Cavitary pneumonia due to Rhodococcus equi in a heart transplant recipient

Abstract: Rhodococcus equi is an uncommon human pathogen that usually affects immunocompromised patients. We present a case of a 68-year-old male heart transplant recipient, who developed rhodococcal pneumonia with secondary bacteremia 10 months post-transplant. The patient was a retired carpenter who was involved in breeding of horses. He responded completely to the treatment with vancomycin and imipenem/cilastin, followed by oral ciprofloxacin and minocycline for total treatment duration of 5 months. This case highlights the association between an animal exposure and infection with a unique opportunistic pathogen.     

Trials of daily, long-term minocycline and rifampin or clarithromycin and rifampin in the treatment of borderline lepromatous and lepromatous leprosy

Daily, long-term treatment with minocycline 100 mg and rifampin 600 mg was initiated in 24 previously untreated borderline lepromatous (BL) and lepromatous (LL) patients for a total of 646 patient-months, averaging 26.9 months per patient. The same regimen was started in 12 BL and LL patients having a bacteriologic relapse for a total of 379 patient-months, averaging 32.5 months per patient, and in 12 patients judged to be at high risk for relapse for a total of 354 patient-months, averaging 29.5 months per patient. Daily, long-term treatment with clarithromycin 500 mg and rifampin 600 mg was initiated in 8 previously untreated BL and LL patients for a total of 174 patient-months, averaging 21.8 months per patient. The results in these 56 patients were compared to those obtained in 34 previously untreated BL and LL patients who were treated concurrently receiving daily, long-term dapsone 100 mg and rifampin 600 mg. No evidence of dangerous drug reactions or bone marrow, kidney or liver toxicity was seen in any of these five patient groups. Drug intolerance in 10 of the 90 patients studied necessitated discontinuing the chosen regimen, 4 from rifampin, 3 from dapsone, 2 from minocycline and 1 of undetermined attribution. The use of either minocycline or clarithromycin in conjunction with rifampin appears to pose no great risk when used long term.     

Apparent cure of intracranial Nocardia asteroides infection by minocycline.

Currently preferred therapy for CNS Nocardia infection is high-dose sulfonamide coupled with surgical drainage. Neither of these could be used in our patient; this led to therapy with minocycline alone. Several months after completion of minocycline therapy, the patient apparently is cured. His favorable outcome probably resulted from a combination of susceptibility of the organism to minocycline coupled with good CNS penetration of the agent resulting in CNS levels of drug 16 to 22 times higher than the Nocardia inhibitory concentration.     

Subcutaneous infection with Mycobacterium fortuitum after allogeneic bone marrow transplantation.

Reports of cases of mycobacterial infections after SCT are rare. We report a 30-year-old female with a cutaneous infection of Mycobacterium fortuitum 30 months after allogeneic bone marrow transplantation for acute lymphoblastic leukemia. The patient was successfully treated with surgical debridement followed by oral minocycline and clarithromycin. Mycobacterial infections should be considered in SCT patients with undiagnosed refractory chronic cutaneous infection, and surgical debridement is useful for the diagnosis and treatment of such infections.     

Relapsing Campylobacter coli bacteremia with reactive arthritis in a patient with X-linked agammaglobulinemia

A patient genetically diagnosed with X-linked agammaglobulinemia repeatedly developed bacteremia due to Campylobacter coli (C. coli) for one year and seven months in spite of immunoglobulin replacement therapy. Throughout the clinical course, C. coli with identical genetic patterns was repeatedly isolated from both blood and stool cultures, thus indicating that the patient had latent intestinal infection. The bacteremia was always accompanied by reactive arthritis. Since the immunoglobulin level was extremely low with severe B cell deficiency, the reactive arthritis must have been induced in a humoral immunity-independent manner. Adding oral minocycline following intravenous meropenem was very effective; the stool cultures became negative and the patient has been well for more than one year without relapse of bacteremia.     

Pulmonary infection with rapidly growing mycobacteria in a singer with achalasia: a case report

We report the case of a 37-year-old male patient with prolonged pneumonia and achalasia. Culture and molecular genetic typing identified Mycobacterium abscessus as causative agent. Treatment with clarithromycin and minocycline over 8 months gradually resolved the infection. Rapidly growing, non-obligate pathogenic mycobacteria are widespread in the environment. Several cases of pulmonary infections with these mycobacteria in patients with achalasia have been reported, suggesting a causative association. This is the first report of a case with isolation of M. abscessus in this context.     

