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Talaromycosis

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Updated 2024 NIH/HIVMA/CDC/IDSA guidelines for the prevention and management of talaromycosis.

Background

Overview

Definition
Talaromycosis, formerly known as penicilliosis, is an invasive mycosis caused by the pathogenic fungus Talaromyces marneffei, endemic in tropical and subtropical Asia.
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Pathophysiology
The pathophysiology of talaromycosis involves the inhalation of Talaromyces marneffei, a tropical thermally dimorphic fungus. This is followed by an incubation period, after which the fungus spreads to other internal organs via the hematogenous route. Rainy seasons and humid conditions increase the risk of exposure.
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Epidemiology
Endemic areas for talaromycosis include tropical and subtropical regions in Asia, particularly Thailand, Vietnam, Myanmar, Laos, southern China, Hong Kong, Taiwan, and northeastern India. The prevalence of talaromycosis is estimated at 3.6% in patients with HIV infection.
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Risk factors
Risk factors for talaromycosis primarily include advanced HIV disease and other immunosuppressive conditions. The disease disproportionally affects people in low-income and middle-income countries, particularly agricultural workers in rural areas. The disease is highly associated with the tropical monsoon season when flooding and cyclones occur.
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Disease course
Disseminated infection is the most common form and presents with symptoms such as fever, weight loss, respiratory symptoms, joint pain, and characteristic skin lesions with central necrosis. Hepatosplenomegaly and lymphadenopathy are often present.
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Prognosis and risk of recurrence
Talaromycosis is associated with a mortality rate of 10-33%, varying by geographic region.
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Guidelines

Key sources

The following summarized guidelines for the management of talaromycosis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2024). ...
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Medical management

Antifungal therapy: as per CDC/HIVMA/IDSA/NIH 2024 guidelines, administer the following regimen as the preferred therapy in patients with talaromycosis:
Situation
Guidance
Induction
Liposomal amphotericin B 3-5 mg/kg/day IV for 2 weeks
Onsolidation
Itraconazole 200 mg PO BID for 10 weeks
A
Maintenance
Itraconazole 200 mg PO daily
B
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More topics in this section

  • Antiretroviral therapy

Specific circumstances

Pregnant patients
As per CDC/HIVMA/IDSA/NIH 2024 guidelines:
Postpone pregnancy in patients on secondary prophylaxis with itraconazole or other azoles until the CD25 counts have been restored with antiretroviral therapy and prophylaxis can be discontinued.
B
Substitute amphotericin B for high-dose azoles in the first trimester in pregnant patients.
B

Preventative measures

Primary prophylaxis: as per CDC/HIVMA/IDSA/NIH 2024 guidelines, advise patients with advanced HIV to avoid visiting the areas where talaromycosis is highly endemic, particularly highland regions during the rainy and humid months.
B
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Follow-up and surveillance

Therapeutic drug monitoring: as per CDC/HIVMA/IDSA/NIH 2024 guidelines, assess serum itraconazole and voriconazole levels to ensure adequate drug exposure (trough concentrations > 0.5 µg/mL for itraconazole and > 1 µg/mL for voriconazole), if therapeutic drug monitoring is available.
B