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Chest Infections |

An Endobronchial Mass Due to a Mycobacterium avium Complex Infection

Daniel Gorbett, MD; Hiram Rivas-Perez, MD; Nitin Bhatt, MD
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The Ohio State University Wexner Medical Center, Columbus, OH


Chest. 2013;144(4_MeetingAbstracts):184A. doi:10.1378/chest.1700003
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Mycobacterium avium complex (MAC) presenting as an endobronchial mass is an uncommon entity which typically responds to antibiotic therapy. We describe a female with disseminated MAC, on appropriate antibiotic therapy for nine months, complicated by an endobronchial mass. She presented with neutropenic fever and was found to have a post obstructive pneumonia due to partial obstruction of her bronchus intermedius (BI). This was subsequently managed with bronchoscopic debulking. We describe the case and an innovative management strategy.

CASE PRESENTATION: A 52 year-old female with a history of CLL, on therapy with the tyrosine kinase inhibitor Ibrutinib, as well as disseminated MAC on triple antibiotic therapy presented with recurrent neutropenic fevers. During her first admission, she underwent bronchoscopy. An endobronchial mass was seen which was found to have non-caseating granulomas and MAC. She then re-presented four months later with neutropenic fever and cough. Chest CT upon presentation was notable for new right lower lobe infiltrate. Bronchoscopy was notable for an increase in the size of the mass and near total occlusion of the BI. Repeat biopsies were positive for MAC and all other cultures were negative. Debulking bronchoscopy with cryotherapy was performed on three occasions. Since then, she has had no further pulmonary complaints. She remains on her MAC therapy and has not required repeat bronchoscopy.

DISCUSSION: Endobronchial MAC is uncommon with few reports in the literature. Classically, it has been described in the AIDS population, and previous reports have suggested that the pathogenesis may be related to immune reconstitution syndrome. In these reports, as the patients’ immune status improved, there was clinical response to standard MAC therapy. The reason for her lack of response is not obvious as her CLL was stable, and there was no evidence of macrolide resistance. A rare syndrome of granulomatous inflammation and a “sarcoid-like” reaction has been described in relation to CLL. This was considered; however, the positive culture data argued against this phenomenon. Given her neutropenic fevers and post-obstructive pneumonia, debulking was done. Debulking of endobronchial masses is a common procedure in malignant disease, but is less commonly used for lesions of infectious etiology.

CONCLUSIONS: Endobronchial MAC is rare, and has been described in patients with AIDS. It typically responds to antibiotic therapy. Our report describes a case associated with CLL and describes a novel management strategy.

Reference #1: Salama C, et. al. M. Isolated pulmonary MAC infection in patients with human immunodeficiency virus infection: case reports and literature review. Clin Infect Dis 2003; 37:e35-40

Reference #2: Brunner et al. A. Granulomatous reactions cause symptoms or clinically imitate treatment resistance in small lymphocytic lymphoma/CLL more frequently than in other non-Hodgkin lymphomas. J Clin Pathol 2005; 58:815-819

DISCLOSURE: The following authors have nothing to disclose: Daniel Gorbett, Hiram Rivas-Perez, Nitin Bhatt

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