A case of pulmonaly bulla infection with Mycobacterium fortuitum

We report a case of bulla infection caused by Mycobacterium fortuitum. The patient was a 66 year-old female associated with interstitial pneumonitis. The chest X-ray film showed cavities with thick walls and niveau formation, which initially suggested pulmonary abscesses. The chest CT scan showed infiltrative shadows surrounding multiple bullae. Smears and cultures of the sputum were repeatedly positive for mycobacteria, which was identified to be M. fortuitum. By chemotherapy with imipenem/cilastatin sodium, clarithromycin, levofloxacin, and minocycline on the basis of susceptibility test, sputum converted to negative within 2 months, abnormal shadows on the roentgenogram and laboratory data showed improvement. There are no signs of recurrence after completion of the treatment for 12 months.     

Mycoplasma pneumoniae pneumonia with a tumorous shadow on chest radiography--a case report]

A 16-year-old woman was admitted with a 1-week history of increasing cough and fever. Chest radiography and computed tomography revealed a tumorous shadow in the right upper lung field. Serologic testing provided evidence of a Mycoplasma pneumoniae infection. The clinical findings did not improve after 3 days of minocycline treatment, or after another 3 days in which levofloxacin was administered in combination with minocycline. The patient gradually improved after treatment with erythromycin replaced the minocycline treatment. This was a rare case of Mycoplasma pneumoniae pneumonia with a tumorous shadow in the chest radiograph.     

Characteristics of hospitalized children infected with macrolide-resistant Mycoplasma pneumoniae

BackgroundThe aim of this study was to clarify retrospectively the characteristics of children hospitalized for respiratory tract infection caused by macrolide-resistant Mycoplasma pneumoniae (M. pneumoniae).MethodsChildren who were hospitalized for respiratory tract infection due to M. pneumoniae were enrolled in this study. The diagnosis of M. pneumoniae infection was made on the grounds of polymerase chain reaction results.ResultsThirty-three children were hospitalized due to lower respiratory tract infection with M. pneumoniae. Of the 33 children, 31 (median age five years) were identified as being infected with macrolide-resistant M. pneumoniae (A2063G:30, A2064G:1) by sequence analysis. Of the 31 children infected with macrolide-resistant M. pneumoniae, 21 (68%) had received 14- or 15-membered macrolide antibiotics and four (13%) had received minocycline before hospitalization. During hospitalization, minocycline was administered to 16 (52%) of the 31 children infected with macrolide-resistant M. pneumoniae. Of the 20 children infected with macrolide-resistant M. pneumoniae under eight years of age, six (30%) were treated with minocycline during hospitalization. The difference in total febrile days between children receiving minocycline treatment before hospitalization and children not receiving minocycline treatment was three days.ConclusionsThe majority of hospitalized children with respiratory tract infection due to macrolide-resistant M. pneumoniae infection was of preschool age and had received 14- or 15-membered macrolide antibiotics before hospitalization. Because macrolide-resistant M. pneumoniae is widespread in Japan, the administration of minocycline as a second-line antibiotic in children under eight years of age cannot be withheld when clinical symptoms do not improve with macrolide antibiotics.     

Drug-induced thyroiditis and papillary carcinoma in a minocycline-pigmented black thyroid gland

We describe a 31-year-old woman who had ingested minocycline for 18 months prior to presenting with hyperthyroidism and a palpable thyroid nodule. There was no evidence of Graves' disease or autonomous nodule on thyroid scintigraphy, and a clinical diagnosis of thyroiditis was made. Fine-needle aspiration biopsy of the palpable lesion suggested papillary carcinoma, and the patient underwent a total thyroidectomy. Intraoperatively, the thyroid gland was found to have a striking black discoloration. Subsequent histological examination revealed the accumulation of pigment globules within the apical cytoplasm of the follicular cells, and associated findings of a drug-induced thyroiditis. The tumor nodule showed features of infarction and was felt to represent a necrotic papillary microcarcinoma. We postulate that in addition to causing black thyroid pigmentation, chronic minocycline use in our patient resulted in thyroiditis and subsequent hyperthyroidism. The papillary microcarcinoma was probably a coincidental finding.     

Minocycline for the treatment of bronchiolitis obliterans associated with rheumatoid arthritis]

We discribe a rare case of rheumatoid arthritis (RA) complicated with bronchiolitis obliterans that was successfully treated with minocycline. Sixty four-year old woman with a four-years history of RA was admitted to the hospital because of dyspnea on exertion and polyarthritis. Pulmonary function test revealed marked decrease in V25 (0.10 l/s: 6.9%) and MMFR (12.6%). High resolution CT of the lung showed scattered centri-lobular micronodules in both lung fields, mucoid impaction, and hyperinflation. These findings indicated the presence of bronchiolitis obliterans. After 3 months of the treatment with minocycline, the patient showed a significant improvement of both arthritis and pulmonary function. Chest CT findings also improved after 1 year. The present case suggests that minocycline is effective for the treatment of bronchiolitis obliterans seen in patients with RA.     

