Avium-intracellulare Infection Research Articles

Letter: Abdominal Mycobacterium avium-intracellulare Infection—A Series in Immunocompromised and Port Site Infections

Letter: Abdominal Mycobacterium avium-intracellulare Infection—A Series in Immunocompromised and Port Site Infections

LBODP105 A Case of Significantly Increased Levothyroxine Requirement With Rifampin Therapy

Abstract Introduction Rifampin has a wide range of drug interactions through increased hepatic microsomal enzyme activity. We are reporting a case of a patient with post-surgical hypothyroidism on stable thyroid hormone replacement therapy who required significantly higher doses of levothyroxine after starting rifampin. Case Report Patient is a 78-year-old woman with history of Papillary Thyroid Cancer (PTC) in remission status post thyroidectomy in 1994 and radioactive iodine therapy in 1997. Patient had been on a stable dose of Levothyroxine of 75-88mcg daily until a visit in January 2013 when her TSH was found to be 39 despite compliance with levothyroxine. Further history revealed that she was diagnosed with Mycobacterium Avium Intracellulare (MAI) infection of the lungs for which she was given rifampin therapy. Her Levothyroxine dose was progressively increased to 150mcg daily. She received rifampin therapy for 18 months, from August 2012 until April 2013. Her Levothyroxine dose was later changed to average 139 mcg /day based on TSH levels and continued to be the same through the rifampin course. In April 2014, and following discontinuation of rifampin, Levothyroxine was decreased to 100mcg daily and subsequently 75mcg daily. During a relapse of MAI in March 2016, her levothyroxine dosage was similarly again increased to 125mcg daily for TSH of 24.58. In June 2017, rifampin was discontinued after completion of second course of MAI treatment, and Levothyroxine dose decreased to 88 mcg daily, and subsequently 75 mcg in September 2017, and average daily 64mcg most recently given age and long-term remission with target mid normal TSH. Discussion Rifampin is used to treat active tuberculosis and MAI infection among other uses. It is a hepatic enzyme inducer which significantly interacts with other drugs. It has been reported previously to cause hypothyroidism in patients with underlying thyroid disorder and increased serum TSH while on levothyroxine, but its impact range on thyroid function has not been clearly described. Our patient was on stable levothyroxine dose following thyroidectomy, and required almost a 100% increase of levothyroxine dose when started on rifampin therapy, returning to baseline levothyroxine requirements off rifampin. This case highlights the severe hypothyroidism and significant impact on levothyroxine dose requirements following rifampin therapy, and the importance of close thyroid function monitoring in patients with hypothyroidism and on rifampin, especially in context of post-surgical hypothyroidism. Presentation: No date and time listed

Rare Immune Dysregulatory Disorder Leading to Lung Transplantation

<h3>Introduction</h3> Interleukin-12 receptor β1 is a common receptor chain of the pro-inflammatory cytokines IL-12 and -23. IL-12/IL-23Rβ1 deficiency is a rare autosomal recessive disorder characterized by predisposition to mycobacteria infections, whereas IL-12/IL-23Rβ1 gain-of-function mutation may cause a systemic disease that manifests as a chronic inflammatory condition and organ fibrosis. We describe the first case of lung transplantation (LTx) in lung-fibrosis due to this immune dysregulatory disorder. <h3>Case Report</h3> We present a 27-year-old patient diagnosed with gain-of-function mutation in IL-12/IL-23Rβ1. The disorder led to multi-organ involvement consisting of interstitial lung disease with secondary pulmonary hypertension, hepatitis, dermatosis and hepatosplenomegaly. Multiple immunosuppressive and modulating agents were tried without improving lung function. The patient showed no susceptibility to infections. With increasing pulmonary hypertension and progressive respiratory failure, he reached indication for LTx. Prior to listing, concerns were raised due to his exceptional pro-inflammatory immunodeficiency and potentially increased risk of rejection. After extended research and with few other treatment options left, LTx was performed in 2017 (ABO-compatible and negative crossmatch) with an uncomplicated perioperative course. He received standard immunosuppression with the goal of high cyclosporine level within standard target range. In his first year post-transplant he was treated 3 times successfully for minimal acute rejection and has since then had no further rejections. In 2018 he developed Candida dubliensis sepsis and osteomyelitis and was treated for 16 months. A pan-JAK-inhibitor was initiated, while mycophenolate was reduced and stopped, to try to inhibit a progressive sterile liver and bone inflammation. The regimen had remarkable effect on the patient`s general condition. Recurring CMV reactivation ensued and in 2020 also systemic Mycobacterium avium intracellulare infection, still requiring treatment. Pulmonary function is stable. <h3>Summary</h3> Our experience suggests that LTx is a valid option for this indication resulting in much improved quality of life. It remains challenging to find the right balance between treating the underlying disease while providing adequate immunosuppression to prevent rejection and avoiding infections.

