SESSION TYPE: Infectious Disease Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We present a patient with HIV who came in with symptoms and radiographic evidence suggestive of tuberculosis and was subsequently diagnosed with localized pulmonary MAC infection.
CASE PRESENTATION: 51 year old male presented with complaints of two episodes of hemoptysis associated with low grade fevers, chills, dry cough and 15 lb weight loss in past few weeks. Past medical history is significant for Pulmonary Tuberculosis treated 9 years ago, HIV (on Atripla, CD4-840) and Hepatitis C. He smoked tobacco,marijuana and was an ex-cocaine abuser.Patient lived in New York city. No recent travel or sick contact.Examination was notable for an African American male in no distress; temperature of 100.5F.Lung exam significant for decreased breath sounds on the posterior right chest.Lab data - WBC 6500/μL with 53% neutrophils,37% lymphocytes, hemoglobin 12.9 g/dL ,platelets 372,000/μL, serum creatinine 0.6 mg/dL and normal hepatic profile. CT chest showed a large cavitary lesion at the right apex with internal dependent fluid and extensive tree in bud nodules throughout the right lung. Patient was placed on airborne isolation. Multiple sputum samples were positive for numerous acid fast bacilli. Patient was started on a four drug regimen for presumed Pulmonary Tuberculosis. Subsequently, all sputum cultures were positive for MAC. Therapy was changed to Ethambutol, rifampin and clarithromycin to treat Pulmonary MAC. Patient improved symptomatically and was discharged with out patient follow up.
DISCUSSION: Pulmonary MAC in immunocompetent individuals occurs as two distinct clinical entities- fibrocavitary and reticulonodular lesions. Fibrocavitary MAC is seen in elderly males,smokers with underlying structural lung disease.Healed tuberculosis is a predisposing risk factor. Reticulonodular MAC with cylindrical bronchiectasis is seen in elderly women with no pre-existing lung disease.Though MAC frequently colonizes the respiratory tract in patients with HIV; pulmonary disease due to MAC without dissemination is rare.The disease can mimic pulmonary tuberculosis clinically and radiographically.If presumptive anti-tuberculous drugs show only partial response in this setting, consider adding drugs that are active against MAC until culture results are available
CONCLUSIONS: In patients with AIDS with very low CD4 counts,MAC presents as a disseminated infection. Localized pulmonary disease is uncommon. HIV infected patients with high CD4 counts can develop localized pulmonary disease with MAC similar to that seen in immune competent individuals.Pulmonary MAC without dissemination should be considered in the differential diagnosis in patients with HIV who present with symptoms suggestive of pulmonary tuberculosis with abnormal chest imaging and positive respiratory samples for acid fast bacilli.
1) Griffith DEet al.An official ATS/IDSA statement:diagnosis,treatment,and prevention of nontuberculous mycobacterial diseases.Am J Respir Crit Care Med 2007; 175:367
DISCLOSURE: The following authors have nothing to disclose: Poornima Ramanan, Naseem Saadia, Vel Sivapalan
No Product/Research Disclosure InformationHarlem Hospital, New York, NY