Mycobacterium heckeshornense: an emerging pathogen responsible for a recurrent lung infection

Mycobacterium heckeshornense was responsible for a severe, recurrent and chronic pulmonary infection in an immunocompetent 65-year-old woman. The pathogen, initially identified as Mycobacterium xenopi and considered as a contaminant, led to a delayed adapted antimicrobial treatment. Although M. heckeshornense is phenotypically closely related to M. xenopi, its pathogenicity is noticeably higher. Accurate molecular diagnosis methods and treatment guidelines are needed to improve the management of patients infected by this uncommon pathogen.     

Enteropathy-type T-cell lymphoma that was pathologically diagnosed as celiac disease

A 63-year-old woman was referred and admitted to our department for further examination of protein-losing enteropathy (PLE), which was diagnosed by alpha-anti trypsin test. Her symptoms were frequent vomiting, watery diarrhea and hypoproteinemia. Although intensive examination for PLE was performed in her previous hospital, the origin of the disease was not detected. Abdominal computed tomography revealed diffuse enlargement and swelling of the intestine wall and a 5-cm diameter mass with unclear margin, which involved the mesenteric arteries and veins. Total colonoscopy showed a diffuse edematous lesion with hemorrhage at the terminal ileum. Enteropathy-type T-cell lymphoma (ETL) was diagnosed based on a biopsy of the lesion and CD45 gating analysis. Immediate start of chemotherapy (CHOP) led to a transient regression of the tumor even though her symptoms were not improved. During the second cycle of CHOP, the patient died of massive hemorrhage throughout the intestine. The pathological study revealed that intraepithelial CD3-positive clonal T-cells were present in the lesion, indicating that this case could be associated with celiac disease. In light of the histological findings, we concluded that this was a case of ETL associated with celiac disease, which is extremely rare in Japan.     

Spinal infection by Mycobacterium xenopi in a non-immunosuppressed patient.

A previously fit 77-year-old woman was found to have a paravertebral abscess. This was aspirated, yielding Mycobacterium xenopi, but no other pathogens. Antituberculosis chemotherapy with four first-line agents was commenced, with some response but continuing pain. Reports of extrapulmonary M. xenopi infections are rare. Most previous cases have involved immunosuppressed patients. This is the first reported case of spinal M. xenopi infection in a non-immunosuppressed patient, but radiological evidence suggests that previous tuberculous infection may have damaged the lumbar vertebrae, rendering them susceptible to infection by M. xenopi.     

Pulmonary disease caused by Mycobacterium xenopi:two case reports.

Two cases of pulmonary disease caused by Mycobacterium xenopi are presented. One represents the first case report of Mycobacterium xenopi isolated from surgically resected lung tissue in the United States. The epidemiologic, bacteriologic, and clinical aspects of the disease are presented.     

A case of Mycobacterium intracellulare lung disease that was detected by health examination and was successfully cured by chemotherapy--including discussions on the diagnostic criteria of the disease

A case was 56 years old woman, and she did not have any subjective symptom. She received multiphasic health screening, and abnormal shadow was detected on her chest radiograph. Chest radiography revealed infiltrations in the middle lobe. Computed tomography (CT) of the thorax showed clusters of small nodules in the middle lobe. The bronchial washing specimen showed acid-fast bacilli identified as Mycobacterium intracellulare by DNA-DNA hybridization (DDH) method. This case was diagnosed as Mycobacterium intracellulare lung disease. The patient received combination therapy with rifampicin, ethambutol, and clarithromycin for one year with radiological improvement. CT findings were characteristic and useful for the early diagnosis of MAC infection, which led to cure of the disease by chemotherapy.     

Mycobacterium xenopi infection of a 50-year-old oil plombage complicated by bronchopleural and pleurocutaneous fistulas.

We report the rare combination of simultaneous bronchopleural and pleurocutaneous fistulas 50 years after oil plombage, together with infection of both the plombage and the contralateral lung with Mycobacterium xenopi. Our case documents imaging patterns of complex fistula formation and subsequent infection resulting from oil plombage. Our case also emphasizes the infectious potential of Mycobacterium xenopi.     

Mycobacterium xenopi osteomyelitis in a patient on highly active antiretroviral therapy (HAART)

Skeletal infections with atypical mycobacteria are a manifestation of advanced HIV disease, most patients having CD4 counts of less than 100 cells/mm(3). We report a case of Mycobacterium xenopi vertebral osteomyelitis in a patient on HAART with a CD4 count of 490 cells/mm(3) and viral load below the level of detection at the time of diagnosis.     

