Abundant Acid-fast Bacilli Research Articles

Type II Reaction Erythema Nodosum Leprosum: A Case Report

Leprosy, or Hansen's disease, is a chronic granulomatous infectious disease caused by Mycobacterium leprae. This is a case of a 25-year-old male from Micronesia who presented to a hospital in the Midwest with a two-week history of a widespread, nodular, erythematous, painful rash most severe on his lower extremities and sparing only his hands and feet. In addition to the cutaneous manifestations, the patient met the criteria for Systemic Inflammatory Response Syndrome (SIRS) due to his presentation of tachycardia, tachypnea, leukocytosis, and elevated inflammatory markers. A short course of antibiotics, including Piperacillin-Tazobactam and Vancomycin, and IV steroids were started on admission. A skin biopsy taken from the center and edge of a lesion on the patient’s right arm demonstrated acute and chronic granulomatous superficial and deep inflammation with abundant acid-fast bacilli consistent with lepromatous leprosy from a Mycobacterium leprae infection. Once the National Hansen's Disease Center was contacted previous therapies were stopped and a multidrug therapy, consisting of Rifampin, Moxifloxacin, Minocycline, Methotrexate, and Prednisone was started. The multidrug therapy promptly resulting in substantial clinical improvement over the subsequent months. This case emphasizes the significance of early recognition, accurate diagnosis, and timely initiation of appropriate treatment in leprosy management, even in unlikely regions such as the Midwestern United States.

Characterisation and development of histopathological lesions in a guinea pig model of Mycobacterium tuberculosis infection.

Tuberculosis (TB) remains a very significant infectious disease worldwide. New vaccines and therapies are needed, even more crucially with the increase of multi-drug resistant Mycobacterium tuberculosis strains. Preclinical animal models are very valuable for the development of these new disease control strategies. Guinea pigs are one of the best models of TB, sharing many features with the pathology observed in human TB. Here we describe the development of TB lesions in a guinea pig model of infection. We characterise the granulomatous lesions in four developmental stages (I-IV), using histopathological analysis and immunohistochemical (IHC) techniques to study macrophages, T cells, B cells and granulocytes. The granulomas in the guinea pigs start as aggregations of macrophages and few heterophils, evolving to larger lesions showing central caseous necrosis with mineralisation and abundant acid-fast bacilli, surrounded by a rim of macrophages and lymphocytes in the outer layers of the granuloma. Multinucleated giant cells are very rare and fibrotic capsules are not formed in this animal model.

First identification of Mycobacterium avium subsp. paratuberculosis in wild ruminants in a zoo in Mexico.

Background and Aim:Paratuberculosis (PTB) is an infectious disease that induces chronic enteritis in ruminants. It is caused by Mycobacterium avium subsp. paratuberculosis (MAP). In this study, we evaluated the presence of MAP using bacteriological, molecular, and anatomopathological studies, based on the clinical suspicion of PTB in a zoo, in an area housing 10 scimitar-horned oryx (Oryx dammah), five giraffes (Giraffa camelopardalis), and three blue wildebeests (Connochaetes taurinus).Materials and Methods:From November 2016 to June 2017, fecal samples were collected from individuals of the three species on four occasions, resulting in a total of 56 fecal samples. In addition, five small intestine samples were collected from the necropsies of three adult scimitar-horned oryx females and two oryx calves. MAP identification was performed through isolation in Herrold’s medium with egg yolk, mycobactin, and sodium pyruvate, Ziehl–Neelsen staining, IS900 polymerase chain reaction (IS900 PCR), and anatomopathological examination of intestine samples.Results:Diffuse granulomatous enteritis with abundant acid-fast bacilli was found in two out of five intestine samples from adult scimitar-horned oryx females. MAP was isolated in 7/56 (12.5%) of the fecal samples from four scimitar-horned oryx, one giraffe, and two wildebeest samples. Two out of 5 (40%) samples obtained from scimitar-horned oryx tested positive. IS900 PCR yielded five positive samples (two fecal samples and three small intestine samples). MAP isolates were classified as Type C (Cattle) using type-specific PCR.Conclusion:These results demonstrated the presence of MAP in the area evaluated and indicated the importance of both sampling live animals and conducting postmortem examinations. The use of bacteriological and histopathological diagnostic techniques demonstrated in this study will provide insight into the health status and prevalence of paratuberculosis in wild ruminants under human care.

