|Year : 2019 | Volume
| Issue : 3 | Page : 295-297
A case report of disseminated Mycobacterium colombiense infection in an HIV patient
Eduarda Pena1, Diana Machado2, Miguel Viveiros2, Sofia Jordão1
1 Infectious Diseases Department, Matosinhos Local Health Unit, Matosinhos, Portugal
2 Unit of Medical Microbiology, Institute of Hygiene and Tropical Medicine of NOVA University of Lisbon, Lisbon, Portugal
|Date of Web Publication||12-Sep-2019|
Dr Eduarda Pena
Infectious Diseases Unit, Hospital Pedro Hispano, Matosinhos Local Health Unit, Rua Dr. Eduardo Torres, 4464-513 Sra da Hora, Matosinhos
Source of Support: None, Conflict of Interest: None
Mycobacterium colombiense is a newly recognized member of the Mycobacterium avium complex, and only a few cases of infections caused by this pathogen have been reported. We present an imported case of disseminated disease caused by M. colombiense in an HIV patient in early February 2017.
Keywords: Disseminated disease, HIV, Mycobacterium colombiense
|How to cite this article:|
Pena E, Machado D, Viveiros M, Jordão S. A case report of disseminated Mycobacterium colombiense infection in an HIV patient. Int J Mycobacteriol 2019;8:295-7
|How to cite this URL:|
Pena E, Machado D, Viveiros M, Jordão S. A case report of disseminated Mycobacterium colombiense infection in an HIV patient. Int J Mycobacteriol [serial online] 2019 [cited 2019 Sep 20];8:295-7. Available from: http://www.ijmyco.org/text.asp?2019/8/3/295/266482
| Introduction|| |
Mycobacterium colombiense was first isolated in 2006 from the sputum and blood samples from four Colombian patients with HIV infection. After that, a literature review showed 16 cases of disease due to this agent, of which four were disseminated.
We report, to the best of our knowledge, the first case of M. colombiense-disseminated disease in a Portuguese patient. This report highlights the challenging diagnostic workup that culminated in a surgical procedure showing extensive peritoneal involvement by M. avium complex (MAC) disease, a very rare clinical presentation.
| Case Report|| |
A 47-year-old Portuguese male who had lived in Panama for the past 4 years, was diagnosed with HIV infection in October 2016 at Stage C3 with 98 cells/μL. By then, he was diagnosed with pneumocystosis, cytomegalovirus pneumonitis, and oropharyngeal candidiasis. Later, antiretroviral therapy was initiated with virologic response and 125 cells/μL after 4 weeks. In January 2017, he was hospitalized again with gastrointestinal symptoms and fever. Abdominal computed tomography scan showed homogenous hepatomegaly and multiple retroperitoneal adenopathies. He had an erythrocyte sedimentation rate of 97 mm/h. The main diagnostic hypotheses included disseminated tuberculosis, nontuberculous mycobacterial (NTM) infection, lymphoproliferative disorder, and immune reconstitution inflammatory syndrome. At the 10th day of admission, an exploratory laparoscopy was performed. The histopathology of a lymph node and epiploon revealed multiple necrotizing granulomas with positive Ziehl–Neelsen (ZN) staining. The hepatic biopsy revealed granulomas. Mycobacterial cultures were positive in all the abdominal samples including peritoneal fluid. Bone marrow, blood, and sputum cultures for mycobacteria were negative. The patient was started on treatment with clarithromycin, rifabutin, and ethambutol as soon as the ZN stain was positive. M. colombiense was identified in the lymph node by partial sequencing of the 16S rRNA, hsp65, and rpoB genes as previously described (Kim et al., 1999; Lane, 1991). The lymph node was processed by the conventional mycobacteriological NaOH-NALC method, and aliquots were collected for ZN staining and DNA extraction using the QIAamp DNA mini kit (QIAGEN, GmbH, Hilden, Germany), according to the manufacturer's instructions, and inoculation of mycobacteria growth indicator tube (MGIT) for the BACTEC MGIT 960 System (Becton-Dickinson Diagnostic Instrument Systems, Sparks, MD, USA), according to the manufacturer's instructions and Löwenstein–Jensen solid media. Polymerase chain reaction products were purified and sequenced on both strands (StabVida, Caparica, Portugal). The sequences were edited and analyzed with ChromasPro 2.0.0 (Technelysium DNA sequencing software, South Brisbane, Queensland, Australia). Sequence similarity analysis was done using the basic local alignment search tool at the National Center for Biotechnology Information database (https://www.ncbi.nlm.nih.gov/). Sequence analysis of the 16S rRNA, hsp65, and rpoB genes showed 99% homology with the sequence of the type strain of M. colombiense (DSM_45105). During all admissions, he had fever and intermittent dyspeptic complaints that persisted for the 1st month after discharge. He completed 20 months of treatment with clinical and imagological resolution.
| Discussion|| |
Species of the M. avium complex are the most frequently isolated NTM species from human infections causing pulmonary, skin, soft-tissue, and disseminated diseases. MAC comprises more than ten species or subspecies, and disseminated disease commonly occurs in immunocompromised patients, especially those with impaired cell-mediated immunity.
