Disseminated Mycobacterium haemophilum Infection and Pneumocystis jirovecii Pneumonia in a Patient Receiving Immunosuppressive Therapy

Abstract

Abstract A 53-year-old woman with mixed connective tissue disease and rheumatoid arthritis on successive treatment regimens consisting of rituximab then adalimumab + prednisone then azathioprine + hydroxychloroquine + prednisone developed multiple tender upper and lower extremity skin lesions followed shortly by dry cough and shortness of breath. Skin biopsy and blood cultures eventually revealed Mycobacterium haemophilum, and transbronchial lung biopsy and bronchial washings revealed Pneumocystis jirovecii pneumonia. The patient was treated with endotracheal intubation, clarithromycin/rifampin/ciprofloxacin, and trimethoprim-sulfamethoxazole and survived, gradually returning to baseline state after hospital course during which she was intubated for 17 days. She survived but continues on lower-dose azathioprine and prednisone for her mixed connective tissue disease and rheumatoid arthritis. We conducted a strict review of the literature for all patients with disseminated M. haemophilum infection and looked for concurrent opportunistic infections. There was only one other patient with concurrent disseminated M. haemophilum infection and P. jirovecii pneumonia. Three patients were diagnosed as having P. jirovecii before having a diagnosis of disseminated M. haemophilum infection. Other concurrent opportunistic infections found were herpesvirus-8–associated Kaposi sarcoma and disseminated histoplasmosis. As physicians become more aware of M. haemophilum and as diagnostic techniques improve and become more widely available, we may see more disseminated M. haemophilum infections and associated opportunistic infections.