1394. Autochthonous Leprosy in Missouri

BackgroundIntroduction: Leprosy (Hansen’s disease) is a chronic granulomatous infection of the skin/peripheral nerves caused by Mycobacterium leprae. Of 216 new cases reported in the US in 2019, 70% were in FL, LA, TX, HI, CA, GA and NY. Leprosy is considered a zoonosis in the southern US with the nine-banded armadillo as a reservoir. There have been no reported autochthonous leprosy cases in Missouri.MethodsCase: 55 y/o previously healthy male noted a new rash on his arm 2 years ago. Over time it spread to his extremities/torso. Skin biopsy showed a granulomatous infiltrate, suspected granuloma annulare, but it progressed despite appropriate therapy. He noted progressive numbness of the affected areas of skin and several regional nerve distributions. In the weeks prior to his initial visit he noted facial swelling, eyelid and ear induration, worsening fatigue, diffuse arthralgia, and some vision changes. His travel history is limited to Canada, Colorado and a brief vacation to the Texas/Mexico border (no notable outdoor exposure during the latter trip; no travel outside the country). He lives in rural Missouri where he is exposed to armadillos. His dogs frequently kill them and often bring them into the yard, rolling around on/in the dead carcasses which he disposes of. He typically wears gloves when handling them and has never consumed them. On exam he had diffuse purplish-red nummular infiltrated anesthetic papules and plaques diffusely distributed over the trunk and extremities. Distinct left ulnar neuropathy was noted. He exhibited leonine facies and infiltration of the bilateral helices. Repeat biopsy showed a granulomatous infiltrate with abundant acid-fast bacilli. DNA sequencing confirmed M. leprae. He was preventatively treated with prednisone and methotrexate to minimize immune reaction, and two weeks later began a regimen of monthly rifampin, minocycline, and moxifloxacin with an anticipated duration of 24 months. ResultsDiagnosislepromatous leprosy with pre-treatment immune reaction. This is potentially the first case of autochthonous leprosy in Missouri. Providers should include Hansen’s disease in the differential diagnosis of patients with dermal eruption and cutaneous neurological symptoms to avoid delays in diagnosis/care.Disclosures All Authors: No reported disclosures

Purpuric lesion in a patient with leprosy: Was it a Lucio’s phenomenon or an epiphenomenon?

Background:  Lucio’s phenomenon (LP) is a severe necrotizing cutaneous reaction that occurs in patients with  Lucio ’s  leprosy. The exact pathomechanism is not fully understood, but typically abundant acid-fast bacilli in the walls of blood vessels point to direct perturbation of blood supply to the epidermis. We report a case of LP where epidermal necrosis occurred in the absence of vascular invasion by mycobacteria, raising the question whether this was an epiphenomenon or a true LP. Case Illustration:  A 34-year-old male was referred for an episodic swelling of his hands and feet that persisted for two years. There were signs of leprosy (diffuse shiny skin lesions, anesthesia, and anhidrosis of the extremities) with purpuric patches on lower extremities. The slit-skin smear test revealed a high index of acid- fast bacilli. Histopathological examination revealed epidermal necrosis and leukocytoclastic vasculitis without demonstrable bacillus. WHO multidrug regimen for leprosy and corticosteroids successfully cured the patient and prevented ulcer development. Discussion:  Despite the presence of classical LP characteristics clinically and histologically, mycobacterium was absent in the  vessels’ walls . We hypothesized that, in LP, vascular impairment might also be secondary due to antigen – antibody reaction and hypercoagulable state. Conclusion:  Purpuric patches in Lucio ’s  leprosy might be the first sign of skin necrosis or vascular damage (purpura and ulceration). Besides the antimycobacterial drugs, anti-inflammatory drugs should be administered. Laboratory test for hemostasis might be advised. Keywords:  Lucio’s phenomenon, mycobacteria, histopathology,  vasculitis

Intestinal Mycobacterium avium Infection in Pet Dwarf Rabbits (Oryctolagus cuniculus)