HYPERCALCEMIA UNMASKING UNDERLYING MYCOBACTERIUM AVIUM-INTRACELLULARE INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Common causes of hypercalcemia include malignancy and granulomatous disease; however nontuberculous mycobacteria (NTM) infections are also rarely associated with hypercalcemia. We present a case of hypercalcemia secondary to underlying Mycobacterium avium-intracellulare (MAI) infection in a patient with acquired immunodeficiency syndrome (AIDS). CASE PRESENTATION: A 36-year-old male with recently diagnosed AIDS (CD4 count 17 cell/uL, viral load 52,400 copies/mL at diagnosis) on anti-retroviral therapy (ART) presented with three days of generalized weakness, nausea, vomiting, and poor appetite associated with night sweats, 20-pound weight loss, dyspnea, and non-productive cough. Vital signs were unremarkable, physical exam revealed moderate lower abdominal tenderness with hepatosplenomegaly, and bloodwork was notable for a corrected calcium of 13.1 mg/dL, undetectable parathyroid hormone (PTH) of <1 pg/mL, elevated 1,25-dihydroxyvitamin D to 112 pg/mL, and decreased PTH-related protein of 7 pg/mL. Hypercalcemia was treated with intravenous fluid hydration and pamidronate. Computed Tomography of Chest/Abdomen/Pelvis revealed bulky retroperitoneal and mesenteric adenopathy and splenomegaly, concerning for lymphoma versus paradoxical worsening of existing opportunistic infection secondary to immune reconstitution with the initiation of ART (CD4 70 cell/uL, viral load 42 copies/mL). He underwent diagnostic laparoscopy with mesenteric lymph node biopsy for definitive diagnosis, with both biopsy and acid-fast bacillus (AFB) culture positive for MAI, clinical picture consistent with disseminated infection. He was started on Ethambutol and Azithromycin and discharged with close infectious disease follow-up. DISCUSSION: Many etiologies exist for hypercalcemia, the most notable being malignancy and granulomatous diseases. In patients with AIDS, NTM infection should also be considered in the differential. To date, there have only been eight reported cases of MAI-associated hypercalcemia, making this the ninth case, and the fourth one with hypercalcemia as the presenting symptom [1]. Though the mechanism is not well understood, one theory postulates the involvement of immune reconstitution inflammatory syndrome (IRIS). In newly diagnosed AIDS patients, the restoration of the immune system due to ART to fight off latent infection causes rebound production of interferon-gamma, which enhances granuloma formation to facilitate the eradication of infection. In turn, granulomas produce 1-alpha hydroxylase, leading to increased 1,25-vitamin D and calcium production [2]. CONCLUSIONS: Non-PTH-mediated hypercalcemia is often attributed to malignancy. However further investigation is warranted to rule out opportunistic infections, especially in newly diagnosed cases of AIDS. REFERENCE #1: Ayoubieh H, Alkhalili E. Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient. Braz J Infect Dis. 2017;21(1):116-118. doi:10.1016/j.bjid.2016.08.002 REFERENCE #2: Tsao YT, Wu CC, Chu P. Immune reconstitution syndrome-induced hypercalcemic crisis. Am J Emerg Med. 2011;29(2):244.e3-244.e244006. doi:10.1016/j.ajem.2010.03.013 DISCLOSURES: No relevant relationships by Sudheer Konduru, source=Web Response No relevant relationships by SANA MULLA, source=Web Response No relevant relationships by Mrunal Sharma, source=Web Response No relevant relationships by Vihitha Thota, source=Web Response No relevant relationships by Manaswitha Thota, source=Web Response

