A case of pulmonary Mycobacterium kansasii infection complicated with pleural effusion

A 60-year-old man was admitted to our hospital complaining of general malaise for a few months, discomfort of the right shoulder and fever in May 2003. Chest X-ray film showed an infiltrative shadow in the right lung field and chest CT scan revealed right pleural effusion. Pulmonary tuberculosis complicated with pleurisy was first suspected from the findings of high ADA level of the effusion and positive result of PPD skin test. But, microscopic examination of the specimens obtained by transbronchial lung biopsy disclosed granulomatous lesions and Mycobacterium kansasii was identified from all specimens; sputum, fluids of brushing and bronchial washing. The patient was diagnosed as pulmonary Mycobacterium kansasii infection and treated with anti-tuberculous drugs including RFP. His clinical course was good and no recurrence of pleural effusion was seen. This case was a rare case of pulmonary Mycobacterium kansasii infection complicated with pleural effusion.     

A case of pulmonary Mycobacterium gordonae infection progressed for no therapy]

A 68-year-old woman, who had been healthy until this event, presented with a complaint of productive cough since 2000. She went to a neighboring hospital because of bloody sputum in October 2001. Although chest radiograph showed abnormal findings then, she received only an expectorant and cough remedy. She consulted us complaining of dyspnea on exertion in April 2005. Chest radiograph revealed cavity formation, bronchiectasis and a nodular shadow, and her condition had deteriorated. Microbiologically, acid-fast bacilli were detected three times in the culture of sputum, and Mycobacterium gordonae was identified by the biochemical method. However, this Mycobacterium gordonae could not be identified by the DNA-DNA hybridization method. Our case also probably was considered to be a primary type pulmonary nontuberculous infection because of her clinical course. In addition, we recognized that pulmonary M. gordonae infection also worsens without the therapy.     

A case of Mycobacterium avium pulmonary disease accompanied with pleural effusion

Nontuberculous mycobacterial infection is seldom complicated with pleural involvement. We report a very rare case of M. avium pulmonary disease accompanied with pleural effusion. A 76-year-old man was admitted to our hospital because of cough and low-grade fever. A chest radiograph and computed tomograph showed centrilobular nodules in the right middle lobe and left lingula, and right pleural effusion. The patient had had a right spontaneous pneumothorax 50 days before his admission. The sputum smear was negative for acid fast bacilli. The smear of pleural effusion was positive for acid fast bacilli, the level of adenosine deaminase in the effusion was markedly elevated, and pleural effusion was positive for M. avium as assessed by polymerase chain reaction (PCR). The pleural biopsy specimen showed fibrous change without granuloma, while the transbronchial biopsy specimen showed noncaseous epithelioid granulomas. We considered that the pneumothorax was caused by the spread of pulmonary M. avium infection to the visceral pleura with its perforation.     

A case of Mycobacterium avium lung infection with a pleural effusion

Pleural effusions seldom accompany nontuberculous mycobacterial infections. We reported one such case of M. avium lung infection with pleural effusion. A 40-year old male was admitted to our hospital complaining of right chest pain and general fatigue. His chest X-ray showed a consolidation in the right lower lung field. The day after admission, a right pleural effusion appeared. The fluid was exudative and microbiological examinations of the effusions, including staining and culturing, proved negative. However, one month afteradmission, acid fast bacilli were observed in his sputum and a subsequent sputum culture specimen revealed the presence of M. avium. Treatment with antimycobacterial agents was promptly commenced and the patient's effusion and lung consolidation was gradually resolved.     

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.     

Cutaneous infection with Mycobacterium gordonae

A case of cutaneous infection with Mycobacterium gordonae and other reports of extrapulmonary infection due to this organism are reviewed. This case confirms the pathogenic potential of M. gordonae which must now be included among the scotochromogens capable of causing cutaneous disease. Isolates of this organism should be tested against a full range of antimicrobial agents since traditional antituberculous therapy may be of limited efficacy. Pending the results of in vitro susceptibility testing, amikacin, ethambutol, rifampicin and co-trimoxazole are suggested as empirical therapy for infections caused by this organism.     

