A 30-year-old Chinese female was admitted to our hospital with persistent fever and cough as well as and chest and back pain (lasting for 8 and 3 months, respectively). The maximum body temperature was 39.4 C, the fever was irregular. No other symptoms or signs of organ involvement was present. She had been initially admitted and treated at a local hospital. An examination at the local hospital showed an erythrocyte sedimentation rate of 59 mm/h. The HIV test yielded negative results; the results of the purified protein derivative test and interferon-gamma release assay, which used the ELISA, were normal. The results of the acid-fast bacillus (AFB) test, smear, and cultures of the sputum and bronchoalveolar lavage fluid did not reflect any abnormalities. Even after 21-day antibiotic therapy (cefoperazone sulbactam), the patient showed no improvement. Considering her symptoms and the imaging features (Figure 1A) observed in her chest CT, she was prescribed anti-tuberculosis treatment comprising isoniazid, rifampicin, pyrazinamide, and ethambutol on December 15, 2021. She was non-responsive to the medications for up to six months. Meanwhile, her condition deteriorated, and she started experiencing chest and back pain. 2-deoxy-2-[fluorine-18] fluoro-D-glucose positron emission tomography/X-ray computed tomography (18F-FDG PET/CT) indicated that the thoracic (T-6) vertebral body showed low metabolism (Figure 2A), and the left upper lobe of the lung indicated high metabolism (Figure 2B). Chest CT scans showed some osteolytic damage in the vertebrae (Figure 2C). The patient was then transferred to our hospital for further diagnosis and treatment. The patient had no history of unprotected sex or blood transfusions. In addition, there was no history of other personal or hereditary diseases. She also denied traveling to any area except her hometown over the past 10 years. The vital signs during the initial examination were as follows: body temperature, 37.3 C; blood pressure, 107/74 mmHg; heart rate, 107 beats/min; and respiratory rate: 20 breaths/min. Physical examination was normal, except for tenderness at the 5/6 thoracic spine level. Initial laboratory examinations reported the following: white blood cell count, 13.83 x 109/L; red blood cell count, 3.03 x 1012/L; hemoglobin level, 77 g/L; neutrophil percentage, 95.4%; lymphocyte percentage, 2.8%; and albumin level, 35.9 g/L. C-reactive protein (112.00 mg/L), procalcitonin (17.70 ng/mL), and interleukin-6 (26.40 pg/mL) levels and erythrocyte sedimentation rate (110.00 mm/h) showed significant elevation. Multiple peripheral blood cultures yielded normal results. The possibility of bacterial infection was first considered based on the clinical characteristics and auxiliary examinations. The physician intravenously administered piperacillin-sulbactam and levofloxacin to the patient. However, the patient was feverish, with a maximum temperature of approximately 39 C.
Owing to the poor response of the patient to antibiotic and anti-tuberculosis therapy, we further searched for potential evidence of any other kind of infection. The beta-1,3-D-glucan test, Aspergillus galactomannan test, Cryptococcus antigen test, Pneumocystis japonicum DNA test, repeated purified protein derivative test, interferon-gamma release assay (using the ELISPOT assay), and acid-fast staining and sputum culture were all negative for their associated infections. Table 1 presents immunological reports of the patient under investigation. Chest CT scans showed scattered patches, nodules, and ground-glass shadows in the left upper lobe with ill-defined borders and thickening of some interlobular septa (Figure 1B). White blood cell count and C-reactive protein levels continuously increased, while hemoglobin and plasma albumin levels progressively decreased. Upon testing for them, we did not find any of the following antibodies in the patient: antinuclear antibodies, anti-double stranded DNA antibodies, anti-cyclic citrullinated peptide antibody, anti-keratin antibody, anti-neutrophil cytoplasmic antibodies, and HLA-B27. In conclusion, the diagnosis remained unclear. On the fifth day after admission to our hospital, the patient's blood pressure decreased to 70/42 mmHg, and she developed asthenia. A large amount of fluid was administered for rehydration; and the blood pressure was not raised significantly with fluid resuscitation. Vasoactive drug (m-hydroxyamine 50mg) was used to raise blood pressure, her blood pressure then increased to 90/60 mmHg, and we adjusted her treatment to intravenous meropenem and levofloxacin. A percutaneous lung biopsy was performed after the patient's condition had slightly improved, which showed granulomatous inflammation. Some pathogens were observed in the macrophages and interstitium suspiciously. Hexamine silver (Figure 3A) and periodic acid-Schiff (PAS) staining (Figure 3B) were positive suspiciously, whereas AFB, mucous card red staining, and TB-qPCR were negative. Tumors were not detected. Due to scarce availability of lung tissue and denial by the patient's family, biopsy specimens were not sent for culturing. Eventually, we performed mNGS, which detected 1655 reads of Talaromyces spp. (Illumina NextSeq 550, Chengdu, China), including 1160 reads of T. marneffei, 435 reads of Human gamma herpesvirus 4 (EBV), no other bacteria and parasite had been detected. The MRI of spine showed the lesions of thoracic vertebra (Figure 1E). Thoracic cone biopsy was also performed to identify any thoracic vertebral lesions. mNGS of bone tissue revealed no pathogens. Pathological examination of the bone and bone marrow showed focal granuloma formation, and AFB smear, silver hexamine, PAS staining, and TB-qPCR results were negative. We could finally confirm T. marneffei infection via PCR amplification targeting the rDNA internal transcribed spacer region followed by a BLAST sequence comparison (https://blast.ncbi.nlm.nih.gov/Blast.cgi; GenBank accession no. MN700106.1, coverage 97%, identity 99.23%) (Figure 4A). These results showed that the patient was infected with T. marneffei. Anti-fungal therapy with amphotericin B was immediately initiated. She was treated with intravenous amphotericin B (0.6-1.0 mg/kg.d, ivgtt) as standard initial therapy. After 3 days of the antifungal treatment, the patient's body temperature normalized, and the talarmycosis-associated clinical symptoms were relieved. ELISA confirmed that the patient had a high titer of anti-IFN-gamma autoantibodies (1:2500), the value of optical density (OD) was 1.149, which was much higher than negative control (Figure 4B). During the antifungal treatment, the patient's renal function was impaired. After discussing it with her family, we adjusted the antifungal therapy to liposomal amphotericin B (30 mg/d, ivgtt). Chest CT scans showed that the lesions in the left upper lobe of the lung had been absorbed after 2 weeks of cumulative treatment with amphotericin B (Figure 1C). The MRI of spine showed the lesions of thoracic vertebra were absorbed (Figure 1F). The main clinical diagnosis was severe T. marneffei pneumonia, spine T. marneffei infection, septic shock. Oral itraconazole was administered successively. Five months after discharge, there was no recurrence, which was confirmed via a telephonic follow-up, and Chest CT scans of the local hospital showed that the lesions in the left upper lobe of the lung had been absorbed furthermore (Figure 1D). A timeline of the patient with relevant data on the episodes and interventions is presented in Figure 5.