Mycobacteriosis has been rarely described in pet rabbits (Oryctolagus cuniculus). Here we present two cases of intestinal mycobacteriosis from north-eastern Germany. The first adult rabbit was euthanized due to severe cardiovascular failure, hypothermia and chronic weight loss. Necropsy revealed cachexia and a focal, fibrinonecrotic lesion in the caecum. Histologically, severe granulomatous inflammation, with numerous multinucleated giant cells and abundant acid-fast bacilli, was detected under the fibrinonecrotic material in the abdominal wall adjacent to the caecal lesion, caecal lymph nodes, spleen, liver and lungs. Microbiological culture detected Mycobacterium avium subspecies hominissuis, Escherichia coli, Clostridium disporicum and Bacteroides ovatus. A retrospective assessment of 2,013 other pet rabbit necropsies, performed between 1995 and 2019, revealed one additional case of intestinal mycobacteriosis. This animal had been euthanized due to persistent hindlimb lameness and necropsy revealed comminuted fractures of the pelvic bones and multiple large liquefied abscess-like lesions in the caecal and colonic walls. Histology revealed granulomatous inflammation with acid-fast bacilli. Polymerase chain reaction on formalin-fixed, paraffin-embedded tissue identified the presence of M. avium spp. In contrast to European wild rabbits (Oryctolagus cuniculus) from Scotland, these findings indicate that intestinal mycobacteriosis is rare in pet rabbits from north-eastern Germany. Zoonotic potential should be considered due to the close contact between pets and their owners and the chronic course of the disease with an initial lack of clinical signs.

Case report and literature review of Buruli Ulcer (BU): An emerging disease in australia caused by mycobacterial ulcerans skin infection

A skin biopsy was received from a 68-year-old female who presented with a non-healing ulcer on the buttock. Microscopically, ulcerated skin was seen with underlying necrotic tissue and patchy active chronic inflammation. Ziehl–Neelsen and Wade–Fite stains demonstrated abundant acid-fast bacilli in and around the ulcer site, consistent with BU. BU is an indolent skin infection caused by Mycobacterial ulcerans. People of any age can get infected, and symptoms may occur from 4 weeks to 10 months after exposure. The method of transmission is unclear. Three clinical stages described are: pre-ulcerative, ulcerative and healed disease. PCR or microbiology confirmation is usually necessary for treatment. The first line treatment for early lesions is a combination of antibiotics while surgery is reserved for refractory cases. The disease exists in 31 countries worldwide, mostly in West and Central Africa. There has been a steady increase in BU notifications since 2015 in Australia. Most cases were encountered in parts of Victoria and Queensland, with a few sporadic cases in Northern Territory, Western Australia and New South Wales. Awareness among pathologists is important to perform special histochemical stains for Mycobacteria in persisting ulcers, nodules, papules, oedema or cellulitis, especially on exposed parts of the body.

Emerging infections: mimickers of common patterns seen in dermatopathology.

The following discussion deals with three emerging infection diseases that any dermatopathologist working in the northern hemisphere can come across. The first subject to be dealt with is gnathostomiasis. This parasitic disease is produced by the third larvarial stage of the parasite that in most patients is associated with the ingestion of raw fish. Epidemiologically, it is most commonly seen in South East Asia, Japan, China, and the American continent, mainly in Mexico, Ecuador, and Peru. Nowadays, the disease is also seen in travelers living in the developed countries who recently came back from visiting endemic countries. The disease produces a pattern of migratory panniculitis or dermatitis with infiltration of eosinophils in tissue. The requirements for making the diagnosis are provided, including clinical forms, common histological findings on skin biopsy as well as the use of ancillary testing. Buruli ulcer, a prevalent mycobacterial infection in Africa, is described from the clinical and histopathological point of view. The disease has been described occasionally in Central and South America as well as in developed countries such as Australia and Japan; Buruli ulcer has also been described in travelers returning from endemic areas. Clinically, the disease is characterized by large, painless ulcerations with undermined borders. Systemic symptoms are usually absent. Classical histological findings include a particular type of fat necrosis and the presence of abundant acid fast bacilli in tissue. Such findings should raise the possibility of this disease, with the purpose of early therapeutically intervention. Lastly, the infection by free living ameba Balamuthia mandrillaris, an emerging condition seen in the US and Peru, is extensively discussed. Special attention is given to clinical and histological characteristics, as well as to the clues for early diagnosis and the tools available for confirmation.

