Pulmonary Mycobacterium gordonae infection treated with clarithromycin

We reported a case of 51-year-old female immunocompetent patient with pulmonary Mycobacterium gordonae infection. The patient complained persistent cough and sputum and occasionally hemosputum. Chest radiograph and computed tomography (CT) of the lung showed bronchiectasis and small nodules in middle lobe. Bronchofiberscopy was performed twice, and bronchial washing specimen repeatedly revealed acid-fast bacilli. The organism was identified as Mycobacterium gordonae by biochemical tests and direct sequence method. She was treated with clarithromycin (400 mg/day) over 6 months and the chest CT findings showed improvement. The case was considered to be sensitive to clarithromycin in vitro drug susceptibility test. The case suggested that clarithromycin was a useful therapeutic agent to Mycobacterium gordonae infection.     

A case of pulmonary Mycobacterium gordonae infection with pleural effusion]

A 65-year-old woman, treated with prednisolone (5 mg daily) for rheumatoid arthritis, visited our hospital because of right chest pain. Chest CT showed small nodular shadows in the right lung accompanied with right pleural effusion. A pulmonary Mycobacterium gordonae infection was diagnosed, since M. gordonae was identified twice from her sputum. She was treated with rifampicin, ethambutol and streptomycin for two months, and then streptomycin was replaced with clarithromycin. Three months after the initial treatment, M. gordonae was eradicated from her sputum. Pleural puncture revealed bloody, exudative, lymphocytotic pleural effusion, but no malignant cells were identified. Although pathological diagnosis by thoracoscopic pleural biopsy could not be performed, it is likely that the pleural effusion was associated with the pulmonary M. gordonae infection in the present case.     

An elderly case with Listeria monocytogenes sepsis and pulmonary non-tuberculous mycobacterial infection

A 88-year-old woman, who had lived in a nursing home, was admitted to our hospital because of the suspicion of pulmonary tuberculosis. She had a cough, fever and diarrhea on admission. She suffered from sepsis because Listeria monocytogenes was isolated from only the blood culture twice. We immediately administered imipenem/cilastatin to her on admission. She simultaneously had pulmonary non-tuberculous mycobacterial infection because the chest roentgenogram showed a cavity in the right upper lung field and Mycobacterium intracellulare was isolated from the sputum many times. She was treated with isoniazid, rifampicin and clarithromycin for the pulmonary non-tuberculous mycobacterial infection. Her condition improved soon after the administration of IPM/CS but a low grade fever and cough persisted. L. monocytogenes and M. intracellulare are important pathogens in the elderly because cell-mediated immunity mainly works as host defenses against both organisms.     

A case of bronchiectasis with abundant expectoration of Mycobacterium gordonae

A 68 year old woman consulted our hospital because of 6 month history of dry cough. Her chest X-ray revealed bronchiectasis in the left lung. Three sputum specimens were culture positive for acid fast bacilli (AFB) 200 colonies. The bacilli were scotochromogenic, niacin test was negative and hydrolysis of tween 80 was positive, and they were identified as M. gordonae. M. gordonae is rarely implicated as a pathogen but a few reports suggest it may be pathogenic. Though our patient had clinical symptom and expected abundant M. gordonae, her chest X-ray revealed no progression. Thus, it was hardly possible to consider this case as a case caused by the infection with M. gordonae. In previous reports of M. gordonae pulmonary disease, chest X-ray findings showed cavity, infiltration and consolidation, however, no case with bronchiectasis was reported and chest X-ray findings of this case are interesting.     