An evaluation of efficacy of minocycline as an anti-rheumatic drug in patients with active and refractory rheumatoid arthritis]

The efficacy and safety of minocycline was investigated in Japanese patients with rheumatoid arthritis (RA) who had already received more than three disease modifying anti-rheumatic drugs (DMARDs). Minocycline was administered at 100 mg twice a day to fifteen patients with active RA. The drug efficacy was evaluated by the clinical variables including the number of painful and/or swollen joints, the duration of morning stiffness, grip strength, the erythrocyte sedimentation rate, serum concentrations of C-reactive protein, and the titer of rheumatoid factor. Three patients experienced adverse effects such as dizziness and abdominal pain or discomfort, but only one patient with abdominal pain and dizziness was discontinued. Fourteen RA patients, who had taken minocycline for at least 6 months, were subjected to the clinical evaluation. Among them, 8 patients (54%) showed a significant improvement of clinical valuables for disease activity, beginning even at 4 weeks of the therapy. The continued effects were observed in 8 patients with over 1 year-minocycline therapy. Intriguingly, an active patient with a history of multiple DMARDs-resistancy showed a marked favorable response to this drug. The present study indicates that minocycline may be an effective DMARD with highly safe performance for patients with active and refractory RA. This is the first demonstration of the benefit of minocycline in the Japanese patients.     

Isolation of Nocardia species in patients with cystic fibrosis

The isolation of Nocardia species from the respiratory secretions of patients with cystic fibrosis presents problems with important clinical implications. From the sputum culture of a total of 387 patients with cystic fibrosis, Nocardia species was isolated in 9 cases (2%; 8 females and 1 male) with a mean (SD) age of 17 (7) years. Sixty-seven percent of the patients were asymptomatic and no relevant radiographic or analytical changes were detected. In only 3 patients was of Nocardia species isolated again in successive samples. Two patients were not treated, 7 were treated with cotrimoxazole and 3 with minocycline; in 2 cases therapy was intravenous. After a mean follow-up of 48 (33) months, all patients had improved. Isolation of Nocardia species from the secretions of patients with cystic fibrosis does not necessarily imply infection and the need for treatment should be assessed on an individual basis.     

Multiple-antibiotic-resistant Helicobacter pylori infection eradicated with a tailor-made quadruple therapy

In 2008, a 44-year-old woman with mild epigastralgia diagnosed as having Helicobacter pylori-positive chronic gastritis without peptic ulcer underwent eradication therapy with lansoprazole (LPZ), amoxicillin (AMPC) and clarithromycin (CAM) for 7 days, but it failed, so treatment with rabeprazole, AMPC, and metronidazole (MNZ) for another 7 days was given, but it also failed. She was then prescribed a modified, 14-day sequential therapy of LPZ and AMPC with an increased dose of CAM followed by MNZ supplement, but the infection was still not eradicated. The H. pylori was cultured and examined for antibiotic susceptibility with the agar dilution method and was found to be resistant to CAM, MNZ, and levofloxacin, and non-sensitive to AMPC, namely multiple-antibiotic-resistant, although sensitive to minocycline. The CYP2C19 genotype of the patient was an extensive metabolizer (G681A: G/A, G636A: G/G). In 2010, she gave informed consent for a 14-day, tailor-made, modified classical (or modified high-dose PPI + AMPC) quadruple therapy comprising 30 mg LPZ, 500 mg AMPC and 500 mg bismuth subnitrate, qid, and 100 mg minocycline, bid. Two months later, her urea breath test was negative. Histology and bacterial culture were still negative 1 year after the therapy. She did not have any adverse events during or after the novel therapy, nor did she feel any further epigastralgia.     

Nocardia farcinica pleuritis in a lepromatous patient with severe necrotizing reaction: an unusual presentation.

A young, male, lepromatous leprosy patient with a severe necrotizing erythema nodosum leprosum reaction treated with prolonged oral steroids and thalidomide developed pleuritis that was caused by a rare opportunistic pathogen, Nocardia farcinica. This organism was resistant to most antibiotics but was susceptible to amikacin and minocycline. During the course of treatment the patient developed severe gastritis which necessitated the removal of clofazimine and the inclusion of an H2 receptor antagonist. Bilateral steroid-induced cataracts needed surgical correction. This case is being presented for its rare opportunistic bacterial infection and for the multiple complications which made treatment difficult.     