A case of infected bulla caused by Mycobacterium gordonae]

A 65-year-old man was admitted to Tokyo Metropolitan Geriatric Medical Center because of dyspnea on effort, loss of appetite and general fatigue. Chest radiography on admission showed niveau formation in, and infiltration around, the bulla. Percutaneous drainage of the intrabullous fluid was performed and Mycobacterium gordonae was repeatedly cultured from it. The patient was treated with RFP, INH and CAM and the intrabullous fluid and infiltration around the bulla was markedly improved. Seven cases of pulmonary infection by M. gordonae have been reported in Japan, but this is the first case of bulla infected by this organism.     

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.     

A case of pulmonary sarcoidosis with pneumothorax and pleural effusion after improvement of pulmonary impairment]

A 23-year-old man was admitted to our hospital for a complete medical evaluation of abnormal pulmonary shadows found on a chest radiograph during his annual check-up. Chest radiography and chest CT showed a diffuse spread of micronodules in both lung fields and mediastinal lymphadenopathy. A transbronchial lung biopsy demonstrated evidence of noncaseating epithelioid cell granuloma with multinucleated giant cells, and a diagnosis of sarcoidosis was made. The pulmonary shadows improved without therapy. Twenty months later, the patient was readmitted to the hospital because of chest pain and dyspnea. Pneumothorax appeared on the right in a chest radiograph, but subsided after drainage therapy, and two weeks later, a right side pleural effusion was seen. We determined that the pleura was involved in the sarcoidosis, and the patient was treated with oral prednisolone 20 mg daily. The pleural effusion gradually subsided. This is the first reported case in Japan of pulmonary sarcoidosis with pneumothorax and pleural effusion after improvement of pulmonary impairment.     

A case of toxocariasis with eosinophil-rich pleural effusion]

A 68-yr-old man presented with fever, cough, and appetite loss. On admission, clinical examination revealed pleural effusion (with eosinophils accounting for 25% of the cellular component), eosinophilia, and mildly elevated liver enzymes. A diagnosis of toxocariasis was reached on the basis of a positive enzyme-linked immunosorbent assay for Toxocara canis, and the efficacy of steroid and tiabendazole. Typical thoracic involvement of toxocariasis causes cough, wheezing, transient infiltration shadows on the radiographs, and other symptoms of L?ffler's syndrome. The infiltration shadows reflect the migration of the larvae through the lung, which involves their breaking through the alveolar walls. We report a rare case of toxocariasis with thoracic and pleural involvement without transient pulmonary infiltrates.     

A case of sparganosis with eosinophilic pleural effusion]

A 61 year-old man was admitted to our hospital complaining of exertional dyspnea and presented with left pleural effusion. Laboratory findings showed peripheral eosinophilia and a slightly elevated inflammatory reaction. Chest X-ray film and CT revealed left pleural effusion, but there were no particular abnormal findings on the lung fields. Pleural effusion was exudative, yellowish and contained numerous eosinophils. His detailed medical history showed that he had eaten uncooked snakes, which led us to suspect parasite diseases. Multiple-dot ELISA method was performed to detect specific anti-parasite antibody. The patient was diagnosed with sparganosis after the detection of a highly positive reaction against Spirometra erinacei-europaei in both serum and pleural effusion. Parasite disease is an important consideration on differential diagnosis of eosinophilic pleural effusion, and multiple-dot ELISA method might be helpful for screening it.     

