2. Pathogen : Penicillium marneffei dimorphic fungus yeast like with cross septum

3. Mode of transmission : respiratory infection disseminated disseminated : Wright stain or Giemsa stain yeast like with cross septum 3 µ m ( usually in macrophage )

5. Penicillium other than P.marneffei organnumber Lung Prosthetic endocarditic Infected CAPD EndophthalmitisSepticemiaEsophagitis Upper respiratory infection Brain infection 124651111 ( Lyratzopaelos G, etal J infect 2002 ; 45 :184 – 207 )

6. Hypersensitivity pneumonitis Cheese – worker lung Peat moss worker’ lung Salami worker’s lung Malt worker ‘s lung Farmer ‘s lung

7. Vienman 1956: bamboo rat ( Rhizomys sinesis ) Khwase 1986: Li, et al study 16 Rhizomys pruinosus Khwase 1986: Li, et al study 16 Rhizomys pruinosus 93.1 % identified P. Marneffei 87.5 % culture from lung 56.3 % culture from liver 56.3 % culture from spleen 50 % culture from abdominal lymph node lymph node

8. Mode of Transmission - Respiratory - Skin ?? - GI??

9. Pathology 1. Granulomatous reaction : lymph mode 2. Suppurative form : microbuses 3. Anergic and necrotizing lesion : focal necrosis

10. Clinical manifestation of HIV infected patient with P.marneffei, Chiang mai university hospital Sign and symptom Number (%) Sign fever skin lesion skin lesion cough cough diarrhea diarrhea 74 (92.5) 54 (67.5) 39 (48.7) 25 (31.2)

11. Sign and Symptom Number (%) Symptum : fever ≥ 38°C weight loss weight loss anemia anemia jaundice jaundice oral candidiosis oral candidiosis hairy lenkoplakia hairy lenkoplakia Patatal papules Patatal papules generalized lymphadenopathy generalized lymphadenopathy hepatomegaly hepatomegaly splenomegaly splenomegaly genital ular genital ular 79 (95) 61(76.2) 62 (77.5 ) 6 (7.5) 79( 73.7) 6 (7.5) 3(3.7) 46 (57.5 ) 41( 51.2) 13 (16.2 ) 5(6.2)

12. Renew of 155 reported case ( Duong TA.Clin Infect DIS 1996;23:(25-30) Clinical sign and symptom Number ( % ) feveranemia weight loss Skin lesion HemoculturelymphadenopathyCoughHepatomegalyDiarrheaSplenomegalyPericarditis Osteolytic lesions arthritis 152(98) 116 (74.8) 111 (71.6) 108 (69.7) 84 (54.2) 81 (52.3) 77 (49.7) 68 (43.9) 36(23.2) 21 (13.5) 7 (4.5) 6 (3.9)

13. Diagnostic smear  Skin scraping ( skin biopsy touch smear, bone marrow, lymph node biopsy touch smear  Wright’s stain  Oral yeast, 3-5 micron  With septum ( binary fission )

14. 80 Patients from Chiang Mai university hospital specimennumberpositive%positive Blood culture Skin culture Bone marrow culture Sputum culture Lymph node culture CSF Palatal papule scraping Liver biopsy culture Pleural fluid culture Pharyngeal ular scraping 78522641920----5947261493311175.690.410034.110015----

15. 30 Sample from CMU, 1993 antifungalnumber MIC( µ g/ml) Geometric mean range FluconazoleItraconazoleKetoconazoleMiconazole Amphotericin B 5-Flucytosine3028292929297.9370.0090.0270.0010.9760.2480.313-20.0 <0.002- 0.19 <0.002- 0.078 <0.002- 0.156 0.25-4.0 <0.015- 0.46

16. Treatment  Severe case : Amphotericin B 0.6 mg /kg/day for 2 weeks Itraconazole 200 mg bid for 10 weeks.  Mild case : Itraconazole 200 mg bid for 10 week

17. Amphotericin B 1. Amphotericin B Deoxycholate - drip with 5 % dextrose in water 2. Lipid-complexed Amphotericin B - Ampho B colloidal dispersion ( Amphotec ) - Ampho B lipid complex ( Abelect ) - Liposomal Ampho B ( Ambisome )

18. Side effect of Amphotericin B : Acute infusion – related reaction - Fever, chill, tachypnea - not anaphylaxis

19. Side effect of Amphotericin B : Nephrotoxicity - dose dependent - loss K, Mg, bicarbonate - risk : combine with other nephrotoxic drug hypotensiondehydration kidney disease

20. Side effect of Amphotericin B : other side effect nausea, vomiting thrombophlebitis anemia,thrombocytopenia, leucopenia