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An Elusive Pathogen Comes to Light: A Rare Case of Disseminated Mycobacterium szulgai in a Patient With Lung Transplant FREE TO VIEW

Tushar Chopra*, MBBS; William Gibbons, MD; Anil Patel, MD; James Yossef, MD
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State University of New York at Buffalo, Department of Internal Medicine, Buffalo, NY

Chest. 2012;142(4_MeetingAbstracts):273A. doi:10.1378/chest.1366732
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SESSION TYPE: Infectious Disease Student/Resident Case Report Posters III

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Mycobacterium szulgai, a non-tuberculous mycobacterium (NTM) is a rarely isolated scotochromogen. It is acquired through the lungs from an unknown environmental source. There are under 100 reported cases, most of whom had tuberculosis-like pulmonary disease. Infection occurs in patients with pre-existing lung disease (e.g. tuberculosis, COPD) and in immunocompromised hosts.

CASE PRESENTATION: A 55 year-old male with history of sarcoidosis, post-unilateral lung transplantation on immunosuppression since 7 years, and recurrent Pseudomonas pneumonia presented with chronic cough, generalized fatigue,and low-grade fever for 3 months. He also noticed new skin lesions on his extremities. He is a non-smoker. An initial chest CT scan revealed a chronic loculated pleural effusion with left lower lobe consolidation. Sputum gram staining detected Pseudomonas, however the sputum plus wound AFB stain was positive. Surveillance transbronchial biopsy reports,obtained from an out-of-state tertiary care center,showed no signs of rejection. However, presence of Mycobacterium szulgai was reported in the cultures in 2010 and 2009. In consultation with an infectious disease specialist and based on in-vitro sensitivities, we started treatment with isoniazid, rifampicin, ethambutol, and azithromycin. Sputum AFB culture turned negative after 4 months of treatment. The patient's skin and respiratory symptoms improved modestly. He continues to be on multi-drug macrolide-based therapy.

DISCUSSION: Mycobacterium szulgai usually causes disease and should not be considered a colonizer. Our patient had an indolent course over 2 years, eventually disseminating to the skin forming nodulo-ulcerative lesions. There are approximately 9 reported cases of cutaneous lesions and fewer cases with disseminated disease. This is the only case,to our knowledge,in a patient with lung transplant. The pathogen responds well to treatment. The patient met the American Thoracic Society criteria for NTM disease and was thus started on a multi-drug regimen based on in-vitro susceptibilities. Although clarithromycin has been successful in treating Mycobacterium szulgai, we added azithromycin for its immunomodulatory effects and fewer known interactions with rifampicin. Since infections with this organism can relapse, a triple-drug regimen based on in-vitro susceptibilities for at least 1 year after sputum cultures are negative is reasonable.

CONCLUSIONS: We hope this case encourages compliance with ATS guidelines for diagnosing NTM disease and increases awareness about Mycobacterium szulgai and its treatment.

1)Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367-416.

2)van Ingen J, Boeree MJ, de Lange WCM, de Haas PEW, Dekhuijzen PNR, van Soolingen D. Clinical relevance of Mycobacterium szulgai in The Netherlands. Clin Infect Dis 2008;46:1200-5.

DISCLOSURE: The following authors have nothing to disclose: Tushar Chopra, William Gibbons, Anil Patel, James Yossef

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State University of New York at Buffalo, Department of Internal Medicine, Buffalo, NY




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