A case of secondary pulmonary cryptococcosis with pleural effusion involving type 1 allergy]

A 69-year-old man who had been followed for pneumoconiosis complained of dyspnea with effort. He was hospitalized because chest roentogenography showed pleural effusion. Further examination of this pleural effusion revealed an eosinophilic cell population and with a varied appearance. First, we suspected tuberculous pleuritis from the characteristics of the pleural effusion, but we could not demonstrate the existence of any acid-fast bacilli. During diagnostic studies, the patient's respiratory status gradually worsened, making it impossible to obtain essential findings. We initiated steroid administration as an antidote to progressive respiratory failure, and carried out bronchoscopy; As a result, we diagnosed secondary pulmonary cryptococcosis from bronchoalveolar lavarge and transbronchial lung biopsy. Pulmonary cryptococcosis with pleural effusion is rare, and this may be the first report of a case involving a type 1 allergy. We speculate that immunological dysfunction contributed to disease progression in this case.     

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 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.     

A solitary pulmonary nodule due to Mycobacterium gordonae

Mycobacterium gordonae is rarely pathogenic in humans. In this case it was cultured from the tissue of a resected pulmonary nodule in an immunocompetent patient. One year after completing 12 months of chemotherapy, the patient remains disease free. Atypical mycobacterium should be considered in the differential diagnosis of solitary pulmonary nodules.     

A case of Sj?gren's syndrome with pleural effusion]

A 45-year-old woman was admitted to our hospital because of a fever. A round erythema was noted on the skin, suggesting collagen disease. Bilateral pleural effusion developed during hospitalization, and serum and pleural effusion were positive for antinuclear antibody, RA factor, anti-SS-A antibody, and anti-SS-B antibody. A diagnosis of Sj?gren's syndrome was made on the basis of reduced lacrimation and the histological findings in a biopsy specimen from the lip. The cells in the pleural effusion were predominantly lymphocytes, and so a pleural lesion associated with Sj?gren's syndrome was suspected, but reports of this condition have been scarce. Good therapeutic results were obtained by corticosteroid administration. Sj?gren's syndrome should be considered in the differential diagnosis of pleural effusion associated with collagen disease.     

A case of post-traumatic bilateral eosinophilic pleural effusion]

A 58-year-old man was admitted to our hospital with chest pain caused by chest trauma. After admission, his chest pain decreased and he was discharged. Later, he was admitted again with a high fever and dyspnea. Laboratory findings on second admission showed a leukocyte count of 7,900/microliter (9% eosinophils) and a C-reactive protein of 17.0 mg/dl. Chest radiography and chest CT scanning on second admission showed moderate bilateral pleural effusion. Close examination showed an increase of eosinophils in the pleural effusion (14% of total cell counts on the right and 27% of total cell counts on the left) that was exudate. Post-traumatic bilateral eosinophilic pleural effusion was diagnosed. The patient was treated with antibiotic therapy and his condition improved. A chest CT scan afterwards showed improvement of the bilateral pleural effusion. The eosinophil count in the peripheral blood was 1% at chest trauma, 15% in the hospital to the max and decreased to 3% with the decrease of pleural effusion. Post-traumatic eosinophilic pleural effusion may be accompanied with inflammatory findings, and the mechanism is guessed by immunological reaction.     

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 pulmonary Mycobacterium avium infection with a rapid-growing solitary node]

A 72-year-old man was admitted to our hospital because of an abnormal shadow on his chest radiograph. Computed tomography revealed a 3 cm solitary nodular opacity in the right S1. Bronchofiberscopy could neither give any specific histological findings nor bacteriological findings. This nodular shadow increased in size to 1.5 times that in the first chest radiograph. In addition, since there was no abnormal finding in the chest radiograph one year before, we performed partial pulmonary resection by video-assisted thoracoscopic surgery, taking into consideration the possibility that the solitary node was malignant. The pathological findings of the resected specimen were an epitheloid cell granuloma with Langhans giant cell and caseous necrosis. We could not detect any acid-fast bacilli or malignant cells. After surgery, M. avium was detected in a 6-week culture of the resected specimen. We treated the patient with RFP, EB and CAM for 6 months. Outpatient follow-up revealed no relapse.