A case of environmental infection with pulmonary Mycobacterium avium complex disease from a residential bathroom of a patient suggested by variable-number tandem-repeat typing of Mycobacterium avium tandem repeat loci

A 63-year-old woman was referred to our hospital because of bilateral infiltrations and nodular opacities in her chest radiograph taken in the mass radiography screening in September 2010. The chest computed tomography showed patchy infiltrations with bronchiectasis in the lower lung fields on both sides. She was diagnosed with pulmonary Mycobacterium avium complex (MAC) disease based on the bacteria recovered from the sputum and the bronchoalveolar lavage fluid. To elucidate an environmental MAC source, we investigated her home, and isolated M. avium and M. gordonae from the bathtub and shower tap, respectively, in her residential bathroom. Analysis of the hsp65-PRA variants digested with BamHI and some insertion sequences showed that the clinical strains recovered from sputum and strains from the bathtub were M. avium subsp. hominissuis. A dendrogram of the Mycobacterium avium tandem repeat loci variable-number tandem-repeat (MATR-VNTR) analysis of the MAC strains showed that the bathtub strains formed a polyclonal colonization, and that 1 of the 5 MATR-VNTR patterns was identical to the corresponding pattern of the sputum strain from the patient. In conclusion, we believe that the residential bathroom of the patient was the environmental source of her pulmonary MAC disease, as has been previously reported.     

A case of pulmonary infection due to Mycobacterium simiae]

A 61-year-old woman presented to our hospital with a chronic cough. She had been diagnosed with pulmonary infection due to non-tuberculous mycobacteria by her previous doctor and had received antimycobacterial chemotherapy for 1 year. Chest radiography and computed tomography on the first visit to our hospital revealed nodular shadows with a cavity in the right upper lung field and infiltrative shadows with bronchiectasis in the lingular segment. Mycobacterium simiae was identified using DNA hybridization methods. Analysis of base sequences from sputum samples using 16S rRNA confirmed the identity of all tested isolates as Mycobacterium simiae, and the organism was isolated repeatedly from sputum mycobacterial tests. Pulmonary infection due to Mycobacterium simiae was diagnosed. Rifampicin, Ethambutol and Clarithromycin were administered to the patient, but clinical symptoms have continued, and findings on chest radiography have deteriorated. Cases of pulmonary infection due to Mycobacterium simiae are rare, and this represents the first such case reported in Japan.     

Pulmonary infection caused by Mycobacterium gordonae in immunocompetent patient

We report a case of 67-year-old female immunocompetent patient admitted to our hospital because of hemoptysis. Computed tomography (CT) of the lung showed bronchiectasis in the right S5 and small nodules in the right S6 and left S5. The cultures of sputum and bronchial washing specimen repeatedly revealed acid-fast bacilli identified as Mycobacterium gordonae (M. gordonae) by DNA-DNA hybridization (DDH) method. Thus, she was diagnosed to be infected with M. gordonae. She was treated with isoniazid, rifampicin, ethambutol and streptomycin. After treatment, the cultures of sputum and bronchial washing specimen converted to negative, and the chest CT showed improvement of small nodules. M. gordonae is a nontuberculous mycobacterium of very low pathogenic potency. Recently there have been a few reports of infection by M. gordonae not only in immunocompromised patients but also in immunocompetent patients. These cases were considered to be sensitive to initial standard antimycobacterial therapy, therefore, it is important to examine for M. gordonae in cases suspected of nontuberculous mycobacterial infection.     

Pulmonary tuberculosis with cerebellar lesion in a patient after anti-TNF-alpha (infliximab) treatment for rheumatoid arthritis]

We report a case of pulmonary tuberculosis in a 51-year-old Japanese woman, who received treatment with infliximab for active rheumatoid arthritis. She had cough and sputum after the second infusion of the drug, small nodular lesions of right lung field and left lower lobe on her chest CT and a small nodular lesion of right cerebellar lobe on her cranial MRI were identified. Mycobacterium tuberculosis was cultured from her sputum. Therefore, we diagnosed her illness as pulmonary tuberculosis with a cerebellar lesion. The patient was treated with anti-tuberculosis drugs and showed marked improvement in lesions of the lung and brain. We considered this case a tuberculosis reactivation after infliximab treatment because of the short interval between the administration of infliximab and the occurrence of tuberculosis, and the complication of extrapulmonary lesion that suggested brain tuberculoma.     

