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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 138-140

Atypical mycobacterial infection, a diagnostic and therapeutic challenge-Case report and review of literature


Department of Microbiology, Institute of Post-Graduate Medical Education and Research, 244 AJC Bose Road, Kolkata, West Bengal, India

Date of Submission03-Apr-2018
Date of Acceptance13-Apr-2019
Date of Web Publication30-Jul-2019

Correspondence Address:
Dr. Nupur Pal
Department of Microbiology, Institute of Postgraduate Medical Education and Research, 244 A.J.C. Bose Road, Kolkata - 700 020, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_33_18

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  Abstract 


As atypical mycobacterial disease is very difficult to be differentiated from Mycobacterium tuberculosis, mycobacterial culture results can be the corner stone to solve the problem and avoid the un-necessary suffering of the patient and in the same time it helps in prescribing the correct drug regime for the patient. Here we present a case of a 23-year-old female who underwent LUCS one year back that was complicated with development of multiple abdominal wall abscesses. Initially she was treated with a combination of intermittent surgical drainage and prolonged antibiotic course, later antitubercular drugs were put on based on the positive AFB smear and biopsy report. This case is of interest that Mycobacterium abscessus was isolated from the patient who was improved after therapy with sensitive drugs. Our case highlights the fact that NTM disease should be put into consideration in patients with positive AFB smear and requires referral of samples to specialized microbiology laboratories.

Keywords: Atypical mycobacterial infection, diagnostic challenge, positive AFB smear


How to cite this article:
Pal N, Pal S, Ray R. Atypical mycobacterial infection, a diagnostic and therapeutic challenge-Case report and review of literature. J NTR Univ Health Sci 2019;8:138-40

How to cite this URL:
Pal N, Pal S, Ray R. Atypical mycobacterial infection, a diagnostic and therapeutic challenge-Case report and review of literature. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Dec 9];8:138-40. Available from: http://www.jdrntruhs.org/text.asp?2019/8/2/138/263634




  Introduction Top


Atypical Mycobacteria or nontuberculous Mycobacteria (NTM) encompass a group of acid-fast microorganisms of mycobacteria species apart from Mycobacterium tuberculosis and Mycobacterium leprae. NTM are environmental bacteria usually found in natural and treated waters, soils and aerosols throughout the world.[1],[2] Humans get infected by exposure to environmental reservoirs.[3] Nosocomial transmission occurs by direct inoculation via unsterilized instrumentation, drug injection, reusable devices implantation etc.[1],[2],[4] We believe that our patient was infected during her lower uterine caesarean section (LUCS), through the water supplies in hospitals which may act as a reservoir, leading to contamination of surgical instruments, irrigation solutions, and injectable medicines.


  Case Report Top


23 year old female was admitted in the Gynae and Obstretric Department on December, 2017, with multiple discharging sinuses in the left side of abdomen just above the scar of LUCS done on December 2016 in a private nursing home.

After one week of LUCS, she developed a superficial fluctuating painful swelling in the left side of the abdomen four finger above the scar. It was drained with antibiotics coverage. Pus was sent for culture and sensitivity (C/S). However, no growth was found at that time. Patient again developed same type of swelling at the site of wound even on antibiotics therapy. Incision and Drainage was done again. After few months, another painful swelling was appeared in the right side of the abdomen just four finger above the scar. Surgical drainage was performed several times (around 7 times) along with prolonged antibiotic courses. But intermittent discharge from the right sided wound, along with pain and itching, was continuing, for which she came to our hospital in June 2017. Blood investigation reports showed Hb 11.2 gm%, TLC 8400, neutrophil 60%, lymphocyte 34% monocyte 03%, eosinophil 03% ESR 28, Urea 26, Creatinine 0.9, LFT, serological profile and chest X-ray were within normal limit. Exision of fistula tract was done and sent for histopathological examination. Biopsy report showed chronic inflammatory cell infiltration and granuloma formation. Zeihl-Nelson (ZN) stain was done and Acid fast bacilli (AFB) found. Patient was referred to RNTCP and Antitubercular drugs (CAT1) were started from August 2017. After taking medicine for 1 month, she again developed multiple abdominal swellings that eventually burst and appeared as discharging sinuses [Figure 1]a. Case was sent to microbiology department for opinion. Gram stain, C/S, ZN stain and TB culture—both on conventional LJ media and automated BACT/ALERT system—were done. Sample was also sent for molecular Genexpert (CBNAAT) test for exclusion of Mycobacterium tuberculosis. AFB was found on ZN stain, growth was detected on the 2nd day by BACTALERT and the 4th day on LJ media [Figure 2]a, [Figure 2]b. Rapid grower atypical mycobacteria was diagnosed by rapid immunocromatography (TB Ag MPT 64) test from growth. Final diagnosis of Mycobacterium abscessus was done by biochemical test like nitrate reduction test and growth on 5% Nacl. Drug sensitivity test was performed by microbroth dilution method as per CLSI guidelines.[5] Genexpert (CBNAAT) test for Mycobacterium tuberculosis was found negative. The report was then communicated to clinicians. Treatment began with sensitive drugs, Ciprofloxacin and Clarithromycin. She was discharged at home and on follow up, after 1 month, it was found that patient was improving dramatically with no discharge and rapidly healing wound [Figure 1]b.
Figure 1: (a) Right sided abdominal wounds before diagnosis and treatment; (b): Right sided abdominal wounds with treatment on follow up

