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Talaromycosis Flashcards

1
Q

What is Talaromycosis?

A

An invasive fungal infection caused by the dimorphic fungus Talaromyces marneffei

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2
Q

Where is Talaromycosis endemic?

A

Southeast Asia, East Asia, and South Asia

Endemic regions include northern Thailand, Vietnam, Myanmar, southern China, Hong Kong, Taiwan, and northeastern India.

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3
Q

What major risk factor is associated with Talaromycosis?

A

HIV infection

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4
Q

What percentage of Talaromycosis cases occur in individuals with HIV?

A

Approximately 88%

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5
Q

What is the CD4 T lymphocyte count associated with advanced HIV disease and Talaromycosis?

A

<100 cells/mm3

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6
Q

What animal is known to be the reservoir for Talaromyces marneffei?

A

Wild bamboo rat

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7
Q

What environmental conditions increase the incidence of Talaromycosis?

A

Increased humidity during rainy months

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8
Q

What are the common clinical manifestations of Talaromycosis?

A
  • Fever
  • Weight loss
  • Hepatosplenomegaly
  • Lymphadenopathy
  • Respiratory and gastrointestinal abnormalities
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9
Q

What percentage of patients with Talaromycosis experience skin lesions?

A

40% to 70%

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10
Q

What is a rare manifestation of Talaromycosis with high mortality?

A

Meningoencephalitis

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11
Q

What is the common laboratory finding associated with Talaromycosis?

A

Anemia and thrombocytopenia

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12
Q

What is the median CD4 count in patients with Talaromycosis?

A

<50 cells/mm3

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13
Q

How is Talaromycosis primarily diagnosed?

A

Microscopy, histology, and culture

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14
Q

What is the typical appearance of skin lesions in Talaromycosis?

A

Central-necrotic papules

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15
Q

What distinguishes Talaromyces marneffei from Histoplasma or Candida species under microscopy?

A

Identification of a clear midline septum in a dividing yeast cell

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16
Q

What is the culture yield for diagnosing Talaromycosis from bone marrow?

A

100%

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17
Q

What is the sensitivity of the Mp1p ELISA for detecting Talaromycosis?

A

86.3%

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18
Q

What is the minimum inhibitory concentration (MIC) of itraconazole for Talaromyces marneffei?

A

Consistently low

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19
Q

What is a significant factor for preventing exposure to Talaromycosis?

A

Avoiding highland regions during rainy and humid months

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20
Q

Who should receive primary prophylaxis for Talaromycosis?

A

Individuals with a CD4 count <100 cells/mm3 unable to access ART

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21
Q

What is the mortality rate associated with Talaromycosis despite antifungal therapy?

A

Up to 30%

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22
Q

What type of infection is Talaromycosis classified as?

A

Saprozoonotic infection

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23
Q

What is the common coinfection with Talaromycosis in endemic regions?

A

Tuberculosis

24
Q

What are the three histopathological forms of Talaromycosis?

