The First Case Report : Mycobacterium riyadhense Pneumonia Newly Diagnosed HIV Patient

Case Presentation :The First Case Report : Mycobacterium riyadhense Pneumonia First Miss Identified as a Mycobacterium Terrae in Newly Diagnosed HIV Patient

Presented By : Dr . Hythum Salah Hassan Mohamed.

22- 01-2014 Wednesday

King Abd Alaziz Medical City –National Guard Hospital-Riyadh

Department of Medicine –Division of infectious Diseases

Clinical Presentation • In July 2013 , 44 years old female patient her Husband recently known to

have HIV infection , present to the National Guard Hospital –Riyadh complaining of history of one month of productive cough of yellow sputum , which contain blood in the last two weeks , shortness of breath , fever , and vomiting after persistent cough, also she had a history of decrease of appetite and loss of weight in the last two months .

• she had no TB history before . • she has past medical history of Hypothyroidism on replacement therapy

Dr.Hythum Salah H. Mohamed ,, MBBS-AAHIVS.

KAMC-IM-ID-Riyadh-January 2014.

• Also she had a history of admission due to preterm labor in 35 weeks of gestation with hydrops fetalis in February 2007 and one month before that her fetus develop fetal arrhythmia with third degree heat ,abnormal ventricular contractility and mild pericardial effusion .



• Also she was admitted twice for bloody diarrhea in November 2007 and May 2008 and colonoscopy revealed pan colitis versus Ulcerative colitis

• Also one month before the recent admission she was investigated for chronic GERD and dysphagia for about two years and result of Barium Swallow reported esophagitis as irregularity of esophageal mucosa and tiny ulceration ,and that is raised the question of immunocompromised state of patient at that time .

• Also she had a history of other hospitals recurrent admissions for different complaints.



Workup

• CXR showed right perihilar airspace opacity extended to the right upper lobe.



Chest High resolution CT scan –Angiography showed diffuse back ground –glass attenuation in both lungs with focal segmental consolidation in the right upper lobe that contain small cavity , also few small to borderline enlarged thoracic and axillary Lymph nodes , small bilateral pleural effusion , segmental consolidation with air bronchogram in both lower lobes and few scattered nonspecific lung nodules .



• Abdominal US showed liver enlargement 17.3 cm and left adnexal Cyst .

• first three sputum samples were negative for AFB .

• CBC showed mild Anemia other investigations all were negative .



Hospital Course

• patient admitted in 6 of July as a case of community acquired pneumonia in the Word , in the first day of admission she received Ceftriaxone and Azithromycin empirically but not improved .

• in the next day CCRT( Critical Care Response Team ) activated for hemodynamic instability and hypoxemia ( ABG Po2 68.3 mmhg PCo2 31.6 mmhg ) and patient transferred to the ICU where she received CPAP and other management .



• . patient admitted in ICU for two weeks till day 20 of July when she transferred to the Word after being stable .

• During ICU admission , the next sputum tests were positive for AFB smear , also culture showed Mycobacterium Terrae growth after 6 weeks in 22 of August 2013.



• TB PCR was negative from sputum .• Fungal culture from sputum showed moderate Candia Albicans .• Urine culture and smear was negative for AFB .• leukocytosis WBCC 18.8 noted in day 7 of admission ( WBCC 9 on

admission ) also marked thrombocytosis PLT 909 noted in day 19 of admission (PLT 452 on admission ) .



• after sputum smear showed AFB patient received INH , Rifampin , Pyrazinamide and Ethambutol , patient also received Tazocin and then Imipenem in ICU .

• patient developed drug induce Hepatitis , INH , Rifampin and pyrazinamide are stopped , they started patient on Moxifloxcin , Clarithromycin and continue Ethambutol also Pyrazinamide reintroduced again after LFTs back to normal , patient discharged to home in good condition in second of August 2013 with above medication plus Pyridoxine , Levothyroxine and Esomeprazole .



• But unfortunately patient readmitted again after about one week of discharge due to Fever and epigastric pain , she diagnosed with Drug induce Hepatitis (ALT 956 ) and UTI with E.coli ESBL .

• Pyrazinamide stopped with continue of other anti TB medications • After more than two weeks of admission she discharged again

after improved .



• In November HIV screening and confirmatory tests were positive .• But for non adherent to her medications and miss of medical

appointment she readmitted again in December 2013 with chest infection ( sever dyspnea , mild cough and fever ) .

• Diagnosis at that time was PCP VS M terrae Pneumonia .• Oral Candidiasis also was found ( heavy oral thrush ) .



• Viral load was 71877 and CD4 29 .• Sputum test requested for pneumocystis jirovecii and Mycobactrium

Terrae and for culture and sensitivity , but unfortunately not done because sample was sliva .

• She received treatment for 5 days (Bactrim , Fluconazole , prednisolone , Moxifloxcin ) , patient improved and she was discharged to home .

• She started on HAART ( Truvada and Efavirenze ) .



• Unfortunately patient is still coming with different presentations , last admission just two days before .

• Yesterday we receive confirmation from Microbiology Lab for positive sputum sample culture is identified as Mycobacterium riyadhense .