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Figure 2: (a) Growth on Lowenstein Jensen media after four days of inoculation; (b): Microscopic view of acid fast bacilli from growth

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  Discussion Top


Nontuberculous mycobacteria (NTM) are mycobacterial species different from the classic  Mycobacterium tuberculosis Scientific Name Search mplex. They are ubiquitously distributed in the environment (soil and water) with worldwide isolation rates that vary between 1-1.8 cases per 100,000 people.[1] Previously, it was considered mostly as colonizers or ignored as environmental contaminants, but are now increasingly reported as important pathogens causing infections ranging from skin and soft tissue infections to pulmonary and disseminated diseases in both immunocompromised and immunocompetent population.[1],[2],[4] Prevalence of NTM is unknown in India due to limited data available and there is lack of awareness among clinicians coupled with lack of laboratory capacity to diagnose these infections.[3] Skin and soft tissue infections result from colonization of mycobacteria by direct inoculation acquired via trauma, surgery, drug injections, and animal bites.[1],[2],[4] Biofilms protect these mycobacteria from eradication by ordinary disinfection processes.[1] Depending on the growth rate, NTM can be classified into rapidly growing mycobacteria (RGM) and slowly growing mycobacteria (SGM). Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus are three species of RGM responsible for the majority of clinical cases of skin and soft tissue infections. Clinical findings of RGM are usually non-specific and variable. For this, a high index of suspicion is required to diagnose skin infections caused by RGM.[6] Factors pointing towards the diagnosis of RGM include lack of response to conventional antibiotic regimen, recurrent wound infections, wound dehiscence, and poor wound healing, as seen in our patient.[5] As there is no clear consensus in treatment and there are no prior well-controlled trials to guide the treatment of atypical mycobacteria, from the data available from few drug susceptibility studies, it is found that RGM are susceptible to oral antibiotics: macrolides (clarithromycin, azithromycin), fluoroquinolones (ciprofloxacin, levofloxacin, and moxifloxacin), tetracyclines (doxycycline, minocycline), linezolid, and trimethoprim-sulfamethoxazole.[2],[7],[8] M. fortuitum is more susceptible to drugs than M. chelonae and M. abscessus. In conclusion, we can say that mycobacterial culture or molecular identification is must before starting treatment with ATD of a patient with positive AFB smear.

With the help of this case report, we want to make aware the clinicians that atypical mycobacteria should be put in mind before starting treatment and that all AFB +ve smear should be further processed either by culture or by molecular method by specialized microbiology laboratory.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

RNTCP or project fund

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma P, Jimena L, Guillamet V, Miljkovic G. Atypical mycobacterial infection after abdominoplasty overseas: A case report and literature review. Case Rep Infect Dis 2016; 2016:3642567. doi: 10.1155/2016/3642567.  Back to cited text no. 1
    
2.
Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, 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.  Back to cited text no. 2
    
3.
Shaarawy H, Elhawary AT. Risk factors for atypical mycobacterial disease in patients with smear positive pulmonary TB. Egypt J Chest Dis Tuberc 2014; 63:657-61.  Back to cited text no. 3
    
4.
Lamb RC, Dawn G. Cutaneous non-tuberculous mycobacterial infections, Int J Dermatol 2014; 53:1197-204.  Back to cited text no. 4
    
5.
Clinical and Laboratory Standards Institute. Susceptibility Testing of Mycobacteria, Nocardiae and Other Aerobic Actinomycetes; Approved Standard CLSI Documents M24-A2. 2nd ed. Wayne, Pennsylvania: Clinical and Laboratory Standards Institute; 2011.  Back to cited text no. 5
    
6.
Gopinath K, Singh S. Non-tuberculous mycobacteria in TB-endemic countries: Are we neglecting the danger? PLoS Negl Trop Dis 2010; 4:e615.  Back to cited text no. 6
    
7.
Goswami B, Narang P, Mishra PS, Narang R, Narang U, Mendiratta DK. Drug susceptibility of rapid and slow growing non-tuberculous mycobacteria isolated from symptomatics for pulmonary tuberculosis, Central India. Indian J Med Microbiol 2016; 34:442-7.  Back to cited text no. 7
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8.
Brown-Elliott BA, Nash KA, Wallace Jr. RJ. Antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria, Clin Microbiol Rev. 2012; 25:545-82.  Back to cited text no. 8
    


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