Tuberculosis in captive sloth bear (Melursus urcinus)

A carcass of 10 year old male Sloth Bear (Melursus ursinus) from Maharaj Bag Zoo, Nagpur was brought for a post mortem examination with the history of illness since 15 days and no response to the treatment. The postmortem examination revealed pale mucous membrane, hide bound condition and dehydration. Both the lungs revealed presence of large numbers of caseative nodules of various sizes with enlarged and calcified mediastinal lymphnodes.The impression smears prepared from the caseative nodules of lung showed abundant acid fast tubercular bacilli. Histopathological examination of lungs revealed areas of typical granulomatus reaction with caseasation and aggregation of chronic inflammatory cells and sever thickening of inter alveolar septa due to deposition of fibrin, inflammatory cells, and erythrocytes

A Case of Severe Mycobacterium kansasii Infection Complicated with the Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

We present a case of severe Mycobacterium kansasii infection due to the clinical and radiological progression and complicated with syndrome of inappropriate antidiuretic hormone secretion (SIADH). This 54-year-old male alcoholic and heavy smoker as predisposing factors presented severe anorexia, asthenia and cachexia. Abundant acid-fast bacilli (AFB) were observed in the patient’s sputum and pleural fluid after Ziehl-Neelsen (ZN) staining. The strain was identified as M. kansasii by culture. A treatment with isoniazid, pyrazinamide, ethambutol, clarithromycin and moxifloxacin were then initiated. The course of the illness includes impaired consciousness, behavioural disturbances and agitation; we believe was a consequence of SIADH, because of the severe hyponatremia with low serum osmolality condition. Also, generalized or local infections are important and unregarded causes of SIADH. Multiple infectious diseases are associated with this syndrome [1]. An awareness of this www.omicsonline.org/open-access/pathogenicity-of-entamoeba-species-depends-on-cell-line-conversiongenome-reprogramming-and-epigenetic-gene-regulation-2157-7013-1000245.phppathogen with clinical, radiologic, and microbiologic parameters are all needed to establish the diagnosis of this infection and the eradication of disease requires prolonged combination drug therapy.

Comparison of a quantitative real-time polymerase chain reaction (qPCR) with conventional PCR, bacterial culture and ELISA for detection of Mycobacterium avium subsp. paratuberculosis infection in sheep showing pathology of Johne’s disease

A quantitative real-time PCR (qPCR) assay employing IS900 gene specific primers of Mycobacterium avium subsp. parartuberculosis (MAP) was compared with conventional PCR, bacterial culture and enzyme-linked immunosorbent assay in 38 sheep showing granulomatous enteritis and lymphadenitis with and without demonstration of acid-fast bacilli (AFB). The lesions were classified as multibacillary (MB) (n = 23), which had diffuse granulomatous lesions with abundant AFB, and paucibacillary (PB) (n = 15), which had focal or multifocal granulomatous lesions with few or no AFB. In the multibacillary group (MB), IS900 PCR detected 19 (82.6%), and qPCR detected all 23 (100%) sheep positive for MAP in the intestine and lymph node tissues. In the paucibacillary group (PB), IS900 PCR detected 2 (13.3%), and qPCR detected all 15 (100%) sheep positive for MAP in tissues. When results of both groups were taken together, IS900 PCR detected 21(55.2%), and qPCR detected all 38 (100%) animals positive for MAP genome either in the intestine or lymph node tissues. On Herrold egg yolk medium, tissues of 14 (60.9%) MB and 5 (33.3%) PB sheep were found to be positive for MAP. Out of 27 sheep (PB = 8, MB = 19) tested by an ELISA, 21 (77.7%) were found to be positive for MAP antibody, of which 25% (2/8) and 100% (19/19) sheep were from PB and MB sheep, respectively. Based on the results of the present study, it was concluded that qPCR was a highly sensitive test in comparison to conventional PCR, ELISA and bacterial culture for the diagnosis of paratuberculosis on infected tissues especially from paucibacillary sheep.

