Step 1: View clinicals

A 45-year-old man presents with multiple lumps over his face and neck for 3 months. The lumps are small, painless, and non-tender. Close questioning reveals intermittent low-grade fever, a non-productive cough, anorexia, and a loss of 10 kg of weight, all over the last half-year. His medical and surgical histories are unremarkable, and he is not on any medications. He does not smoke, but drinks around 7 to 10 units of alcohol per week. He has had unprotected sexual intercourse with multiple women over the past two decades. He has never engaged in intravenous (IV) drug abuse. He unmarried, a Thai citizen, and lives and works in Bangkok. He is currently visiting his brother, who persuaded him to seek medical attention for his complaints. A complete blood count shows a hemoglobin of 10.5 g/dL (normal: 11-18), WBC of 3,500/mm3 (normal: 4,600-11,000), and platelet count of 180,000/mm3 (normal: 150,000-450,000). Plain x-rays of the chest reveal diffuse reticular infiltrates bilaterally. A renal profile, liver profile, random plasma glucose, and HbA1c are all within normal parameters. Screening for HIV is positive; follow-up testing with a western blot assay is also positive.

Step 2: Order all relevant investigations

CD4+ count

CD4+ count: 40/µL (500-1400)

Skin biopsy

Following staining of the biopsy specimen with silver methenamine, microscopy reveals multiple non-budding yeast cells with a transverse septum. Samples are sent for culture; these are positive for Talaromyces marneffei.

STI screening

Negative for chlamydia, gonorrhea, syphilis, hepatitis B, and hepatitis C.

Bronchoalveolar lavage

Gram stain: negative Ziehl-Neelsen stain: negative Silver methenamine stain: non-budding yeast cells with transverse septum Cultures of the bronchoalveolar lavage specimen are positive for Talaromyces marneffei.

Step 3: Select appropriate management

Antifungal therapy
Antituberculous therapy
Antiretroviral therapy
Corticosteroid therapy

Score: ★★☆