Literature Review

• Mycobacterium terrae is a slow-growing species of Mycobacterium was first isolated by Richmond and Cumming in 1950 from radish washings and was described an acid-fast saprophyte this organism is sometimes referred to as the “radish bacillus .

• mycobacterium terrae is on of Mycobacterium terrae complex which are three (M. terrae, Mycobacterium nonchromogenicum, and Mycobacterium triviale ) .

• In 1967, the Centers for Disease Control in the United States reported 5 clinically significant cases of M terrae infection .



http://en.wikipedia.org/wiki/Mycobacterium

• From 1966 to 2010, a total of 54 cases of M. terrae complex causing clinical disease were reported, with synovial and joint infections of the upper extremities representing the majority (32/54 [59%]) also other three case were reported till October 2012 .

• all cases of Mycobacterium Terrae were in non HIV patients , except one case was in HIV patient .



• spectrum of Mycobacterium Terrae infections includes tenosynovitis, septic arthritis, and osteomyelitis of the upper and lower extremities.• It has also been reported to cause gastrointestinal tract, urinary

tract, pulmonary, and disseminated infections .



• In Human immune deficiency Virus ( HIV ) isolation of M. terrae complex has been described only in 1 patient out of 35 HIV-infected patients , there was infected with different species of nontubeculus Mycobacterium (isolation occurred only in 1 case) .

• This organism was cultured from the blood and bronchoalveolar lavage fluid from a 45-year-old Mexican man with AID but clinical manifestations were not mentioned .



• In May 2000 the first HIV-related case of clinically relevant and significant of Mycobacterium Terrae disease was reported in Clinical Infectious Disease Journal, official publication of IDSA , for A 29-year-old HIV-infected woman with invasive M. Terrae infection ( Mucocutanuse and Lung ) .

• In introduction of case report in Journal they said ( Mycobacterium terrae has been rarely implicated in human disease and never in patients infected with human immunodeficiency virus (HIV) ).



• Patient had fever ,productive cough with multiple painless, nonitching , papulonodular skin lesions (up to5 mm) throughout the body, mainly on the face, and slight bilateral enlargement of axillary lymph .

• First sputum sample also was negative for AFB .



• AFB was positive from urine• AFB was positive from second sputum sample , also CT showed

change , CD4 count 19/ml ,before start specific therapy patient develop ARDS and died , culture after six weeks showed

M.Terrae .



• treatment of Mycobacterium Terrae infections in HIV patient there is no clear data or specific guide lines .

• In non HIV patients The optimal treatment of M. terrae infections has also not been defined , rifampin and isoniazid have been used to treat M. terrae complex infections, they have not been established as a standard of care or as empiric therapy because of the paucity of data and variable success .



• Mycobacterium terrae complex has also shown susceptibility to clarithromycin ethambutol ,rifampicin thionamide, azithromycin, amikacin, streptomycin, linezolid, ciprofloxacin, cycloserine, trimethoprim-sulfamethoxazole, and some aminoglycosides .



M. riyadhense• M. riyadhense is identified a novel mycobacterial species .• The first case and isolation was from 19 years old male patient in Riyadh

present with pain and swelling of the left side of his face with protrusion of left eye after blunt trauma , in King Faisal Specialist Hospital in 2009 .

• Total of Five case are reported from the world , first one from Saudi Arabia , 2 cases from France , 1 from Korea and 1 from Bahrain and all are in non HIV patient .



• M. riyadhense is a slow-growing , non-chromogenic Mycobacterium which produces rough, white colonies after four weeks of incubation at 36ºC. Generally,

• the biochemical profile of the M. riyadhense is unique, although it shares characteristics with M. szulgai and Mycobacterium malmoense

• M. riyadhense can infect a patient without predisposing factors resulting in the tuberculosis-like clinical Syndrome , but can be fatal if not treated.



• In five reported cases , one case was cured with standard anti-TB therapy of INH, RIF, and EMB (Saudi Patient ) ,that was ineffective in other case , who successfully treated with the combination of amikacin,ethionamide,moxifloxacin, clarithromycin, and EMB.

• Other two cases treated with INH, RIF, EMB, PZA and INH, RIF, CLR, CIP respectively .

• One of cases documented relapsed after receiving clarithromycin and ciprofloxacin for 12 months, but then improved with drugs (INH, RIF, EMB, PZA, clarithromycin, and ciprofloxacin).



• Standard TB treatment is insufficient for NTM, including M. riyadhense; currently reported cases followed at least nine months of first-line drug therapy to attain a cure .

• All cases presented with Pulmonary Infection including our patient , except for Saudi patient presented with Bone Infection in maxillary Sinus .

• Drug Susceptibility for our patients is came as , Resistant for INH and PZA and sensitive for RIF, EMB, CLR and Streptomycin.



Messages • HIV is areal health problem in our communities and must be in mind of

Health care Professionals . • HIV test must be in the top of the list with patients showing clinical

evidence of low immunity (immunocompromised ) with no clear evidence of other diagnosis , especially in

High risk groups and patient with Aids defining illness .• M . riyadhense and Atypical Mycobacterium must alarm Health care

Professionals for HIV test .



Thanks



REFFERENCES

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Available from :http://http://cid.oxfordjournals.org/content/30/5/831.long. •

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The First Case Report : Mycobacterium riyadhense Pneumonia Newly Diagnosed HIV Patient

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