Intestinal Strictures, Fibrous Adhesions and High Local Interleukin-10 Levels in Goats Infected Naturally with Mycobacterium avium subsp. paratuberculosis

This study describes pathological findings and their association with the production of interferon (IFN)-γ and interleukin (IL)-10 in goats infected naturally with Mycobacterium avium subsp. paratuberculosis (MAP). Twenty-seven goats were subjected to pathological examination. More than half of the animals had severe, diffuse, transmural granulomatous enteritis, often with abundant acid-fast bacilli (AFB), which was most evident in the proximal jejunum. Jejunal strictures and fibrous, peritoneal adhesions were findings that are not often reported in animals with paratuberculosis. Immunohistochemical labelling of IL-10 was seen within diffuse, granulomatous lesions and this may have prevented optimal local IFN-γ production and exacerbated the disease. However, since IFN-γ production was detected in cells from blood, jejunum and jejunal lymph nodes of goats with severe lesions by enzyme-linked immunosorbent assay, intracellular labelling and in-situ hybridization, the up-regulation of IL-10 might have been a consequence rather than a cause of the severe disease. The IL-10 labelling was co-localized with major histocompatibility complex (MHC) class II(+) cells, but rarely with CD4(+) cells. Comparable numbers of CD4(+) and CD8(+) T cells were recruited to both severe, diffuse lesions and small to moderate granulomatous lesions, while few T cells expressing the γδ form of the T-cell receptor were associated with both types of lesions.

Sclerosing cholangitis-like changes in hepatobiliary tuberculosis

Atypical presentations of tuberculosis might cause difficulties in diagnosis, especially in developing countries. Primary hepatobiliary tuberculosis is a rare condition and the diagnosis of this condition necessitates a high index of suspicion. In this report, we present a case with obstructive jaundice, dilated intrahepatic bile ducts and lymphadenopathies in the porta hepatis. Endoscopic retrograde cholangiopancreaticography showed irregularities, strictures and dilatations both in the intra- and extrahepatic bile ducts resembling sclerosing cholangitis. The liver biopsy showed caseous granulomatous hepatitis and Langhans giant cells compatible with tuberculosis, and a lymph node biopsy obtained from the left cervical region demonstrated caseating confluent granulomas with abundant acid-fast bacilli. The present case shows that primary hepatobiliary tuberculosis may mimic primary sclerosing cholangitis and should be considered in the differential diagnosis of patients with sclerosing cholangitis-like changes on endoscopic retrograde cholangiopancreaticography.

Atypical mycobacteriosis of the larynx: an unusual clinical presentation secondary to steroids inhalation

Vocal cords stiffness can be associated with a variety of etiologic agents, but it is rarely seen with atypical mycobacteria, for example, Mycobacterium avium complex. We report a case of a 35-year-old white woman who is and was maintained on inhaled steroids. She presented with hoarseness and low-grade fever, but her medical history was otherwise unremarkable. Laryngoscopy revealed bilateral scarring of the vocal cords. Vocal cord biopsies were performed. Histologic examination revealed unremarkable laryngeal mucosa, except for abundant subepithelial non-necrotizing granulomata. The differential diagnosis included sarcoid, Klebsiella scleroma, and tuberculosis. Special stains reviewed abundant acid-fast bacilli, later confirmed by a DNA assay on induced deep sputum, consistent with M avium complex. Subsequently, steroids were withdrawn, and the patient was treated with a multiple-drug antituberculous regimen and had a full recovery. This unusual clinical presentation of the atypical mycobacteriosis may be encountered by otolaryngologists and pathologists, and it is critical to recognize it in patients immunocompromised because of steroids.