Disseminated Mycobacterium avium-intracellulare infection in an HIV-infected patient

Disseminated Mycobacterium avium-intracellulare infection in an HIV-infected patient

Disseminated Mycobacterium avium-intracellulare infection in an HIV-infected patient

Disseminated Mycobacterium avium-intracellulare infection in an HIV-infected patient

Isolation, Molecular Typing, and Antibiotic Susceptibility Testing of Mycobacterium avium Subspecies hominissuis From a Dog With Generalized Mycobacteriosis.

Mycobacterium avium-intracellulare complex infections are becoming an increasing concern in veterinary medicine because they affect livestock, wildlife, and companion animals. Here we describe the isolation, molecular typing, and antibiotic susceptibility testing of the causative agent of a rare case of generalized mycobacteriosis in a crossbred dog. Mycobacterial colonies were isolated from a popliteal lymph node aspirate sample and molecular typed by SNPs typing of the genes gyrB and rpsA, the 3′ region of the hsp65 gene and the internal transcribed spacer (ITS), and MIRU-VNTR analysis. Colonies were also tested in vitro against the macrolide clarithromycin and other drugs, using a resazurin microdilution assay, in order to provide the most appropriate treatment for the dog. Results from SNPs typing of gyrB and ITS, as well as from MIRU-VNTR analysis suggested the isolation of a single strain of M. avium subsp. hominissuis (Mah). On the other hand, SNP typing of rpsA revealed DNA polymorphisms that led colonies to cluster into two groups. The presence of two distinct strains of Mah has been assumed. All colonies, regardless of the nucleotide sequence of rpsA, were found to be sensitive to all of the drugs tested except for ethambutol. Although the therapy administered was adequate, the dog's overall clinical status worsened progressively and the animal died 8 months later. In conclusion, we report on the isolation of Mah from a dog with generalized mycobacteriosis.

Patterns of Mycobacterium avium-intracellulare complex infection in duodenal endoscopic biopsies in HIV/AIDS patients

Mycobacterium avium-intracellulare complex (MAIC) is a nontuberculous opportunistic infection in immunocompromised patients. Involvement of the gastrointestinal tract (GIT) is usually part of a disseminated disease in AIDS patients with a low CD4 count, however with standard antiretroviral therapy (ART), a localized presentation is more likely. It can affect any part of the GIT, mostly the duodenum and typically as patches. Incomplete or refractory ART for HIV-strains, therapy-related side effects, noncompliant or incomplete treatment to previous MAIC infections, superimposed complications and comorbid opportunistic infections may result in atypical clinical, endoscopic and histopathologic manifestations. We performed a retrospective review study retrieving cases of MAIC in duodenal endoscopic biopsy. We found five cases of MAIC in HIV/AIDS patients. They were males with an average age of 40-years. They showed different histopathologic features, variable patterns of MAIC-histiocytic infiltrates, and varying intensity of intracellular acid-fast positive bacilli. Enterocytes vacuolization and transepithelial elimination were also observed. Three cases were associated with cytomegalovirus and cryptococcal infections. A case was complicated by lymphangiectasia-associated protein-losing enteropathy. Initially, three cases were morphologically missed. Ziehl-Neelsen stain helped reach the correct diagnosis. Pathologists have an important role in patients' management by guiding clinicians to the correct diagnosis. Pathologists should be aware of these different histopathologic manifestations, their potential pitfalls, look for certain helpful clues complemented with multiple levels and special stains. In particular, AFB stains are mandatory in all mucosal biopsy specimens from HIV/AIDS patients regardless of their appearances.

M253 A CASE OF RECURRENT MYCOBACTERIUM AVIUM INTRACELLULARE CERVICAL LYMPHADENITIS

This is a case of a 17-month-old male with persistent, extensive Mycobacterium Avium Intracellulare (MAI) infections despite optimum medical therapy; he is currently being investigated for a genetic defect leading to persistent mycobacterial disease.

