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Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 435-437

Diagnosis of atypical mycobacterial and fungal coinfection

Department of Internal Medicine, General Universitary Hospital Gregorio Marañón, Doctor Esquerdo Street, 46, Madrid, 28007, Spain

Date of Submission21-May-2020
Date of Decision01-Jul-2020
Date of Acceptance21-Jul-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Víctor Mato Jimeno
Department of Internal Medicine, General Universitary Hospital Gregorio Maranon, Doctor Esquerdo Street, 46, Madrid, 28007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_98_20

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A 74-year-old female was hospitalized for further study of chest computed tomography (CT) scan compatible with mycobacterial infection. She had no history of underlying lung disease or immune alteration. At the moment of admission, she was completely asymptomatic. Scedosporium apiospermum a filamentous fungus was isolated first in the bronchoalveolar lavage. Weeks later, Mycobacterium avium complex grows in the mycobacterial culture sample.

Keywords: Bronchoalveolar lavage, chest computer tomography-scan, Mycobacterium avium complex, Scedosporium apiospermum

How to cite this article:
Jimeno VM, Muñoz EC. Diagnosis of atypical mycobacterial and fungal coinfection. Int J Mycobacteriol 2020;9:435-7

How to cite this URL:
Jimeno VM, Muñoz EC. Diagnosis of atypical mycobacterial and fungal coinfection. Int J Mycobacteriol [serial online] 2020 [cited 2023 Jan 28];9:435-7. Available from: https://www.ijmyco.org/text.asp?2020/9/4/435/303461

  Introduction Top

We present a rare case of lung coinfection by Mycobacterium avium complex (MAC) and Scedosporium apiospermum. To the best of our knowledge, there are described other two cases of lung coinfection by these microorganisms in the literature. We describe the diagnosis process and the treatment of this disease in our patient, and we describe the different clinical forms and how to treat each of them.

  Case Report Top

A 74-year-old female was admitted to our center for further study of lesions compatible with mycobacterial infection observed in a previous chest scan. She does not have remarkable previous medical history. She had never smoked. She had been hospitalized because of a chest computed tomography (CT) scan in which bronchiectasis, nodules, and cavitations were observed, being these findings compatible with mycobacterial infection [Figure 1]. The CT scan was done for further study of a solitary nodule observed in a previous chest radiography done, a few weeks earlier due to a persistent cold. Although the patient remained completely asymptomatic at the moment of the hospitalization, she had presented symptoms of two respiratory tract infections in the previous 6 months. The physical examination was normal. Cell blood count was normal. The rest of the laboratory parameters, including liver enzymes, renal function, ions, vitamins, and serum immunoglobulin levels, were within normal range. Lymphocyte population's values were in the range. Microbiological tests results were negative for human immunodeficiency virus, hepatitis virus serologies, and interferon-gamma release assay. Three sputum samples were collected without evidence of acid alcohol-resistant bacillus (AARB) in the auramine stain and negative culture after 6 weeks of incubation. A bronchoalveolar lavage (BAL) was done. In the BAL samples, filamentous fungus in the calcofluor stain was observed and finally identified by the culture as S. apiospermum. No AARB was identified in the auramine stain. Polymerase chain reaction for Aspergillus was negative. After prolonged incubation, MAC was isolated in the BAL cultures. Therefore, the diagnosis of lung infection due to S. apiospermum in combination with MAC pulmonary disease was finally established. The patient received antifungal treatment with voriconazole. Then, as the patient was completely asymptomatic, the decision was close follow-up without treatment for the mycobacterial infection.
Figure 1: Chest computed tomography scan. (a) Bronchiectasis in the left upper lobe. (b) Cavitating opacity in the right lower lobe

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  Discussion Top

Nontuberculous mycobacteria (NTM) are opportunistic human pathogens associated with infectious pulmonary disease. If a mycobacterial pulmonary infection is suspected, the implication of Mycobacterium tuberculosis complex should be first dismissed. However, atypical mycobacterial infection should be also considered.[1] Infectious pulmonary disease due to NTM is more frequent to develop in patients with immunosuppression or underlying lung disease, but there are some cases described in immunocompetent patients. The clinical and microbiologic criteria for diagnosing NTM lung disease established by the American Thoracic Society and Infectious Disease Society of America include symptoms or imaging studies consistent with pulmonary disease and current isolation of mycobacteria from at least two sputum samples or isolated from at least one BAL.[2] MAC includes several species of NTM. There are two major clinical presentations in pulmonary disease caused by MAC. The first one, the fibrocavitary form, is a pulmonary disease in patients with known underlying lung disease in which clinical manifestations are cough, weight loss, and infiltrates with cavities in the chest images. The second one, the nodular/bronchiectasic form, more frequent develops in patients without known underlying lung disease, mainly nonsmoking women aged over 50 years.[3] This clinical form called “Lady Windermere Syndrome” was first described in women with radiologic pattern limited in the lingula or middle lobe.[4]