Long-term remission of cyclic Cushing's disease that was diagnosed and treated surgically in non-active phase

Cyclic Cushing's disease is a rare clinical entity that is defined as a periodic excessive production of adrenocorticotropic hormone (ACTH) and cortisol. Only 42 cases with cyclic Cushing's disease have been reported in the literature. The diagnosis is very difficult because of the fluctuating secretion of ACTH and cortisol. We report a 78-year-old woman with a pituitary adenoma presenting with cyclic Cushing's disease. In the present case, several interesting issues are pointed out: 1) MRI study detected the presence of an adenoma and selective venous sampling in the cavernous sinus disclosed the hypersecretion of ACTH from a pituitary adenoma. These neuroimaging and endocrinological studies were helpful for the diagnosis, even in the remission phase. 2) The disease was in the long-term remission phase after transsphenoidal surgery despite the high recurrence rate in this clinical entity, although it recurred four years later. Even in the remission phase of cyclic Cushing's disease, meticulous endocrinological and neuroimaging examinations can reveal the presence of a pituitary adenoma, which should be treated surgically.     

A case of vocal cord dysfunction diagnosed as bronchial asthma, that was improved by psychosomatic therapy]

A 19-year-old psychologically disturbed female was admitted to our hospital because of intractable dyspnea and wheezing for twenty two months. She had been diagnosed as having asthma and had received several medications including steroids before admission to our hospital. According to our clinical observations, she was considered not to have asthma because neither FEV1.0 nor PaO2 was decreased during the periods of wheezing and FEV1.0 was not changed by inhalation of bronchodilators, although she had a family history of allergy and false bronchial hyperreactivity by asthograph. On physical examination, diffuse wheezing was heard mainly over the larynx during inspiration at the times of dyspnea. There was flattening of the inspiratory flow-volume loop during wheezing. Bronchoscopy performed during an attack confirmed that wheezing was due to adduction of the vocal cords throughout the respiratory cycle. Therefore, this case was diagnosed as vocal cord dysfunction. Her symptom was considered to be a form of conversion reaction derived from her unhappy past history. Following psychosomatic therapy, all of her medications became unnecessary. She understood the mind-body relationship of her condition, and learned to achieve self-control.     

U型反转胃镜法活检能够提高胃底病变的检出率

总结U型反转胃镜方法活检胃底病变的经验,提高胃底病变的诊断水平。采用前视型胃镜,利用U型反转法活检胃底病变。与传统的俯视法相比,U型反转法活检胃底病变具有视野清楚、活检部位准确的优点,并且能够避免活检后出血和穿孔的发生。采用U型反转胃镜方法活检胃底病变能够提高胃底病变的诊断水平。     

Pulmonary disease caused by Mycobacterium xenopi in HIV-negative patients: five year follow-up of patients receiving standardised treatment

The literature concerning the management of pulmonary disease caused by Mycobacterium xenopi is scanty and consists of retrospective reports, mostly of small series of patients. Our aim was to document the clinical features and response to treatment of this rare but challenging disease. Patients were treated in a randomised, multi-centre trial with either rifampicin plus ethambutol or rifampicin, ethambutol and isoniazid. Clinical, bacteriological and radiological progress was monitored at set intervals for 5 years. As no differences emerged between the two groups, the results have been combined to provide this prospective survey. Forty-two patients were studied. Mean age was 65 years, three-quarters were male and two-thirds had other lung disease(s). Sputum was positive on direct smear in 62%. Cavitation was present in 81%, mostly large cavities, and disease was extensive in 38%. Despite good clinical response and little toxicity the death rate was high (69%), but less than 10% died primarily because of the M. xenopi disease. The failure of treatment/relapse rate was 12%. Only 11 (26%) were known to be alive at 5 years of whom seven (17%) were known to be cured. There was no correlation between failure of treatment/relapse and in vitro resistance. Better methods of susceptibility testing and more effective regimens are needed, but it is also evident that improved management of concomitant diseases and better general health will play a major part in increasing survival.     

A case of lung infection complicated by pneumothorax caused by Mycobacterium marinum

Mycobacterium marinum is a waterborne mycobacterium that commonly infects fish and amphibians worldwide, but transmission to humans can occasionally occur, typically as a granulomatous skin infection following minor hand trauma. Infection involving the lungs is very rare. We herein describe a case of M. marinum-associated pneumonia and pneumothorax. In August 2008, an 81-year-old man was admitted to a hospital for detailed examination of weight loss and an abnormal shadow on chest imaging. Based on a sputum test, nontuberculous mycobacteriosis caused by M. marinum was diagnosed. At that time, the blood chemistry revealed no respiratory symptoms or inflammatory findings, and the patient was treated on an outpatient basis with erythromycin and an expectorant. In late November 2008, sputum and coughing were observed. Furthermore, the patient developed a fever and chest pain that increased while breathing and he visited the emergency outpatient unit of our hospital on December 1. Hypoxemia, bilateral pneumonia, and right pneumothorax were observed, and a chest tube was inserted into the right thoracic cavity. Results of an acid-fast bacteria smear from the sputum and pleural effusion were positive, and M. marinum was identified on culture. The patient was diagnosed as having a lung infection complicated by pneumothorax caused by M. marinum. The lung infection was ameliorated with clarithromycin, rifampicin and ethambutol. However, no decreased in the air leaking from the chest tube was noted and inflation of the lung was incomplete. The department of respiratory surgery therefore performed thoracoplasty and lung cerclage. Subsequently, the air leak subsided, allowing removal of the chest tube and the patient was discharged.