SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: A man whose only risk factor is severe COPD presents with pneumonia due to Mycobacterium abscessus and aspergillus.
CASE PRESENTATION: A 71 year-old man was admitted with four days of productive cough, fever, hypoxia, and worsening dyspnea. His past medical history included severe COPD. He was initially treated with broad spectrum intravenous antibacterials. High resolution CT chest showed a large area of consolidative infiltrate in the left upper lobe along with smaller patchy infiltrates in the right upper and lower lobes. His dyspnea and hypoxic respiratory failure worsened, and he required non-invasive positive pressure ventilation. Sputum cultures grew high-grade Aspergillus fumigatus and voriconazole was added to his antibiotics; however, he continued to clinically worsen. On hospital day #8, sputum cultures grew a non-tuberculous mycobacterium that was later speciated as Mycobacterium abscessus. The same organism was isolated from sputum culture on multiple different days. He was initiated on amikacin, imipenem, and clarithromycin. Unfortunately, he did not improve. After prolonged hospitalization, he ultimately elected for comfort care measures only and passed away peacefully in the presence of his family.
DISCUSSION: Mycobacterium abscessus, a rapidly growing mycobacterium (RGM), is an uncommon but life-threatening cause of pneumonia. The typical presentation is a multi-lobar pneumonia with upper lobe predominance.1 Unfortunately, our patient’s clinical outcome was not unusual for patients with M. abscessus pneumonia with death due to progressive infection reported in as many as 20% of cases.1 There are currently no reliable antibiotic regimens that consistently result in cure. Current standard of care is months of intravenous antibiotic therapy with consideration for surgical resection of affected lung.1 Our patient had co-infection with Aspergillosis fumigatus. From the available information, we cannot definitively determine which organism was the primary cause of our patient’s syndrome. However, it was felt based on the imaging characteristics that M. abscessus was most likely to be the primary infection. Simultaneous aspergillus and non-tuberculosis mycobacterial infections have been reported by previous authors, including a case series of four patients with underlying COPD.2
CONCLUSIONS: 1) Mycobacterium abscessus is an uncommon but life-threatening pulmonary infection that should be considered in the differential diagnosis of any patient with multi-lobar pneumonia unresponsive to conventional antibacterials. 2) Co-infection with pulmonary aspergillosis can occur in patients with non-tuberculosis mycobacterial pneumonia.
1) American Thoracic Society. Diagnosis, treatment, and prevention of nontuberculous mycobacterial disease. Am J Respir Crit Care Med 2007; 175: 367-416.
2) Hafeez I, et al. Non-tuberculous mycobacterial lung infection complicated by chronic necrotising pulmonary aspergillosis. Thorax 2000;55:717-719
DISCLOSURE: The following authors have nothing to disclose: Joseph Skalski, Benyam Addissie, Paul Scanlon
No Product/Research Disclosure InformationMayo Clinic, Rochester, MN