Paradoxical worsening of Emergomyces africanus infection in an HIV-infected male on itraconazole and antiretroviral therapy

Abstract

A 42-year-old male from an urban informal settlement in Cape Town, South Africa, was seen at a tertiary-care hospital for progressively enlarging lesions on his nose. He had initially presented to medical care 6 months earlier with a 3-month history of anorexia, weight loss, nonproductive cough, and nasal congestion. An HIV test was reactive, and his CD4 count was 32 cells/L. He also had renal insufficiency with a creatinine clearance of 40 mL/min. Two weeks after diagnosis, he was initiated on antiretroviral therapy (ART) consisting of lamivudine (150 mg by mouth twice daily), stavudine (30 mg by mouth twice daily), and efavirenz (600 mg by mouth once daily). One week later, he developed widespread erythematous nodules and plaques on his face and a crusted mass on his nose (Fig 1A ). A chest X-ray demonstrated a reticular opacity within the right middle lobe. A skin biopsy of a facial plaque demonstrated a minimal inflammatory response (Fig Methenamine silver staining revealed small (3-5m) yeast-like cells with occasional narrow-based budding (Fig Fungal culture of skin tissue and blood grew Emergomyces africanus (formerly Emmonsia sp.); identification was confirmed by sequencing of the internal transcribed spacer region (ITS). He was treated with intravenous amphotericin B deoxycholate (1 mg/kg) for 14 days. Thereafter, his ART was changed to lamivudine (150 mg by mouth twice daily), zidovudine (300 mg by mouth twice daily), and combination lopinovir/ritonavir (400/100 mg by mouth twice daily), and he was commenced on itraconazole (200 mg capsule orally once daily, to be taken with food) to continue for 1 year pending immune reconstitution.