FATAL MYCOBACTERIUM ABSCESSUS INFECTION WITH BRONCHOESOPHAGEAL FISTULA

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Mycobacterium abscessus is known as the most prevalent rapidly growing non-tuberculous mycobacterium (NTM) (1). It is difficult to treat as it has numerous ways to evade the host immune system. Risk factors for infection include immunodeficiencies, smoking, and pulmonary disorders including cystic fibrosis and bronchiectasis. Tigecycline has been recommended as part of a multi-drug regimen therapy. However, the efficacy of multiple regimens is still being evaluated. Some of the novel therapies include b-lactamase inhibitors as well as macrophage therapy (1). CASE PRESENTATION: We present a 69-year-old female with a past medical history of blindness, atrial fibrillation, anemia, breast cancer with metastasis to the lungs and bones who comes in for generalized weakness from her oncologist office. She was noted to have a significantly worsening consolidation of the left lung with cavitation. (Figure 1 and 2). Furthermore, it showed a small area of communication between the left main stem bronchus and esophagus. Bronchoscopy was performed which showed a broncho-esophageal fistula (Figure 3). Cultures were positive for Pseudomonas aeruginosa which was sensitive and treated with cefepime. Due to the severity of the left lung consolidation, the patient was transferred to a tertiary hospital for placement of a bronchial and esophageal stent. Despite placement of stents, she passed of hypoxic respiratory failure after placement of the stents. A postmortum acid fast culture from the sputum and bronchial alveolar lavage grew Mycobacterium abscessus. Further speciation, macrolide, and additional antibiotic sensitivities were not ordered when culture was sent to National Jewish Laboratory in Denver, CO. DISCUSSION: In this case, the cavitary findings and severe lung consolidation appeared to be clinically out of proportion with the patient's community acquired Pseudomonas aeruginosa infection. Furthermore, a broncho-esophageal fistula has not been seen with Pseudomonas infections. So, the late finding of the Mycobacterium abscessus infection clarified why the patient had such a severe infection and fistula. Acquired broncho-esophageal fistulas are rare and there is one case of an esophago-pulmonary fistula reported in the Japanese literature (3). In this patient, we present a fatal case of a Mycobacterium abscessus and Pseudomonas aeruginosa with a broncho-esophageal fistula. Pseudomonas aeruginosa co-infection has been listed as a risk factor, which contributed to the development of the fistula (1). It is important to consider additional testing with severe pulmonary infections with only Pseudomonas aeruginosa. CONCLUSIONS: Broncho-esophageal fistula has been rarely reported in the literature. So, we felt it was important to report this case of Mycobacterium abscessus and Pseudomonas aeruginosa co-infection causing a consolidation, cavitary lesion and a denouveau broncho-esophageal fistula. REFERENCE #1: Johansen, M.D., Herrmann, JL. & Kremer, L. Non-tuberculous mycobacteria and the rise of Mycobacterium abscessus. Nat Rev Microbiol 18, 392–407 (2020). https://doi.org/10.1038/s41579-020-0331-1 REFERENCE #2: Strnad L, Winthrop KL. Treatment of Mycobacterium abscessus Complex. Semin Respir Crit Care Med. 2018 Jun;39(3):362-376. doi: 10.1055/s-0038-1651494. Epub 2018 Aug 2. PMID: 30071551. REFERENCE #3: Kokuho N, Hayashi H, Matsuyama M, Miura Y, Hayashihara K, Saito T. [A case of pulmonary Mycobacterium abscessus disease complicated with esophago-pulmonary fistula causing repeated exacerbation]. Nihon Kokyuki Gakkai Zasshi. 2010 Sep;48(9):696-701. Japanese. PMID: 20954373. DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response