A
  • Granulomatous reaction
  • Suppurative reaction
  • Anergic and necrotizing reaction
25
What is the CD4 count threshold for initiating primary prophylaxis for talaromycosis?
<100 cells/mm3
26
What are the preferred and alternative therapies for primary prophylaxis in individuals residing in endemic areas?
* Preferred Therapy: Itraconazole 200 mg PO once daily (BI) * Alternative Therapy: Fluconazole 400 mg PO once weekly (BII)
27
What is the recommended primary prophylaxis for individuals traveling to endemic areas?
* Preferred Therapy: Begin itraconazole 200 mg PO once daily 3 days before travel and continue for 1 week after leaving the endemic area (BIII) * Alternative Therapy: Begin fluconazole 400 mg 3 days before travel, then continue 400 mg once weekly while in the area and take final dose after leaving the endemic area (BIII)
28
Under what conditions can primary prophylaxis for people residing in endemic areas be discontinued?
* CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII) * Viral load suppression for ≥6 months on ART (BIII)
29
What is the indication for restarting primary prophylaxis?
CD4 count decreases to <100 cells/mm3 and the person still resides in or travels to high-risk areas (BIII)
30
What are the preferred and alternative therapies for treating acute infection in severely ill patients?
* Induction Therapy: Liposomal amphotericin B 3–5 mg/kg/day IV for 2 weeks * Consolidation Therapy: Itraconazole 200 mg PO twice daily for 10 weeks (AI) * Maintenance Therapy: Itraconazole 200 mg PO daily (AII)
31
What alternative induction therapy is recommended if liposomal amphotericin B is not available?
* Deoxycholate amphotericin B 0.7 mg/kg/day IV for 2 weeks, followed by * Itraconazole 200 mg PO twice daily for 10 weeks (AI) * Maintenance Therapy: Itraconazole 200 mg PO daily (AII)
32
What is the recommended therapy if amphotericin B is not available?
* Voriconazole 6 mg/kg IV every 12 hours for 1 day (loading dose) and then voriconazole 4 mg/kg IV every 12 hours for 2 weeks, or * Oral voriconazole 600 mg every 12 hours on day 1 (loading dose) and then voriconazole 400 mg PO every 12 hours for 2 weeks
33
What are the criteria for discontinuing chronic maintenance therapy?
* CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII) * Virologic suppression for ≥6 months on ART (BIII)
34
What is the recommended time to initiate ART in patients with talaromycosis?
As early as 1 week after the initiation of treatment for talaromycosis with amphotericin B induction therapy (BII)
35
What adverse reactions should be monitored in patients treated with amphotericin B?
* Infusion-related adverse reactions (fever, rigors, nausea, vomiting) * Electrolyte disturbances (particularly hypokalemia and hypomagnesemia) * Nephrotoxicity (rise in creatinine) * Anemia
36
What are the target serum trough concentrations for itraconazole and voriconazole?
* Itraconazole: >0.5 µg/mL * Voriconazole: >1 µg/mL
37
True or False: Itraconazole is recommended as induction therapy for talaromycosis.
False
38
What are the symptoms of paradoxical IRIS?
* Erythematous or immunological skin lesions * Large and painful peripheral lymph nodes * Synovitis of small joints
39
What is the relationship between treatment failure and induction therapy?
Treatment failure and disease relapse were associated with ineffective induction therapy with itraconazole
40
What is the recommended approach for patients with paradoxical IRIS?
Judicious use of nonsteroid anti-inflammatory medicine; corticosteroids for synovitis that interferes with daily function
41
Fill in the blank: The case fatality rates with antifungal therapy for talaromycosis range from _____ to _____%.
10% to 30%
42
What should be done before each amphotericin B infusion to reduce nephrotoxicity?
Hydration with 500 mL to 1,000 mL of normal saline and potassium supplementation
43
What percentage of patients not treated with ART had disease relapse within 6 months after discontinuation of antifungal therapy?
>50%
44
What is associated with higher mortality in patients?
Non-adherence to ART or virologic failure ## Footnote Therapy adherence counseling and TDM for itraconazole and voriconazole are recommended.
45
What percentage of patients not treated with ART had disease relapse within 6 months after antifungal therapy discontinuation?
>50% ## Footnote This highlights the importance of ongoing treatment and monitoring.
46
What was the relapse rate of talaromycosis reduced to with secondary prophylaxis using oral itraconazole 200 mg daily?
0% ## Footnote This was demonstrated in a study with a p-value of <0.001.
47
When should all patients who complete induction and consolidation treatment for talaromycosis receive secondary prophylaxis?
Until they reach criteria for stopping secondary prophylaxis ## Footnote This is recommended as a maintenance therapy.
48
What study has not demonstrated the safety of discontinuation of secondary prophylaxis for talaromycosis?
No randomized, controlled study ## Footnote However, retrospective studies suggest safety under certain conditions.
49
What CD4 count allows for the discontinuation of secondary prophylaxis in ART adherent patients?
>100 cells/mm3 ## Footnote This must be maintained for at least 6 months.
50
When can secondary prophylaxis be reintroduced?
If the CD4 count decreases to <100 cells/mm3 ## Footnote This is crucial for patient management.
51
How is the diagnosis and treatment of talaromycosis during pregnancy similar to?
Nonpregnant adults ## Footnote Considerations regarding antifungal use differ.
52
Has amphotericin B been shown to be teratogenic in humans?
No ## Footnote No increase in fetal anomalies has been seen with its use.
53
What is the recommendation for neonates born to people on chronic amphotericin B?
Evaluate for renal dysfunction and hypokalemia ## Footnote This is important for neonatal health.
54
What is the teratogenic status of itraconazole at high doses in animals?
Teratogenic ## Footnote However, this does not apply to humans due to metabolic differences.
55
What is the FDA category for voriconazole?
Category D ## Footnote This indicates teratogenicity concerns based on animal studies.
56
What is recommended for people on secondary prophylaxis with itraconazole regarding pregnancy?
Postpone pregnancy until CD4 counts are restored ## Footnote This allows for potential discontinuation of prophylaxis.
57
What should be considered if a person becomes pregnant while receiving itraconazole prophylaxis?
Individualized decision based on CD4 count and viral suppression ## Footnote Patient preference is also a factor.

EBAC - Infectious Disease (36 decks)

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