A 74-year-old Iranian woman presented with a 10-day history of malaise, weakness, fever, chills and sweating with no weight loss. She had received oral antibiotics four days after initial symptoms but did not improve.
She had travelled to Thailand about one month earlier and stayed there for three weeks. She reported swimming in the sea there. After returning, she had an 8-day travel to south of Iran, Ahwaz. Few days after coming back to Tehran, her symptoms began. She was a housewife and non-smoker and was diabetic from one year ago, hypertensive for many years and had hypothyroidism in the past eight years. She reported two Cesarean section surgeries and cholecystectomy many years ago. Her medications included glibenclamide, atenolol and levothyroxine. She had no history of blood transfusion, asthma or allergy.
The patient had been admitted to another hospital first where chest X ray was performed and bilateral pleural effusion was observed; pleural tapping was performed and the result showed exudative neutrophilic pleural effusion. She had WBC count of about 2,500/mL (PMN=60%, lymph= 40%), LDH was 240 IU/l, protein and glucose were 4.2g/dL and 74 mg/dL, respectively. Simultaneous serum LDH and protein were 300 IU/L and 5g/dL, respectively. She had received intravenous antibiotics for five days due to the impression of pneumonia but did not improve. Then, she was admitted to our hospital; she was febrile and reported non-productive cough and dyspnea, malaise and sweating. Complete blood count showed only anemia (Hb =9) without any leukocytosis or leukopenia. The erythrocyte sedimentation rate was 120mm/h and C-reactive protein was 68mg/L. Biochemistry tests, electrolyte levels and thyroid function tests were normal. Tuberculin skin test was negative and angiotensin-converting enzyme level was 63mu/L (normal range is up to 65mu/L)
High-resolution chest computed tomography (CT) scan was requested, which showed bilateral pleural effusion again (Figure 1). There was no evidence of pulmonary emboli in chest CT angiography scan and echocardiography. Her echocardiography showed mild pericardial effusion with possible pericardial thickness. At this time, pleural tapping indicated lymphocytic exudative pleural effusion; the WBC count was 750/mL (PMN=40%, lymph=60%). Adenosine deaminase (ADA) was normal and smear was negative for Acid-fast bacilli and other bacteria. Mycobacterium tuberculosis polymerase chain reaction was negative. Meropenem and ciprofloxacin were initiated but the patient did not improve and worsened.
Paecilomyces variotii was isolated from fungal culture of pleural effusion in several plates. Colonies grew on Sabouraud dextrose agar and reached about 7-8 mm after one week. The fungus was recognized based on its colony morphology, microscopic structures and thermophilicity (Figure 2). Thus, the patient was started on Itraconazole 200mg twice daily. After 48 hours, the patient became afebrile and the symptoms improved. She was evaluated for immunodeficiency. Immunoglobulin levels were normal, rheumatologic evaluation and tumor markers were unremarkable and NBT test was 100%.
We continued treatment with itraconazole for four weeks. After four weeks, the patient had good general condition without any sign or symptom, erythrocyte sedimentation rate was 70mm/h, hemoglobin was 10.8mg/dL and her new chest X ray was clear (Figure 3).