The fungus S. apiospermum was also isolated in the BAL of our patient. Human infection often results from inhalation of spores or through direct inoculation. Underlying predisposing factors are wounds in contact with polluted soil or water, immunosuppression, and pulmonary diseases.[5],[6] Our patient did not have any of these underlying factors but has an associated MAC lung infection, which could be a predisposing factor. It is considered invasive mold infection when a positive culture in a histopathological tissue examination is obtained or when there are clinical or radiographic findings compatible with infection and a culture positive for mold obtained from a sterile site with a sterile technique.[7],[8]

There are described in the literature, two other cases of concomitant lung infection due to MAC and S. apiospermum. The first one was a 54-year-old woman, immunocompetent, without lung disease, who works as a cleaner of a swimming pool in a spa.[9] The second one was a 69-year-old woman with previous medical history of rheumatoid arthritis under corticosteroid treatment and interstitial pneumonia due to treatment with gold. Both of them receive antifungal and antituberculous therapy with good progress of the disease.[10]

MAC and S. apiospermum are microorganisms that are found in the environment, especially in polluted mud or water. Our patient lived in the countryside, and she had a swimming pool whose water came from a natural well. Although the water was treated with disinfectants, these microorganisms are usually resistant to the commonly used disinfectants and antiseptic products.

As regards management of MAC nodular/bronchiectasic pulmonary disease, which is considered less severe, if the patient has limited symptoms, a close follow-up evaluating periodically clinical, radiological, and microbiological parameters can be considered instead of initiating pharmacological treatment.[11] Treatment of S. apiospermum lung infection is based in the use of azoles, mainly voriconazole, and it should be continued until symptoms and radiological signs are resolved.[5]

  Conclusion Top

NTM lung disease and also fungal invasive lung infection are more common in patients with immunosuppression or lung underlying diseases. We present a case of concomitant MAC and S. apiospermum lung infection in an elderly woman without known immune alterations or lung disease. MAC lung infection is more common in male adults with underlying lung disease, but there is also other clinical presentation in the elderly women without lung disease or immunosuppression described first as “Lady Windermere's Syndrome.” To our knowledge, S. apiospermum infection was probably favored by the lung lesions secondary to MAC infection.[12]

Ethical consideration

This case report is presented in accordance with the Declaration of Helsinki and with informed consent of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Camarena Miñana JJ, PellicerG, R. Micobacterias atípicas y su implicación en patología infecciosa pulmonar Enferm Infecc Microbiol Clin. 2011;29(Supl 5):66-75.  Back to cited text no. 1
Griffith DE, Aksamit T, Brown-Ellio BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: Diagnosis, treatment and prevention of nontuberculous mycobacteria diseases. Am J Respir Cris Care Med 2007;175:367-416.  Back to cited text no. 2
Prince DS, Peterson DD, Steiner RM, Gottlieb JE, Scott R, Israel HL, et al. Infection with Mycobacterium avium complex in patients without predisposing conditions. N Engl J Med 1989;321:863-8.  Back to cited text no. 3
Reich JM, Johnson RE. Mycobacterium avium complex pulmonary disease presenting as an isolated lingular or middle lobe pattern. The Lady Windermere syndrome. Chest 1992;101:1605-9.  Back to cited text no. 4
San Juan R, Berenguer J, Aguardo JM. Hongos filamentosos emergentes: Scedosporium. Control Calidad SEIMC 2003.  Back to cited text no. 5
Cobo F, Lara-Oya A, Rodríguez-Granger J, Sampedro A, Aliaga-Martínez L, Navarro-Marí JM. Infections caused by Scedosporium/Lomentospora species: Clinical and microbiological findings in 21 cases. Med Mycol 2018;56:917-25.  Back to cited text no. 6
de Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy And Infectious Diseases mycoses study group (EORTC/MSG) consensus group. Clin Infect Dis 2008;46:1813-21.  Back to cited text no. 7
Ayats J, Martín Mazuelos E, Pernán García J, Quindos Andrés G, Sánchez Reus F, García Rodríguez J. Recomendaciones sobre el diagnóstico de la enfermedad fúngica invasora de la sociedad española de enfermedades infecciosas y microbiología clínica (SEIMC). Actualización 2010. Enferm Infecc Microbiol Clin 2011;39:e139-15.  Back to cited text no. 8
Tekavec J, Mlinaric-Missoni E, Babic-Vazic V. Pulmonary tuberculosis associated with invasive pseudallescheriasis. Chest 1997;111:508-11.  Back to cited text no. 9
Murayama T, Amitani R, Tsuyuguchi K, Watanabe I, Kimoto T, Suzuki K, et al. Polypoid bronchial lesions due to Scedosporium apiospermum in a patient with Mycobacterium avium complex pulmonary disease. Eur Respir J 1998;12:745-7.  Back to cited text no. 10
Jeong BH, Jeon K, Park HY, Kim SY, Lee KS, Huh HJ, et al. Intermittent antibiotic therapy for nodular bronchiectatic Mycobacterium avium complex lung disease. Am J Respir Crit Care Med 2015;191:96-103.  Back to cited text no. 11
Sani FM, Uba A, Tahir F, Abdullahi IN, Adekola HA, Mustapha J, et al. Spectrum of pulmonary fungal pathogens, associated risk factors, and anti-fungal susceptibility pattern among persons with presumptive tuberculosis at Gombe, Nigeria. Int J Mycobacteriol 2020;9:144-9.  Back to cited text no. 12
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