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EBAC - Infectious Disease > Talaromycosis > Flashcards

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
Q

What is the CD4 count threshold for initiating primary prophylaxis for talaromycosis?

A

<100 cells/mm3

26
Q

What are the preferred and alternative therapies for primary prophylaxis in individuals residing in endemic areas?

A
  • Preferred Therapy: Itraconazole 200 mg PO once daily (BI)
  • Alternative Therapy: Fluconazole 400 mg PO once weekly (BII)
27
Q

What is the recommended primary prophylaxis for individuals traveling to endemic areas?

A
  • 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
Q

Under what conditions can primary prophylaxis for people residing in endemic areas be discontinued?

A
  • CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII)
  • Viral load suppression for ≥6 months on ART (BIII)
29
Q

What is the indication for restarting primary prophylaxis?

A

CD4 count decreases to <100 cells/mm3 and the person still resides in or travels to high-risk areas (BIII)

30
Q

What are the preferred and alternative therapies for treating acute infection in severely ill patients?

A
  • 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
Q

What alternative induction therapy is recommended if liposomal amphotericin B is not available?

A
  • 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
Q

What is the recommended therapy if amphotericin B is not available?

A
  • 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
Q

What are the criteria for discontinuing chronic maintenance therapy?

A
  • CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII)
  • Virologic suppression for ≥6 months on ART (BIII)
34
Q

What is the recommended time to initiate ART in patients with talaromycosis?

A

As early as 1 week after the initiation of treatment for talaromycosis with amphotericin B induction therapy (BII)

35
Q

What adverse reactions should be monitored in patients treated with amphotericin B?

A
  • Infusion-related adverse reactions (fever, rigors, nausea, vomiting)
  • Electrolyte disturbances (particularly hypokalemia and hypomagnesemia)
  • Nephrotoxicity (rise in creatinine)
  • Anemia
36
Q

What are the target serum trough concentrations for itraconazole and voriconazole?

A
  • Itraconazole: >0.5 µg/mL
  • Voriconazole: >1 µg/mL
37
Q

True or False: Itraconazole is recommended as induction therapy for talaromycosis.

38
Q

What are the symptoms of paradoxical IRIS?

A
  • Erythematous or immunological skin lesions
  • Large and painful peripheral lymph nodes
  • Synovitis of small joints
39
Q

What is the relationship between treatment failure and induction therapy?

A

Treatment failure and disease relapse were associated with ineffective induction therapy with itraconazole

40
Q

What is the recommended approach for patients with paradoxical IRIS?

A

Judicious use of nonsteroid anti-inflammatory medicine; corticosteroids for synovitis that interferes with daily function

41
Q

Fill in the blank: The case fatality rates with antifungal therapy for talaromycosis range from _____ to _____%.

A

10% to 30%

42
Q

What should be done before each amphotericin B infusion to reduce nephrotoxicity?

A

Hydration with 500 mL to 1,000 mL of normal saline and potassium supplementation

43
Q

What percentage of patients not treated with ART had disease relapse within 6 months after discontinuation of antifungal therapy?

44
Q

What is associated with higher mortality in patients?

A

Non-adherence to ART or virologic failure

Therapy adherence counseling and TDM for itraconazole and voriconazole are recommended.

45
Q

What percentage of patients not treated with ART had disease relapse within 6 months after antifungal therapy discontinuation?

A

> 50%

This highlights the importance of ongoing treatment and monitoring.

46
Q

What was the relapse rate of talaromycosis reduced to with secondary prophylaxis using oral itraconazole 200 mg daily?

A

0%

This was demonstrated in a study with a p-value of <0.001.

47
Q

When should all patients who complete induction and consolidation treatment for talaromycosis receive secondary prophylaxis?

A

Until they reach criteria for stopping secondary prophylaxis

This is recommended as a maintenance therapy.

48
Q

What study has not demonstrated the safety of discontinuation of secondary prophylaxis for talaromycosis?

A

No randomized, controlled study

However, retrospective studies suggest safety under certain conditions.

49
Q

What CD4 count allows for the discontinuation of secondary prophylaxis in ART adherent patients?

A

> 100 cells/mm3

This must be maintained for at least 6 months.

50
Q

When can secondary prophylaxis be reintroduced?

A

If the CD4 count decreases to <100 cells/mm3

This is crucial for patient management.

51
Q

How is the diagnosis and treatment of talaromycosis during pregnancy similar to?

A

Nonpregnant adults

Considerations regarding antifungal use differ.

52
Q

Has amphotericin B been shown to be teratogenic in humans?

A

No

No increase in fetal anomalies has been seen with its use.

53
Q

What is the recommendation for neonates born to people on chronic amphotericin B?

A

Evaluate for renal dysfunction and hypokalemia

This is important for neonatal health.

54
Q

What is the teratogenic status of itraconazole at high doses in animals?

A

Teratogenic

However, this does not apply to humans due to metabolic differences.

55
Q

What is the FDA category for voriconazole?

A

Category D

This indicates teratogenicity concerns based on animal studies.

56
Q

What is recommended for people on secondary prophylaxis with itraconazole regarding pregnancy?

A

Postpone pregnancy until CD4 counts are restored

This allows for potential discontinuation of prophylaxis.

57
Q

What should be considered if a person becomes pregnant while receiving itraconazole prophylaxis?

A

Individualized decision based on CD4 count and viral suppression

Patient preference is also a factor.

EBAC - Infectious Disease (36 decks)

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