A RARE CASE OF DISSEMINATED MYCOBACTERIAL SEPTICEMIA (LANDOUZY SEPTICEMIA) IN AN HIV-NEGATIVE PATIENT

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Landouzy septicemia or disseminated mycobacterial septicemia is an uncommon diagnosis. Especially in immunocompetent individuals but one we must not forget. CASE PRESENTATION: 33-year-old Guatemalan woman, with no known history of disease presented with headache, fever, chills, abdominal pain, weakness & shortness of breath for the past two months. Physical examination(PE) was significant for a temperature of 39.4 C, heart rate 128 bpm & blood pressure 96/55 mmHg. Ill-appearance, breath sounds were diminished bilaterally, rest of the PE unremarkable. At admission, CBC and renal function within normal limits, AST/ALT within normal limits, ALP elevated. A day after admission, she developed acute encephalopathy, hypotension & neck stiffness, with Kernig and Brudzinski signs. She was in septic shock, transferred to the ICU for mechanical ventilation, vasopressor support, and broad-spectrum antibiotics. COVID PCR resulted negative. Lactate was 12.6 mmol/L, AST: 549 ALT: 118 U/L. Cr: 1.7 BUN: 36. Bronchoalveolar lavage was positive for rifampin-sensitive Mycobacterium tuberculosis (MTB). Influenza A was positive via intranasal PCR. CT of the chest demonstrated bilateral reticulonodular interstitial infiltrates, suggesting atypical pneumonia, and a T11 vertebral body hypodense lesion. CT of the abdomen & pelvis revealed a nodular liver. Lumbar puncture showed an opening pressure of 29cm H20, CSF studies with hazy appearance, protein 594 mg/dL, glucose <20 mg/dL, & elevated WBC, negative for Toxoplasma, CMV, VDRL, VZV, HIV, HSV-1, enterovirus, cryptococcus, & JC virus, but positive for MTB. MRI of the thoracolumbar spine revealed T11-T12 osteomyelitis, with leptomeningeal and epidural enhancement. An echocardiogram showed a diffuse LV hypokinesis with an EF of 20%. HIV was negative, though she had an absolute CD4 count of 48 cel/mcL. Immunoglobulins were within normal limits. Repeated blood cultures were negative during the hospitalization. We started RIPE therapy and dexamethasone. The patient's mentation did not recover, off sedation. Subsequently, MRI of the brain demonstrated ischemic infarction in the subcortical region with hemorrhagic transformation, & MRV of the head was notable for cortical venous thrombosis. Despite adequate treatment after AFB identification, she expired 11 days into her hospitalization. DISCUSSION: The patient had a rare presentation of a common disease. She ultimately succumbed to landouzy septicemia. A rare manifestation of disseminated tuberculosis resulting in multiorgan failure & carries a high mortality, usually seen in immunocompromised patients, unlike our case. The CD4+ lymphocytopenia associated with influenza A infection might have unmasked the latent disease. CONCLUSIONS: Landouzy septicemia is a rare and severe manifestation of MTB. It should be in the differential even in immunocompetent individuals given the high mortality. REFERENCE #1: Floyd K, Glaziou P, Zumla A, Raviglione M. The global tuberculosis epidemic and progress in care, prevention, and research: an overview in year 3 of the End TB era. The Lancet Respiratory Medicine. 2018;6(4):299-314. REFERENCE #2: Hagan G, Nathani N. Clinical review: Tuberculosis on the intensive care unit. Critical Care. 2013;17(5):240. REFERENCE #3: Nichols JE, Niles JA, Roberts NJ. Human Lymphocyte Apoptosis after Exposure to Influenza A Virus. Journal of Virology. 2001;75(13):5921-9. DISCLOSURES: No relevant relationships by Baher AL Abbasi, source=Web Response No relevant relationships by Carlos Dorta, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Carlos Vergara-Sanchez, source=Web Response