Pulmonary infection caused by Mycobacterium gordonae]

A 57-year-old woman who had been operated on for colon cancer and given chemotherapy, presented in September 1995 with worsening cough and abnormalities on her chest X-ray film. Acid-fast bacilli were isolated from the sputum. The organism was classified as M. gordonae by biochemical tests and DNA/DNA hybridization. The patient was treated with rifampicin and clarithromycin. Subsequently, sputum cultures became negative and the chest x-ray film showed a decrease infiltration. The findings in the present case suggest that M. gordonae may cause pulmonary infection and should be considered as an opportunistic pathogen.     

The combination therapy of clarithromycin and sparfloxacin for pulmonary Mycobacterium gordonae infection]

Seventy years old woman had fever and hemosputum at May 1997. She was diagnosed as mycobacteriosis because of the positive acid fast bacilli smear from sputum. Mycobacterium gordonae was isolated from sputum, gastric juice, and bronchial aspirate. The combination therapy of isoniazid, rifampicin, ethambutol, and clarithromycin was administrated; however, M. gordonae was not eradicated from sputum. Sparfloxacin was administered instead of isoniazid based on the result of drug susceptibility test. The smear became negative and M. gordonae was eradicated from sputum one month after the initiation of treatment with the combination of clarithromycin and sparfloxacin.     

Case report: disseminated Mycobacterium gordonae infection in a nonimmunocompromised host.

Mycobacterium gordonae is considered the least pathogenic of the Runyon Group II mycobacteria, although there are now well-documented reports of infection varying from localized soft tissue infection to disseminated life threatening diseases. We report a 40-year-old Pakistani housewife, treated in childhood for tuberculosis, who presented with severe systemic illness, fever, ascites, hepatomegaly, persistent dysuria with sterile pyuria, pulmonary disease, and anorexia with weight loss. Liver biopsy histology showed multiple granulomata and multiple isolation of M. gordonae from sputum and urine, in keeping with disseminated mycobacterial infection. She had dramatic response to antituberculosis therapy with streptomycin, isoniazid, rifampicin, and pyrazinamide. No evidence existed for disturbed humoral or cellular immunity and HIV infection. This represents the fifth reported case of disseminated M. gordonae infection, the first from the Arabian Gulf. It was treated successfully with standard antituberculosis regimen.     

A case of rapid exacerbation of a pulmonary infection with Mycobacterium intracellulare in an immunocompetent pregnant woman]

We report a very rare case in which pulmonary non-tuberculous mycobacteriosis with Mycobacterium intracellulare deteriorated acutely, presumably because of pregnancy. A 36-year-old immunocompetent woman was referred to our hospital with a cough and a slight fever of 3 weeks' duration when she was 5 months pregnant. Chest radiography at the first visit showed multiple large thin-walled cavities in the left middle and lower lung fields. After antibiotic, cough-depressant and theophyllin treatment, her symptoms almost disappeared for a while although Mycobacterium intracellulare was detected in her sputum. One month later, however, her symptoms were aggravated and infiltrative shadows were observed around the cavities on chest radiographs. She was treated with clarithromycin as well as the antituberculous drugs rifampicin and ethambutol until delivery, and then streptomycin was added. Owing to these medications, her symptoms and the presence of Mycobacterium intracellulare in the sputum were being gradually eliminated. Radiographic improvement of the infiltrative shadows and slight reduction of the size of the cavities were also observed. However, no further improvement of the radiographic findings was observed, despite continued treatment. Finally, it was concluded that this disease may not be curable by such medication. The patient eventually underwent a left pneumonectomy about one year after the first visit.     

