P. marneffei was not always isolated from blood cultures of these patients. The disease course was rapidly progressive, and inpatient mortality was very high. Early initiation of amphotericin B was administered in 5 patients, 3 of whom survived, whereas all 15 patients who did not receive amphotericin B or itraconazole died.