Disseminated Talaromyces marneffei And Mycobacterium avium Infection Accompanied Sweet's Syndrome In A Patient With Anti-Interferon-γ Autoantibodies: A Case Report.

BackgroundPatients with high-titer anti-IFN-γ autoantibodies present disseminated non-tuberculous mycobacterial (NTM) and other opportunistic infections. Due to its rare occurrence and non-specific symptoms, this syndrome is difficult to diagnose during early disease stages. Here, we report a case with high-concentrations of serum anti-IFN-γ autoantibodies who presented with disseminated Talaromyces marneffei and NTM disease accompanied Sweet’s syndrome.Case presentationA 62-year-old Chinese woman with no previous history was admitted to our hospital in August 2016 due to intermittent fever for 2 years, left chest wall redness, and swelling for 3 months. During hospitalization, the patient was confirmed with disseminated T. marneffei and successfully treated with antifungal therapy. In July 2017, upon second admission, Mycobacterium avium intracellular (MAC) pulmonary infection was established after positive cultures from the right lung tissue. The patient failed treatment after 1 month of anti-NTM therapy due to side effects. In May 2018, she was confirmed as having disseminated MAC disease accompanied by hand rashes, which was considered as Sweet’s syndrome. High-level anti-IFN-γ antibodies in the patient serum were detected upon comparison with normal controls (2.85-fold increase). Following anti-NTM therapy, both symptoms and pulmonary infiltration gradually improved, and joint destruction and lymphadenitis remained.ConclusionsPatients with anti-interferon-γ autoantibodies should be considered for severe, recurrent infections in adults in the absence of other known risk factors. Sweet’s syndrome is a common skin manifestation of the syndrome.

Mycobacterium avium-intracellulare septic arthritis of the sternoclavicular joint in an immunocompetent host; a three-year follow-up

A 34 year-old lady was referred for rheumatology review by the orthopaedic team for further investigation of chronic left sternoclavicular joint pain. No preceding event such as trauma, injury or infection had occurred. A rheumatology workup turned out to be negative for an inflammatory arthropathy. After extensive investigations including blood tests, an MRI scan, a CT scan, and a bone scan, and in consultation with the orthopaedic team, the affected joint was biopsied and tested for mycobacterium avium-intracellulare infection. The results came back as positive and the patient was started on anti-mycobacterial treatment. We report the diagnosis, management and 3-year follow-up of this unique case. This highlights an uncommon and often misdiagnosed cause of septic arthritis caused by mycobacterium avium-intracellulare infection. To our knowledge this is the first confirmed sternoclavicular mycobacterium avium-intracellulare infection in an immunocompetent host reported in the literature.

Genitourinary Tract Infection Due to Mycobacterium avium intracellulare Complex Infection in Pretransplant Setting With Recurrence Following Transplant: A Case Report

Genitourinary (GU) tract infection with Mycobacterium avium intracellulare complex (MAI) is very rare and, to our knowledge, has never been reported in the solid organ transplant literature. Case DescriptionA 61-year-old Somali-born woman had a history of liver cirrhosis due to chronic hepatitis C infection. She was diagnosed as having and treated for latent tuberculosis infection and GU tract infection due to MAI. She received a total of 17 months antimycobacterial therapy consisting of azithromycin, ethambutol, and moxifloxacin. Within 5 months of the initiation of antimicrobial therapy, there was documented sterilization of urine mycobacterial cultures. Liver and kidney transplant was performed 3 months after finishing the treatment course. One year following transplant, GU tract infection due to MAI recurred. She declined further diagnostic testing as well as mycobacterial therapy. She died 15 months following transplant for reasons not related to infections. ConclusionThe treatment of MAI infection in solid organ transplant candidates and recipients is challenging, and the duration of therapy in this population is not known. The recurrence of infection following transplant in this case may argue in favor of a duration that extends beyond the date of transplant. The combination of a fluoroquinolone and ethambutol may successfully prevent reactivation of tuberculosis in patients with history of latent tuberculosis infection and deserves further evaluation.

Mycobacterial chylous ascites: report of three cases and systematic review.

