A 27-year-old Thai male with AIDS from Saraburi Province presented with acute abdominal pain that had lasted for 4 days. He originated from Mukdahan Province, in Northeastern Thailand, but had moved to Saraburi Province which is situated in the southern part of Northeastern Thailand, 200 km from Bangkok. He denied other travel histories outside these areas during the past year. He was diagnosed with AIDS 2 months before at another hospital, which recorded an initial CD4 count of 91 cells/mm3 (unknown percentage and HIV viral load) and no complete immune status evaluation was performed. At the time, he presented with respiratory distress which was later identified as pneumocystis pneumonia and presumptive smear-negative pulmonary tuberculosis. He was given a 3-week course of trimethoprim/sulfamethoxazole, and anti-tuberculosis treatment consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol during hospitalization. Anti-retroviral therapy (ART) comprising tenofovir disoproxil fumarate, emtricitabine, and efavirenz was introduced 2 weeks later when he was an outpatient. The anti-tuberculosis regimen was adjusted to isoniazid, rifampicin, ethambutol, and levofloxacin after 4 days, and a chest radiograph demonstrated complete resolution of prior pulmonary opacities after 50 days of treatment. He reported 100% adherence to both anti-tuberculosis treatment and ART and no other new medications had been added to the regimen. The CD4 count 8 weeks before this admission was 91 cells/mm3 (unknown percentage).
At this admission, he presented with abdominal pain mainly in the left upper quadrant that he described as a dull ache, without radiation. The pain was not related to eating food, physical activity, or position. He reported no other associated gastrointestinal complaints such as diarrhea or nausea. Two days later, he developed a high-grade fever without chills, with the highest temperature of 38.9  C. Abdominal pain persisted and partially responded to acetaminophen. In response to this, he attended the emergency department where a physical examination revealed a blood pressure of 120/75 mmHg, a heart rate of 110 beats/min, a temperature of 38.7  C, and a respiration rate of 20 breaths/min. His abdomen was soft, normal bowel sounds were heard, but tenderness on palpation in the left upper quadrant was evident. The spleen could not be palpated. The remaining physical examination was unremarkable including a negative complete skin examination, with no cutaneous lesions on his face, trunk, or extremities, and a neurological examination within normal limits.
Initial laboratory investigations revealed hemoglobin levels of 9.8 g/dL, a white blood cell count of 14,000 cells/mm3, and a platelet count of 225,000 cells/mm3 on a complete blood count. Serum galactomannan (GM) levels by Platelia enzyme-linked immunosorbent assay (ELISA) (BioRad)  were 6.84. The CD4 count on admission was 272 cells/mm3 (19%). A fungal blood culture obtained on hospital day 1 grew white to tan-colored, velvety and flat colonies with red soluble pigment (Figure 1) on day 9. Direct microscopic examination of the colonies with lactophenol cotton blue staining demonstrated septate hyphae and smooth conidia aloft phialides directly borne on metulae (Figure 2). A bone marrow culture grew similar colonies to the blood specimen (Figure 3) on day 12 after the procedure. Contrast-enhanced computed tomography of the abdomen revealed a small hypodense lesion with a thin enhancing rim at the spleen and extensive intra-abdominal lymphadenopathy (Figure 4). At the time, the patient was not able to provide sputum sample for culture and due to the high-risk procedure, intra-abdominal lymph node biopsy for culture and histologic analysis was not performed.
Because of a concern of disseminated fungal infection on admission, empirical intravenous amphotericin B deoxycholate was given at a dose of 1.5 mg/kg/day for 7 days. This was switched to liposomal amphotericin B at 3.2 mg/kg/day in response to acute kidney injury for a total of 21 days. Before discharge, a loading dose of itraconazole was initiated at 600 mg/day for 3 days, then 400 mg/day for the maintenance phase. Of note, plasma itraconazole levels drawn on day 4 were 0.13 mcg/mL, with the highest value throughout the treatment course of 0.21 mcg/mL. The patient continued to improve clinically and was discharged from the hospital after 29 days. Repeat imaging was initially planned at 6 months but was deferred at the patient's request. Serum GM levels 9 months after therapy had declined to 0.11, and he remained asymptomatic at the 12-month follow-up.