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Diagnosis of Penicillium marneffei infection from a blood film

A 22-year-old woman was admitted to our emergency department with a 10-d history of fever and severe shortness of breath for 1 h. She had a past history of a cervical mass, present for 5 months, which had not responded to anti-tuberculosis treatment. Despite aggressive supportive treatment including intubation and mechanical ventilation, the patient quickly deteriorated with multi-organ dysfunction and died on the day of admission. There was no history of human immunodeficiency virus (HIV) infection and HIV serology was negative. A blood count and film and blood cultures revealed the underlying diagnosis: full blood count showed white blood cells 17 31 9 10/l, haemoglobin concentration 128 g/l and platelets 42 9 10/l; a blood film showed yeast-like organisms within the cytoplasm of neutrophils and extracellularly (top left). These organisms had one or two purple-red nuclei and grey-blue cytoplasm, which contained a few purplish-red particles. Large crescentor banana-shaped organisms were noted (top right and bottom left). The organisms were Gramnegative (bottom left) and periodic acid–Schiff positive (bottom right). Blood culture grew Pencillium marneffei. A diagnosis of disseminated penicilliosis was thus confirmed. P. marneffei is a thermally dimorphic species of penicillium which, as in our patient, can cause a lethal systemic infection.