A CASE OF TSUKAMURELLA PULMONIS MASQUERADING AS PLEURAL TB IN AN IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Interesting Presentations of Infectious Diseases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 1:00 PM - 2:00 PM INTRODUCTION: Respiratory infections due to Tsukamurella have been described in immunodeficient patients. To our knowledge, only one other case report of respiratory infection has been described in an immunocompetent patient. We hereby present a case of Tsukamurella infection causing tuberculosis like syndrome in an immunocompetent patient. CASE PRESENTATION: A 42-year-old male with a past medical history of hyperthyroidism who recently moved to the United States from India presented to the hospital with chest pain and shortness of breath (SOB). The patient had a viral upper respiratory infection three weeks before presentation and eventually developed worsening sharp chest pain and SOB. He saw a provider in the clinic who recommended a chest X-ray which revealed a right-sided pleural effusion. He underwent an outpatient thoracentesis, a liter of fluid was drained and revealed an eosinophilic predominant exudative fluid. A Quantiferon gold test was negative during that time. At our hospital, the patient was again found to have a right-sided pleural effusion, underwent repeat thoracentesis and eventually, a chest tube was placed. Pleural fluid analysis revealed a monocyte predominant exudative fluid. He later underwent a decortication procedure due to re-accumulation of fluid. Cultures from the fluid and the tissue were negative for acid-fast bacilli. Pathology of the pleura revealed benign tissue with fibrinous pleuritis. Initially, testing for Acid Fast Bacilli (AFB) on three sputum samples and nucleic acid amplification testing (NAAT) remained negative. Throughout this, the patient remained under airborne precautions and was being empirically treated for pleural tuberculosis. Eventually one of the sputum cultures grew acid-fast bacilli within the first week, and this was deemed to be a rapid grower and not Mycobacterium tuberculosis. The culture was sent to Mayo clinic for identification and came back positive for Tsukamurella pulmonis. His antitubercular therapy was discontinued, and he was treated with levofloxacin and rifabutin for 3-6 months. He remained stable and disease free on follow up at 2 months. DISCUSSION: Tsukamurella species are obligate, aerobic, gram-positive, weakly acid-fast Actinomycetales. Infections are mostly related to immunocompromised state and use of intravascular catheters and prosthetic devices. Diagnosis remains a challenge as demonstrated in our case and the infection can mimic tuberculosis like syndrome leading to inappropriate treatment with anti-tubercular therapy. No guidelines exist regarding appropriate treatment, but levofloxacin and rifabutin have been described for treatment of pulmonary infection. CONCLUSIONS: As outlined in our case, Tsukamurella can mimic tuberculosis and diagnosis remains a challenge. A high index of suspicion is required to diagnose this infection in patients with high risk for tuberculosis as it changes management significantly. Reference #1: Inchingolo R., Nardi I., Chiappini F., Macis G., Ardito F., Sali M. First case of Tsukamurella pulmonis infection in an immunocompetent patient. Respir Med CME Reference #2: Chen C.H., Lee C.T., Chang T.C. Tsukamurella tyrosinosolvens bacteremia with coinfection of Mycobacterium bovis pneumonia: case report and literature review. SpringerPlus. 2016;5:2033. Reference #3: Safaei, S., Fatahi-Bafghi, M., & Pouresmaeil, O. (2017). Role of Tsukamurella species in human infections: first literature review. New microbes and new infections, 22, 6-12. https://doi.org/10.1016/j.nmni.2017.10.002 DISCLOSURES: Speaker/Speaker's Bureau relationship with Gilead Please note: $1-$1000 Added 03/15/2019 by Paul Anthony, source=Web Response, value=Honoraria No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Anand Muthu Krishnan, source=Web Response No relevant relationships by Nihar Shah, source=Web Response