This is the first reported case of Sweet’s syndrome associated with the fungal infection, Talaromyces marneffei, and the bacterial infection, Mycobacterium abscessus, due to adult-onset immunodeficiency with anti-interferon-gamma autoantibodies (Xu et al, 2018).
What is adult-onset immunodeficiency with anti-interferon-gamma autoantibodies?
Adult-onset immunodeficiency with anti-interferon-gamma autoantibodies is an immunodeficiency disorder mainly found in Southeast Asians that were previously healthy. The exact cause for this disorder is unknown, but may be linked to the genes HLA-DR and HLA-DQ (Chan et al, 2016). It causes the body to produce higher amounts of anti-interferon-gamma autoantibodies – specific immune system proteins that mistakenly target a person’s own tissues – and prevents immune cells called T-lymphocytes (T1) from responding properly (Chan et al, 2016). This weakens the immune system leading to infection. Symptoms commonly include multiple swollen lymph nodes and skin lesions, particularly Sweet’s syndrome and acute generalized exanthematous pustulosis (Phoompoung et al, 2017). There is no standard therapy for adult-onset immunodeficiency with anti-interferon-gamma autoantibodies and treatment depends on what kind of infection is present.
What is Talaromyces marneffei?
In Southeast Asia, T. marneffei is a fungal infection that has been linked to bamboo rats and soil from their burrows, and is most commonly found in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) due to very weakened immune systems (Chan et al, 2016). Fairly recently, it has been associated with adult-onset immunodeficiency with anti-interferon-gamma autoantibodies.
What is Mycobacterium abscessus?
M. abscessus is a bacterium distantly related to the ones that cause tuberculosis and leprosy. It is a nontuberculous mycobacterial (NTM) infection that can be difficult to treat and is often resistant to antibiotics. NTM infection in people who were previously healthy and HIV negative has been associated with adult-onset immunodeficiency with anti-interferon-gamma autoantibodies (Phoompoung et al, 2017).
A 54-year-old Chinese man was admitted to hospital with a 2 month history of recurrent fever and a 1 month history of multiple swollen lymph nodes. There was nothing unusual about his history, apart from eating bamboo rats a year before. He went on to develop painful skin lesions on the face, back of hands, lower legs and feet. The antifungal, fluconazole, and the antibiotic, levofloxacin, were started to treat infection. The patient was also given the steroid, methylprednisone, and thalidomide to treat Sweet’s syndrome. His skin lesions eventually healed, but a new painful lesion developed under the left side of his jaw. He then had a recurrent fever and enlarging neck lymph nodes with swelling and flushing over his neck. These symptoms improved after levofloxacin was replaced with the antibiotic clarithromycin.
On admission, blood tests had shown raised white blood cell count, raised neutrophil (type of white blood cell) count, elevated erythrocyte sedimentation and C-reactive protein (two tests that can show increased levels of inflammation in the body). Test for HIV was negative, but anti-interferon gamma autoantibodies were positive. Bone marrow biopsy was normal. Blood and sputum cultures showed no fungal or bacterial infection. Biopsy of a skin lesion showed lots of neutrophils in the tissues and fluid in the dermal skin layer (uppermost part of dermis), these findings being consistent with Sweet’s syndrome. Biopsy of a lymph node from the right groin showed a yeast/fungal-like organism under microscope. Biopsy of the jaw lesion showed both yeast/fungal-like organisms and acid-fast rods, the latter indicating myobacterial infection. A diagnosis of deep mycosis (fungal infection in deeper tissues) caused by T. marneffei was given, and the mycobacterial infection was identified as M. abscessus.
Phoompoung, P., Ankasekwinai, N., Pithukpakorn, M., Foongladda, S., Umrod, P., Suktitipat, B., Mahasirimongkol, S., Kiertiburanakul, S. and Suputtamongkol, Y. (2017) Factors associated with acquired Anti IFN- γ autoantibody in patients with nontuberculous mycobacterial infection. PLos One, Apr 24;12(4):e0176342 (PMC).
Xu, H., Liu, D., He, X., Zheng, D. and Deng, Y. (2018) Sweet’s Syndrome Associated with Talaromyces marneffei and Mycobacterium abscessus Infection Due to Anti-interferon-gamma Autoantibodies. Indian Journal of Dermatology, Sep-Oct;63(5):428-430 (PMC).
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