Answer To The Photo Quiz

Diagnosis: borderline leprosy. The diagnosis of was suspected on the basis of the presence of erythematous annular skin lesions associated with hypoesthesia in a woman originating from the Philippines, where Mycobacterium leprae infection is endemic. It was confirmed by punch biopsy of an active skin lesion on the forehead (figure 1), which revealed granulomatous dermatitis, neural inflammation, and easily identifiable acidfast bacilli (AFB) (figure 2). Bacterial and fungal cultures were sterile. Leprosy, also known as Hansen disease, is a chronic granulomatous infection of the skin and peripheral nerves by the noncultivable obligate intracellular pathogen M. leprae. Globally, the majority of cases occur in India, South America, and Southeast Asia [1], In North America, it is usually seen among immigrants from regions where the disease is endemic and typically occurs within the first year after arrival [2]. Unfamiliarity with this disease may lead to delayed diagnosis, as in this case. Humans are the major reservoirs of M. lepraey although infection can occur in other animals (e.g., the 9-banded armadillo and monkeys) [3]. The proposed major route of human transmission is by aerosolized nasal droplets. Direct skin contact plays little, if any, role [1]. After exposure, 95% of individuals do not develop overt disease; the remainder progress to an leprosy stage, characterized by a single, ill-defined, hypopigmented skin lesion [2]. Most of these persons then experience spontaneous resolution of their lesions. However, approximately 25% of individuals who experience indeterminate progress to one of the classical forms of leprosy, which form a clinical spectrum that reflects the interplay between host immune response and pathogen. Tuberculoid leprosy, which is characterized by a robust Thl-like cell immunity with scant or no AFB in the lesions, and lepromatous leprosy, which is characterized by a predominant Th2-like humoral immunity with abundant AFB in lesions, are at the extremes of the clinical spectrum; the intermediate variants (borderline tuberculoid, midborderline, and borderline lepromatous) complete the gradient [2]. It is speculated that our patient's initial response to the topical corticosteroid therapy was related to an attenuation of the inflammatory response in the skin. The identification of AFB on skin biopsy sections stained by the modified Ziehl Neelsen stain (Wade-Fite) can confirm the

Treatment failure in a case of extensively drug-resistant tuberculosis associated with selection of a GyrB mutant causing fluoroquinolone resistance

Multidrug-resistant tuberculosis (MDR-TB), defined by resistance to both isoniazid and rifampin, is an increasing problem that accounts for 400,000 new cases worldwide each year [1]. The prognosis of individuals infected with MDR-TB remains poor, with 10–30% of cases resulting in failure and death [2]. Fluoroquinolones are some of the few potent antibiotics still active against most MDR strains of M. tuberculosis, and their use has been identified as a favorable prognostic factor in cases of MDR-TB [3]. Recently, the emergence of extensively drug-resistant strains (XDR) has been reported and these strains have been associated with a worse prognosis than MDR-TB strains [2]. XDR-TB is an infection with a MDR strain that is resistant to any fluoroquinolone and at least one of the three injectable drugs (capreomycin, kanamycin or amikacin) [4]. We describe here a clinical case of XDR-TB that illustrates the critical role fluoroquinolones play in the management of drugresistant tuberculosis. The case involved a 51-year-old man with no comorbid conditions who had been treated in Algeria for pulmonary tuberculosis since June 2001. The initial antibiotic susceptibility profile of the causative strain was unknown. His original treatment, which included isoniazid, rifampin, ethambutol and pyrazinamide for 3 months followed by isoniazid and ethambutol, had been taken irregularly. When hospitalized in Limoges, France, in June 2002, he suffered fever, anorexia, weight loss (15 kg), cough and hemoptysis. A computed tomography scan showed bilateral cavitations of the upper lobes (Fig. 1). Sputum-smear examination detected abundant acid-fast bacilli. Treatment with rifampin, isoniazid and pyrazinamide was initiated. Culture grew M. tuberculosis. Susceptibility testing of first-line drugs revealed resistance to rifampin, isoniazid, pyrazinamide and streptomycin. Treatment was consequently switched to amikacin (750 mg/day), ofloxacin (800 mg/day), ethionamide (500 mg/day) and ethambutol (1 g/day). Molecular studies performed at the National Reference Center revealed mutations in the katG gene (S315T), rpoB gene (H526D) and pncA gene (T100P), but no mutation in the gyrA gene [5, 6]. Further drug susceptibility tests showed resistance to isoniazid, rifampin, pyrazinamide, streptomycin, ethambutol, kanamycin, ethionamide, thiacetazone and cycloserine. The strain remained susceptible to amikacin, capreomycin, fluoroquinolones and para aminosalicylic acid. As a result, treatment was switched to amikacin (750 mg/day), ofloxacin (800 mg/day) and PAS (10 g/day) for 4 months. Under this treatment the patient’s general condition improved. In January 2003, treatment was continued with the combination of moxifloxacin (400 mg/day) and PAS and maintained for 12 more months. However, in May 2003 the patient returned to Algeria, where he again took his medication irregularly. In March 2004, he was readmitted Eur J Clin Microbiol Infect Dis (2007) 26:423–425 DOI 10.1007/s10096-007-0298-0

Mycobacterium tuberculosis at autopsy—exposure and protection: an old adversary revisited

Background: The risk of encountering tuberculosis (TB) has reduced with the decreased incidence of the disease; however, it still can be found at autopsy. Aim: To assess the magnitude of...

