Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

A Rare Case of Pulmonary Mycobacterium Szulgai Treated With Combined Drug Therapy and Surgery FREE TO VIEW

Mathieu Saint-Pierre, MD; Karlo Hockmann, MD; Gerald Evans, MD; Jorge Martinez-Cajas, MD; J Alberto Neder, MD; Kenneth Reid, MD; Wendy Wobeser, MD; Onofre Moran-Mendoza, MD
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Queen's University, Kingston, ON, Canada

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):185A. doi:10.1016/j.chest.2016.08.194
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION:M. szulgai is an uncommonly isolated nontuberculous mycobacterium (NTM), of clinical and pathological significance1. It is usually managed with antimycobacterial therapy alone2. We describe an unusual case where in addition to drug therapy bilateral upper lobe lung resection was required for persistent large cavitary lesions.

CASE PRESENTATION: A 52-year-old Caucasian woman presented with a 3-week history of dyspnea (Medical Research Council scale 1/5), productive cough and one episode of small-volume hemoptysis. She denied having any constitutional symptoms. She was an active smoker (30 pack-year history) and denied recreational drug use. The patient lived in Southeastern Ontario, Canada, and had several birds. She had no recent travel. She did not have any prior medical history, and was not taking any medications. Physical examination was unremarkable, aside from the presence of digital clubbing. Blood work was noncontributory. Chest imaging showed large bilateral apical lung cavities. Bronchoscopy washings were positive for M. szulgai; bacterial and fungal cultures were negative. The patient was initiated on a multidrug regimen consisting of isoniazid, rifampin, ethambutol and moxifloxacin. Moxifloxacin was changed to cotrimoxazole after 6 months due to concerns about tendonitis. Chest imaging obtained after 12 months of therapy showed persistent cavities of unchanged size. Therefore, left upper lobe wedge resection and right upper lobectomy were performed. Antimicrobials were stopped 3 months after surgery (28 months total treatment). Complete resolution of the cavitary lesions was seen on subsequent imaging, and three sputum samples showed no further evidence of M. szulgai one year after surgery.

DISCUSSION: Although pulmonary disease caused by M. szulgai is very infrequent, the vast majority of reported cases received exclusively medical therapy. There are no widely accepted criteria for surgical treatment in NTM, but it is usually considered in patients with failure to medical treatment, extensive fibrocavitary disease or hemoptysis. Our patient had the last two indications. Surgery has rarely been attempted in patients with M. szulgai, but was previously proven to be effective in another published case3.

CONCLUSIONS: Our report would suggest that patients with pulmonary M. szulgai may benefit from lung resection surgery in some circumstances. Further research is required to develop more widely accepted criteria for surgical treatment.

Reference #1: Griffith DE, et al. An official ATS/ISDA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007 Feb 15; 175:367.

Reference #2: van Ingen J, et al. Clinical relevance of Mycobacterium szulgai in The Netherlands. Clinical Infectious Diseases 46.8 (2008): 1200-1205.

Reference #3: Tsuyuguchi K, et al. A resected case of Mycobacterium szulgai pulmonary disease. The International Journal of Tuberculosis and Lung Disease 2.3 (1998): 258-260.

DISCLOSURE: The following authors have nothing to disclose: Mathieu Saint-Pierre, Karlo Hockmann, Gerald Evans, Jorge Martinez-Cajas, J Alberto Neder, Kenneth Reid, Wendy Wobeser, Onofre Moran-Mendoza

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