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A febrile 8-year-old boy with skin lesions

Prepared by...
Virat Sirisanthana, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
A 8-old-boy was admitted at CMU hospital in June 2001.
Address: Chiang Mai

CC: fever for 7 days
PI: 7 days PTA he had gradual onset of high fever with purulent discharge from his Rt ear. Small papular lesions were also noted on his face and extremities.
3 days PTA he developed swollen hands, elbows, ankles and feet.
Past History: Two months ago he was brought for a check up at Sexually Transmitted Disease Center for his chronic skin lesions at his extremities. His blood test was positive for HIV disease. According to his grandfather he has been well, except for his "off and on" skin lesions at the extremities.

Significant PE: pale, but fully conscious and co-operated.
BW 18 kg (5-10%tile for age), T. 39.5 C., HR 120-140/min, RR 28-40/min, BP 100/60 mmHg,
HEENT: small papular lesions on the face (fig 1, 2), some with central necrosis. Pus in the rt. ear canel. Thrush in his mouth.
Cheast: wnl
Abdomen: liver 2cm. below RCM,spleen not palpable.
Extremities: Old scars of impetigo.... as hypo- and hyper-pigmented areas. Swollen hands (see fig.3), feet and elbows with warmness and tenderness

Figure 1
Figure 2
Figure 3

Initial laboratory investigations: on admission
CBC: Hb 7 gm%, Hct23%, WBC 3,640/cbmm (N 76%, L 20%, Mono 1%), platelet count 145,000/cbmm.
PBS: RBC normochromic normocytic
UA: WNL
CXR: WNL
Nicking of the lesion at his face: Wright stain : see figure 5
X-ray of hands, feet and elbows on admission show osteolytic lesions at most of phalanges (hands and toes) as shown in figure 6, 7 and 8

Figure 5
Figure 6
Figure 7
Figure 8
Summery of problems.
1. Known case of HIV-infected boy
2. High intermittent fever for 7 days
3. Skin lesions at the face as shown in fig 1, 2. Smear and Wright stain as shown in figure 5
4. Swollen hands (see fig.3), feet and elbows with warmness and tenderness
5. Hepatomegaly ( liver 2 cm. below RCM)
6. Chronic otitis media, thrush, pruritic purpurra eruption at the extremities

Further Investigations:
ESR (60min) 110 mm.
BM aspiration and smear: show the same organism as in the skin lesion smear.
Hemoculture: Penicillium marneffei
BM culture: Penicillium marneffei

Course in the hospital:
Specific treatment: amphotericin B iv for 5 weeks, then continued with itraconazole 15 MKD.
Supportive and symptomatic treatment including:
Packed red blood cell transfusion.
Ear toilet and ear drops.

The fever pesisted for 5 weeks, then gradually subsided. He was given IV amphotericin B for 6 weeks, then followed by itraconazole orally. His swollen hands, elbows and feet also gradually dissapeared. He was discharged home with itraconazole 15 MKD and will be followed up in the out-patient-department.

Diagnosis : Disseminated Penicilliosis in HIV-infected boy

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