Recurrent Mycobacterium xenopi infection in a patient with rheumatoid arthritis receiving etanercept

A case of recurrent Mycobacterium xenopi infection presenting as Pott's disease in a patient receiving etanercept for severe rheumatoid arthritis is described. A 49-y-old Caucasian male had received a total of 11 months of anti-mycobacterial therapy for hip infection acquired 15 months earlier; he presented with progressive back pain, which was diagnosed as Pott's disease. He had been treated with etanercept in addition to his prior immunosuppressive agents after the diagnosis of hip infection.     

A case of lung infection due to Mycobacterium abscessus]

We report a case of lung infection due to Mycobacterium abscessus (M. abscessus). A 60 year-old woman was admitted to our hospital because of an abnormal shadow found on chest radiography and a bloody sputum. Chest radiography revealed infiltrative and linear shadows in the middle and lower fields of both lungs. The sputum smears were negative for acid-fast bacilli, but sputum culture was positive. Rapidly growing mycobacteria were detected. The patient was treated with clarithromycin. Since M. abscessus was identified from repeated cultures of the sputa, the patient was treated with Imipenem/Cilastatin and Amikacin for four weeks, during which the chest radiography improved. After discharge, the treatment with clarithromycin and minocycline was continued for ten months, and the chest radiography improved further. Our treatment for M. abscessus may be a useful choice for drug treatment of such cases.     

Impact of minocycline ointment for periodontal treatment of oral bacteria

Topical tetracyclines, such as minocycline ointment, are frequently used for the treatment of periodontal infection. We investigated the influence of minocycline ointment use on oral bacteria, using supragingival plaque samples from adults who had not taken any antibiotics for 6 months. Initially we investigated the effect of topical minocycline administration on the emergence of tetracycline-resistant oral bacteria in four healthy adults. The isolation frequency of tetracycline-resistant oral bacteria to total viable bacteria increased substantially on day 6 after treatment, although it returned to baseline on day 25. Subsequently we investigated the isolation frequency of tetracycline-resistant oral streptococci (TOS) as a representative oral bacterium, using samples from 41 subjects with periodontal diseases. The percentage of TOS (of the total oral streptococci) increased significantly (from 11.9±15.6% to 34.2±24.0%) after minocycline treatment. Various TOS species were identified; S. mitis, S. salivarius, S. sanguinis, and S. oralis were frequently isolated. PCR and Southern blotting allowed us to identify tetM on the Tn916-like elements as the gene responsible for tetracycline-resistance. These findings suggest that the potential risk of the spread of similar genetic elements through bacteria in the oral cavity should be considered.     

Papillary thyroid carcinoma in a patient with sarcoidosis treated with minocycline

Long-term treatment with minocycline is occasionally associated with the development of black thyroid syndrome in which thyroid cancer is frequently found. Here, we report a patient with cutaneous, pulmonary and thyroid sarcoidosis who developed papillary thyroid carcinoma in the presence of a black thyroid syndrome after being treated with minocycline for 2.5 years.     

ANA (+) ANCA (+) systemic vasculitis associated with the use of minocycline: case-based review

Minocycline is a synthetic tetracycline-derived antibiotic with significant anti-inflammatory properties that may benefit patients with rheumatoid arthritis. Surprisingly, chronic exposure to minocycline can also cause a breach in immunologic tolerance resulting in a variety of autoimmune syndromes such as drug-induced lupus or autoimmune hepatitis. Vasculitis, most commonly resembling cutaneous polyarteritis nodosa, has also been seen in patients taking this drug. Herein, we present a case of biopsy-proven systemic vasculitis presenting as an ANA (+) ANCA (+) polyarteritis nodosa-like syndrome in a male patient who was taking minocycline for his acne for approximately 2 years. Patient initially presented with constitutional symptoms such as profound weight loss and fatigue, along with myalgias, oligoarticular arthritis, and livedo reticularis. About 2 months later, he developed a severe left testicular pain. Biopsy showed vasculitis complicated with the infarction of the left testis. Angiography revealed microaneurysms in the renal and splenic circulation. Stopping the offending drug, along with the short course of prednisone and hydroxychloroquine, resulted in prompt resolution of his symptoms. We additionally present a comprehensive review of biopsy-proven cases of vasculitis associated with chronic minocycline treatment focusing on its pathogenesis and clinical manifestations.