Correspondence Address:
Xu-Hua Tang
Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
China

Full Text



Sir,

Reflectance confocal microscopy (RCM) is a promising, noninvasive, high-resolution imaging technique in the auxiliary diagnosis of many skin diseases.^[1] However, to the best of our knowledge, no report demonstrated RCM features in skin lesions of disseminated Penicillium marneffei (DPSM). Herein, we described the RCM features of skin lesions in a DPSM patient with acquired immune deficiency syndrome (AIDS).

A 32-year-old man with AIDS presented with generalized asymptomatic molluscum-like skin lesions for 40 days, fever and cough without expectoration for >10 days. The dermatological examination showed multiple discrete papules and nodules with umbilication, varying in size (5–10 mm), were situated over the face [Figure 1], neck, chest, and upper back. Skin biopsy of a neck lesion revealed granulomas in the upper dermis composed of foamy macrophages and histiocytes filled with multiple Gomori methenamine sliver- and periodic acid Schiff-stained positive yeast cells [Figure 2]. Mycological culture of skin biopsy tissue revealed Penicillium marneffei. The diagnosis of AIDS-associated disseminated penicilliosis marneffei was made. He was referred to the infectious disease hospital for further management and the patient was lost to follow up.{Figure 1}{Figure 2}

Before the skin biopsy, the lesions were examined by RCM (Vivascope 1500; Lucid Technologies, Henrietta, NY). Multiple brightly refractile fine granular structures corresponding to yeast cells were present in the upper dermis. Most of them were arranged in mulberry-like pattern [Figure 3]. We examined dozens of papules of the patient and found this was a consistent pattern seen under RCM.{Figure 3}

Penicilliosis is a fungal infection caused by Penicillium marneffei and is endemic in South-East Asia, particularly Thailand, South China, and Vietnam.^[2],[3] It usually occurs in immunocompromised patients. Patients can present with isolated respiratory symptoms, such as cough, chest pain, and fever, or with signs of dissemination, such as anemia, hepatosplenomegaly, and multiple skin papules.^[2],[3] Skin biopsy stained with hematoxylin–eosin, Gomori methenamine sliver, or periodic acid Schiff shows the presence of intracellular and extracellular fission arthroconidia or unicellular round oval spores. A rapid bedside presumptive diagnosis can be made by finding intracellular and extracellular yeasts on a microscopic examination of Wright-stained touch smears of the skin lesions.^[2],[3],[4]

The RCM features of many premalignant and malignant skin lesions have been reported.^[5] Recently, RCM has also been used in the diagnosis and management of infectious skin diseases.^[1] In this case, multiple brightly refractile fine granular structures were seen discretely or in groups (looks like a mulberry) in the upper dermis under RCM. The discrete brightly refractile fine granular structures correspond to extracellular spores, while the grouped ones correspond to the intracellular spores. We termed such RCM signs as “mulberry-like pattern.” Recognition of this pattern may be helpful in the clinical diagnosis of peniciliosis marneffei and other infections with extracellular and intracellular yeast like microorganisms, such as cryptococcosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis dermatitidis, histoplasmosis, and emmonsiosis as well. More case studies are needed to investigate whether the mulberry-like pattern under RCM is distinct or not as an auxillary diagnostic sign in these mycoses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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