Chylous ascites is an uncommon presentation of mycobacterial infection. We report three cases of tubercular chylous ascites, and in addition, we performed a systematic review of the published literature for the clinical presentation, treatment, and outcomes of mycobacterial chylous ascites. We followed the PRISMA guidelines for the systematic review. A total of 33 cases (including three of ours) were included. The mean age of the reported cases was 32.54 ± 17.56 years, and a male predominance (76%) was noted. The predominant clinical features were abdominal distension, abdominal pain, fever and loss of appetite and weight. Mycobacterium tuberculosis (MTB) and Mycobacterium avium-intracellulare (MAC) infection were responsible for 16 and 15 cases, respectively. All patients with MAC related chylous ascites had HIV infection. The mechanisms were related to lymph nodal enlargement, constrictive pericarditis and remote scrofuloderma. Overall, there was 29% mortality. Use of anti-mycobacterial therapy with use of total parenteral nutrition, octreotide and medium chain triglyceride-based diet resulted in improvement in the rest of the cases. The cause of death in our case was anti-tubercular therapy-induced hepatitis; three deaths were due to disseminated mycobacterial infection, one due to cardiopulmonary failure and unknown in four patients. Chylous ascites due to mycobacterial infection is uncommon and associated with poor outcome. However, early diagnosis and nutritional management along with antimycobacterial therapy can improve outcome.

Pulmonary Mycobacterium Avium-Intracellulare Complex Infection in an Infant: A Silent and Coincidental Finding.

An 11-month-old healthy infant girl was noted to have left lower lobe (LLL) opacities on chest X-ray (CXR) after developing desaturations during an elective cochlear implant surgery. Repeat CXR 10 days later revealed hyperexpansion of the left lung and persistent LLL opacity. Chest computerized tomography revealed enlarged mediastinal lymph nodes, left mainstem bronchial obstruction, and nodular opacities. Bronchoscopic biopsy of the endobronchial tissue revealed multiple necrotizing granulomas and grew Mycobacterium avium-intracellulare, Streptococcus viridans, and Actinomyces odontolyticus. This case illustrates the potential for significant mediastinal lymphadenopathy, and endobronchial and parenchymal lesions caused by nontuberculous mycobacteria, which can present insidiously and without respiratory symptoms in otherwise healthy infants, despite advanced pulmonary disease.

Endotracheal involvement from atypical mycobacterium causing respiratory difficulty: Case report and literature review

Abstract Atypical mycobacterium infections often present as cervicofacial lymphadenitis in pediatric patients. Endotracheal involvement, however, is rare, and has not been previously described with imaging and photographs. An infant with natural killer T-cell deficiency was admitted with cough, rhinorrhea, and cervical lymphadenopathy. Laryngotracheobronchitis-type symptoms persisted and imaging revealed an intraluminal abnormality of the trachea. Endoscopy confirmed a mediastinal lymph node with intrusion into the tracheal lumen. Intraluminal biopsy was deferred due to concerns of airway loss. Biopsy of the associated cervical lymph node confirmed Mycobacterium avium-intracellulare infection. The patient was managed with antibiotics and steroids with clinical resolution of his respiratory symptoms.

An association between pulmonary Mycobacterium avium-intracellulare complex infections and biomarkers of Th2-type inflammation

BackgroundThe rising incidence of pulmonary Mycobacterium avium-intracellulare complex (MAI) infection is unexplained but parallels the growing world-wide epidemic of allergic disease. We hypothesized an association between pulmonary MAI infection and Th2-type immune responses as seen in allergy.MethodsBiomarkers of patient Th2-type immune responses (peripheral blood eosinophil counts and serum IgE levels) were compared between patients with positive pulmonary samples for tuberculosis and non-tuberculous mycobacterial (NTM) infection. A further comparison of clinical characteristics, including respiratory co-morbidities, and biomarkers, was conducted between patients culturing MAI NTM and those culturing NTM other than MAI.ResultsPatients culturing NTM from pulmonary samples had significantly higher peripheral blood eosinophil levels than those culturing Mycobacterium tuberculosis. Furthermore, patients culturing MAI compared to those culturing NTM other than MAI had higher eosinophil counts (mean 0.29x109/L vs 0.15x109/L, p = 0.010) and IgE levels (geometric mean 138kU/L vs 47kU/L, p = 0.021). However there was no significant difference in the frequency of asthma between the two NTM groups.ConclusionsThere is an association between biomarkers of Th2-type immune responses and pulmonary MAI. Prospective and translational research could identify the direction of causation; and so determine whether our finding may be utilized within future management strategies for MAI.