Pulmonary infection caused by Mycobacterium gordonae (M. gordonae) in a healthy middle-aged male]

A 51-year-old man was admitted to our hospital in July 1989 because of an abnormality in his chest radiograph. On his yearly health check-up, an abnormality of his chest radiography was first noted in June 1988. At that time, examinations including bronchoscopy were performed but no specific diagnosis was made. On admission, his chest radiograph revealed new infiltrates at the apex of the right lung which were not present in June 1988. Three out of 5 consecutive sputum specimens after admission produced a pure growth of 100 colonies to 1+ of acid-fast bacilli (AFB). This AFB was scotochromogenic, and hydrolysis of Tween 80 at 5 days was positive. It did not reduce nitrate, and niacin test was negative. It was sensitive to ethambutol at a concentration of 5 micrograms/ml, and was not tolerant to 0.2% picric acid. We thus identified this AFB to be M. gordonae. The patient was treated with rifampicin (450 mg/day), isoniazid (400 mg/day), and ethambutol (1000 mg/day) for 9 months. After 2 months of treatment the sputum cultures became negative, and the chest radiograph showed improvement of the infiltrates. M. gordonae is considered to be one of the least pathogenic AFB to man. Most recent reports of M. gordonae infection have been in immunocompromized hosts or patients with a history of pulmonary tuberculosis. The present case is a very rare example of this organism affecting a healthy male, and thus yields new information on the pathogenesis of M. gordonae in man.     

Mycobacterium gordonae: a possible opportunistic respiratory tract pathogen in patients with advanced human immunodeficiency virus, type 1 infection

STUDY OBJECTIVE: To determine if Mycobacterium gordonae is an opportunistic respiratory tract pathogen in patients infected with human immunodeficiency virus, type 1 (HIV-1). DESIGN: Retrospective review of medical records of all patients with positive cultures for M gordonae from 1987 to 1989. PATIENTS: Fifteen patients had positive sputum cultures for M gordonae: five patients had AIDS or had HIV-1 infections with less than or equal to 180 CD4 cells/cu mm, and ten patients had no clinical evidence of HIV-1 infection. RESULTS: Three of the five HIV-1 infected patients had clinical, roentgenographic, and microbiologic evidence of pulmonary infection due to M gordonae that responded to antimycobacterial therapy. One of the two remaining HIV-1 infected patients had disseminated M tuberculosis and possible coinfection with M gordonae, and the other was lost to follow-up. None of the ten patients without evidence of HIV-1 infection was considered to have M gordonae respiratory tract infection. CONCLUSIONS: Sputum isolates of M gordonae should be considered potential opportunistic respiratory tract pathogens in patients with advanced HIV-1 infection and with otherwise unexplained pulmonary infection.     

X-ray-negative endobronchial tuberculosis with persistent irritating cough that resulted in unpredicted mass infection]

A 24-year-old woman was referred to another hospital because of a barking cough, but her chest radiograph showed no abnormality. Although she had been diagnosed as having other diseases and had been given medical treatment, the barking cough continued. Abnormalities of the chest radiograph appeared 11 months later, and endobronchial tuberculosis was diagnosed from the clinical history, chest CT and a sputum smear positive for acid-fast bacilli. We treated her with INH, RFP, EB for 6 months, and PZA for 2 months. However, truncus intermedius became obstructed nine months after treatment ended, and we re-opened it with a Dumon stent after coring it out using a rigid bronchoscope. Since the patient was a teacher, medical checkups of many people were required, and the number of prophylactic treatments carried out was 80. This was regarded as a mass infection. In the early stages, endobronchial tuberculosis may not show any abnormality on chest radiography, but may still cause mass infection. When a barking cough continues for a long time, endobronchial tuberculosis must be suspected, and examination of a sputum smear for acid-fast bacilli, as well as a sputum culture is necessary.     

Pneumococcal Pneumonia Co-infection with Mycobacterium avium and Nocardia cyriacigeorgica in an Immunocompetent Patient

A 61-year-old woman was transferred with a complaint of a fever and productive cough. She had tested positive for Mycobacterium avium and Nocardia cyriacigeorgica at least twice, and Streptococcus pneumonia (PISP) was isolated (3+) from her purulent sputum. As radiological findings, a lower lung field-dominant infiltration shadow and nodular shadow with cavity were recognized in the bilateral lung fields. We diagnosed her with pneumococcal pneumonia co-infection with M. avium and N. cyriacigeorgica. She was treated with MEPM for pneumococcal pneumonia, a standard regimen containing clarithromycin for pulmonary M. avium complex (MAC) disease, and sulfamethoxazole/trimethoprim for pulmonary nocardiosis. She improved with appropriate treatment.     