Comparison of IS 900 tissue PCR, bacterial culture, johnin and serological tests for diagnosis of naturally occurring paratuberculosis in goats

Comparative efficacy of an IS 900 tissue PCR, bacterial culture, johnin, agar-gel immunodiffusion (AGID) and absorbed-ELISA tests was investigated in 43 goats naturally infected with paratuberculosis. On histological examination, tissue sections from all animals showed typical granulomatous inflammatory changes. The lesions were classified as multibacillary (MB) ( n = 30), which had diffuse granulomatous lesions with abundant acid-fast bacilli (AFB), and paucibacillary (PB) ( n = 13), which had focal or multifocal granulomatous lesions with few AFB. The sensitivities of johnin test, tissue culture, faecal culture, tissue PCR, AGID and ELISA were 68% (17/25), 100% (30/30), 84.6% (22/26), 100% (30/30), 96.2% (25/26) and 100% (26/26) in MB goats, and 88.8 (8/9), 46.1% (8/13), 40% (4/10), 61.5% (8/13), 50% (5/10), and 70% (7/10) in PB goats, respectively. Except for the johnin test, which showed higher sensitivity in PB goats, all other tests displayed significantly higher sensitivities in MB goats. The results indicate the usefulness of tissue PCR, culture and serological tests in the diagnosis of clinically affected paratuberculous goats, especially with multibacillary pathology.

ENDOSCOPIC FINDINGS IN A MYCOBACTERIUM AVIUM COMPLEX (MAC) INFECTION

Our patient is a 48 y/o AA female with a medical history including HIV/AIDs (CD4 count <50), Hepatitis C, COPD, and multi-substance abuse. She presented to our hospital with fevers, chest pain, and dyspnea Her PE revealed a cachectic but comfortable appearing patient with a non-focal exam. With a concern for TB, the patient was placed in respiratory isolation. Initial work-up revealed severe anemia, an elevated WBC and Alkphos, and sputum with subsequent 2+ AFB via fluorochrome stain. Due to the patient's clinical condition and persistent fevers a continued infectious work-up was performed. A CT revealed scattered areas of patchy lung disease, diffuse lymphadenopathy and small bowel wall thickening. An upper endoscopy was then obtained. The small bowel contained prominent and diffuse punctate white plaques. They were circumferential throughout the visualized small bowel. Plaques were approximately 1–2 mm in size (endoscopic photos available). The intervening mucosa appeared normal. Biopsies showed abundant acid fast intracellular bacilli. On hospital day #28 the sputum revealed MAC (via DNa Probe). The final diagnosis was disseminated MAC infection. Disseminated MAC is often a difficult diagnosis. Descriptions of endoscopic findings of disseminated MAC are rare in the literature. The diagnosis is usually made through isolation of MAC from the blood cultures. The mean time for positive blood cultures is 24 days (1). It is known that a low CD4 count is one of the primary risk factors for MAC infection. Disseminated infection usually presents with non-specific symptoms and laboratory abnormalities. Other studies such as stool studies and CT scans can be of assistance. One study showed that 14% of disseminated MAC had small bowel wall thickening on CT scan (2). Many patients with disseminated MAC will undergo an endoscopic work up prior to a definitive diagnosis. With the era of HAART, the evaluation of HIV patients is an evolving practice. Nevertheless, endoscopic evaluation is a key component in the work up of many signs and symptoms. Several studies have evaluated the yield of upper endoscopy for Opportunistic Infections (OI) in HIV patients (3). The diagnostic yield of upper endoscopy for OI is about 25% (4). This case provides us with the impressive visual appearance and histological findings in disseminated MAC with prominent intestinal involvement. References 1–4 available upon request.

Leprous osteitis presenting as bone cyst and erosions

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.