Bedaquiline as a potential agent in the treatment of M. intracellulare and M. avium infections

Recently in this journal, Salfinger and Migliori [1] discussed the accessibility of bedaquiline drug susceptibility testing and the analysis of minimum inhibitory concentrations (MICs) for strains of Mycobacterium tuberculosis . As the recommended treatments for diseases caused by M. avium , and especially M. intracellulare , have high failure rates [2, 3], we measured the MIC of bedaquiline in 20 clinical isolates of these species. Bedaquiline is a potential agent to treat severe or relapsing M. avium-intracellulare complex infections

一次感染型Mycobacterium avium-intracellulare complex症の気管支鏡的検討

一次感染型Mycobacterium avium-intracellulare complex症の気管支鏡的検討

8-4 一次感染型MAC症における中枢気道病変の気管支鏡的検討( 第28回日本呼吸器内視鏡学会総会)

8-4 一次感染型MAC症における中枢気道病変の気管支鏡的検討( 第28回日本呼吸器内視鏡学会総会)

Endobronchial Nodules: A Rare Manifestation of Non-Hodgkin’s Lymphoma

SESSION TITLE: Fellow Case Report Slide: Pulmonary Manifestations of Systemic Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM INTRODUCTION: Lymphoma may involve the lung. Pulmonary manifestations of lymphoma typically involve the lung parenchyma. Endobronchial disease is rarely seen. We present a case of non-Hodgkin’s lymphoma, follicular subtype, with diffuse pulmonary parenchyma and endobronchial involvement. CASE PRESENTATION: A 63-year-old Caucasian female with a history of mycobacterium avium-intracellulare (MAI) infection who is 2 years status post 18 months of usual treatment is referred to the pulmonary department for progressive dyspnea and abnormal chest CT findings. Within the past year, she was diagnosed with follicular lymphoma after an abnormal routine mammogram followed by lymph node excision and bone marrow biopsy. Due to the absence of bulky disease, treatment was not initiated and she was followed by routine surveillance. CT chest for evaluation of her dyspnea was significant for bilateral diffuse nodular parenchymal opacities, endobronchial nodularity with associated bronchial narrowing, and absence of mediastinal lymphadenopathy. Because of these findings with the lack of systemic involvement, lymphoma was thought to be less likely and bronchoscopic evaluation was pursued. Bronchoscopy showed numerous scattered endobronchial polypoid nodules with near complete obstruction of the right upper lobe junction. Microbiological studies on bronchoalveolar lavage specimen were negative, including fungal and mycobacterial cultures. Endobronchial biopsy was positive for follicular lymphoma, consistent with the patient’s known history. The patient was initiated on RCHOP chemotherapy with plans for follow up bronchoscopy to document resolution. DISCUSSION: Lymphoma with endobronchial involvement is rare. Recognition is crucial given its capacity to obstruct the airways. What makes our case more intriguing is the extent of pulmonary parenchyma and tracheobronchial tree disease with absence of mediastinal lymph node involvement. Anecdotal cases show implementation of chemotherapy typically leads to a robust therapeutic response with near resolution of endobronchial lesions. CONCLUSIONS: The pulmonary manifestations of lymphoma can mimic other disease entities and lead to life-threatening complications secondary to endobronchial obstruction. Given its tendency for near resolution with institution of chemotherapy, keeping a wide differential is important when approaching patients with endobronchial lesions. Reference #1: Mcrae, W.m., C.s. Wong, and G.m. Jeffery. Endobronchial Non-Hodgkin’s Lymphoma. Respiratory Medicine 92.7 (1998): 975-77. Web. DISCLOSURE: The following authors have nothing to disclose: Gurminder Dhillon, Andrew Zane No Product/Research Disclosure Information