Detection of pulmonary tuberculosis in patients with a normal chest radiograph

OBJECTIVES: To describe the early symptoms of pulmonary tuberculosis (TB) when the chest radiograph (CXR) is normal. SETTING: Centralized, provincial TB control program. SUBJECTS: Twenty-five patients with culture-positive pulmonary TB and a normal CXR were identified from a review of 518 consecutive patients with culture-positive pulmonary TB in the province of Saskatchewan from January 1, 1988 to March 31, 1997. Patients with abnormal CXRs at the time of diagnosis were excluded from the analysis. RESULTS: Twenty-three of the 25 patients (92%) were symptomatic at the time of diagnosis, with cough/sputum (76%) being reported most commonly. Eleven patients were identified because of contact tracing from cases of infectious pulmonary TB, while the other 14 patients were identified because of an investigation of symptoms. Twenty-four patients (96%) exhibited one or more symptoms of cough for > 1 month, fever for > 1 week, or skin-test conversion after contact with infectious TB. The sputum smear of only one patient was positive. Two patients were pregnant at the time of diagnosis, one patient was HIV-positive, and one patient demonstrated isoniazid-resistant organisms on sensitivity testing. Five patients were diagnosed as having primary TB associated with Mantoux skin-test conversion. The incidence of culture-positive pulmonary TB with a normal chest radiograph was < 1% in the period from 1988 to 1989 and steadily increased to 10% in the period from 1996 to 1997. CONCLUSIONS: Culture-positive pulmonary TB with a normal CXR is not uncommon, and the incidence of this presentation is increasing. Patients with this presentation of TB are typically symptomatic and/or are detected by contact tracing to infectious cases of pulmonary TB. The results suggest that patients presenting with a cough for > 1 month, with a fever for > 1 week, or with documented skin-test conversion < 2 years after known exposure to infectious TB should have sputum submitted for a Mycobacterium tuberculosis smear and culture despite a normal CXR.     

Mycobacterium gordonae urinary infection in a renal transplant recipient

Abstract: The authors present a case of urinary infection by a non-tuberculous mycobacteria (NTM) species, Mycobacterium gordonae , in a renal transplant recipient. A 29-year-old female patient had persistent sterile pyuria after her second kidney transplant. An NTM, M. gordonae , was isolated, and the patient was started on antituberculous treatment, with resolution of leukocyturia. Ureteral stenosis with hydronephrosis and deterioration of allograft function was diagnosed later on and, despite the introduction of intraureteral catheter and resolution of hydronephrosis, there was no recovery of baseline renal function. She ultimately resumed dialysis after a severe pyelonephritis. The authors discuss the problems of establishing diagnosis of infection (versus colonization) by NTM and highlight the difficulty of treating these infections, especially because of the possible interaction with immunosuppressant agents, facilitating anti-allograft immune response.     

A case of pulmonary infection induced by both Aspergillus sp. and Mycobacterium tuberculosis during corticosteroid therapy]

An 83-year-old woman with idiopathic thrombocytopenic purpura had received corticosteroid drugs since December 1998. Pulmonary aspergillosis appeared three months later, but improved with administration of itraconazole. When the dose of corticosteroid had to be increased again because of aggravation of the underlying disease after a 20-month gradually decreased use of the drugs, a new infiltration shadow in the left upper and middle fields appeared after one month of increase. Therefore, a detailed examination was performed. Mycobacterium tuberculosis was identified by the DDH method, Aspergillus sp. was isolated from the sputum culture, and aspergillus antigen was positive serologically, leading to a diagnosis of pulmonary infection induced by both Aspergillus sp. and Mycobacterium tuberculosis. Because of the prolonged administration of corticosteroid drugs, the patient was highly susceptible to infectious diseases. We considered this a case of interest because 20 months after the diagnosis of pulmonary aspergillosis, a mixed pulmonary infection of Mycobacterium tuberculosis and Aspergillus sp. was identified.