M. colombiense is a slow-growing, acid-fast rod first isolated in 2006 by Murcia et al. from the sputum and blood samples from four Colombian patients with HIV infection. Both M. colombiense and M. avium yield a positive result on the most widely used identification laboratory procedures that are considered gold standard for MAC complex, namely the AccuProbe MAC identification assay. Therefore, sequencing analysis of targets such as 16S rRNA, hsp65, and rpoB genes and 16S-23S rDNA internal transcribed spacer or combination of these in a multigene approach has shown to be necessary for species determination. The hsp65 gene polymorphism analysis pattern and the 16S rRNA gene are unique to M. colombiense, and the latter is considered the gold standard molecular marker.
Few studies have reported minimum inhibitory concentrations (MICs) for the commonly used antimycobacterial agents against M. colombiense. A recent report showed that clarithromycin, moxifloxacin, rifabutin, amikacin, and ciprofloxacin are active against M. colombiense, with MICs comparable to those of closely related species of MAC.
However, bacteremia due to M. colombiense was associated with a higher 30-day mortality (75%, n = 4) and HIV coinfection with severe immunodepression (CD4 count ranged from 2 to 136 cells/μL).
Due to the limited number of cases reported, it is difficult to conclude if M. colombiense is more virulent than other members of MAC. Even so, the results of an animal study showed that mice infected with M. avium had higher bacterial burdens than animals infected with M. colombiense, indicating a higher virulence of M. avium.
The most important stage of the treatment for disseminated MAC disease in HIV patients is controlling the HIV disease with antiretroviral therapy.
Initial therapy should include a macrolide plus ethambutol and should be maintained until symptoms resolve and cell-mediated immune reconstitution occurs.
Adding a third drug to the treatment may be necessary in some patients, and it has been demonstrated that adding rifabutin to the combination of clarithromycin and ethambutol improves survival.
We treated our patient with clarithromycin 1000 mg/day, rifabutin 300 mg/day, and ethambutol 1200 mg/day for 20 months with good clinical response.
Involvement of the peritoneum by MAC is very rare and occurs more frequently in HIV patients with a CD4 cell count <100 cells/mL. It is usually a late manifestation of a disseminated infection, and the mortality can be as high as 50%.
In summary, we diagnosed and managed a M. colombiense- disseminated disease in a HIV patient with extensive abdominal involvement, in which correct identification of the mycobacterial strain was essential for deciding the treatment, showing that molecular diagnostic methods are useful tools for the identification of rare NTM species.
Financial support and sponsorship
The work of DM and MV is partially supported by the Global Health and Tropical Medicine (GHTM) Research Center (Grant UID/Multi/04413/2013) from Fundação para a Ciência e a Tecnologia (FCT), Portugal. DM was supported by FCT grant SFRH/BPD/100688/2014.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Murcia MI, Tortoli E, Menendez MC, Palenque E, Garcia MJ. Mycobacterium colombiense
sp. Nov. A novel member of the Mycobacterium avium
complex and description of MAC-X as a new ITS genetic variant. Int J Syst Evol Microbiol 2006;56:2049-54.
Telenti A, Marchesi F, Balz M, Bally F, Böttger EC, Bodmer T. Rapid identification of mycobacteria to the species level by polymerase chain reaction and restriction enzyme analysis. J Clin Microbiol 1993;31:175-8.
van Ingen J, Turenne CY, Tortoli E, Wallace RJ Jr., Brown-Elliott BA. A definition of the Mycobacterium avium
complex for taxonomical and clinical purposes, a review. Int J Syst Evol Microbiol 2018;68:3666-77.
Maurer FP, Pohle P, Kernbach M, Sievert D, Hillemann D, Rupp J, et al.
Differential drug susceptibility patterns of Mycobacterium chimaera
and other members of the Mycobacterium avium
-intracellulare complex. Clin Microbiol Infect 2019;25:379.e1-379.e7.
Lee MR, Chien JY, Huang YT, Liao CH, Shu CC, Yu CJ, et al.
Clinical features of patients with bacteraemia caused by Mycobacterium avium
complex species and antimicrobial susceptibility of the isolates at a medical centre in Taiwan, 2008-2014. Int J Antimicrob Agents 2017;50:35-40.
González-Pérez M, Mariño-Ramírez L, Parra-López CA, Murcia MI, Marquina B, Mata-Espinoza D, et al.
Virulence and immune response induced by Mycobacterium avium
complex strains in a model of progressive pulmonary tuberculosis and subcutaneous infection in BALB/c mice. Infect Immun 2013;81:4001-12.
Daley CL. Mycobacterium avium complex disease. Microbiol Spectrum 2017;5:1.
Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al.
An official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367-416.
Benson CA, Williams PL, Currier JS, Holland F, Mahon LF, MacGregor RR, et al.
A prospective, randomized trial examining the efficacy and safety of clarithromycin in combination with ethambutol, rifabutin, or both for the treatment of disseminated Mycobacterium avium
complex disease in persons with acquired immunodeficiency syndrome. Clin Infect Dis 2003;37:1234-43.