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Talaromyces (formerly Penicillium) marneffei, which is endemic in southeast Asia, is a dimorphic fungus that causes systemic infection predominately in immunocompromised hosts, most commonly in patients with advanced HIV, but increasingly reported in individuals with other immunocompromising conditions; one-third of cases may occur in otherwise normal persons. Clinical manifestations include fever, generalized umbilicated papular rash, lymphadenopathy, cough, and diarrhea. CNS infection has been reported. Diagnosis is made by identification of the organism on smears or histopathologic specimens or by culture, where the fungus produces a characteristic red pigment. The best sites for isolation of the fungus include the skin, blood, bone marrow, respiratory tract, and lymph nodes. Antigen and antibody tests have been developed in endemic regions. Amphotericin B, 0.7–1.0 mg/kg/day intravenously or liposomal amphotericin B, 3 mg/kg/day, if available, are superior to itraconazole for initial therapy and are associated with significantly faster clinical resolution and fungal clearance as well as lower rates of relapse and IRIS (Table 36–1). Parenteral therapy should be continued until patients have had a satisfactory clinical response, at which time they can be switched to itraconazole, 400 mg divided into two doses daily by mouth for 8 weeks. Because the relapse rate after successful treatment is up to 50%, maintenance therapy with itraconazole, 200–400 mg daily orally, is indicated indefinitely, or until immune reconstitution occurs. Criteria for immune reconstitution include greater than 100 CD4 cells/mcL for 6 months or more after the initiation of ART.

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