Infección por el complejo Mycobacterium avium-intracellulare en pacientes con VIH/SIDA en un hospital peruano: Una serie de casos / Infection by the Mycobacterium avium-intracellulare complex in patients with HIV/AIDS in a Peruvian hospital: A series of cases

RESUMEN Existe poca información sobre la presencia del complejo Mycobacterium avium-intracellulare (MAC) en el Perú. Se describen cinco casos de infección por MAC en pacientes con VIH/SIDA del Hospital Nacional Dos de Mayo, Lima-Perú. Los pacientes presentaron, principalmente, fiebre persistente, diarrea crónica, síndrome consuntivo, pancitopenia y citofagocitosis. En todos ellos se identificó bacilos acido-alcohol resistentes en heces, por lo que recibieron tratamiento antituberculoso. El cultivo de heces fue negativo para Mycobacterium tuberculosis y, posteriormente, en todos se identificó a MAC mediante una prueba molecular (Genotype) en el cultivo de heces. Tres pacientes recibieron tratamiento para MAC luego de la identificación; sin embargo, todos fallecieron. Ante presentaciones similares a lo reportado, se sugiere el uso de métodos de mayor rendimiento (hemocultivo, mielocultivo, pruebas moleculares), así como asociar tempranamente drogas con actividad para MAC al esquema antituberculoso con la intención de mejorar el pronóstico de este grupo de pacientes.

ABSTRACT There is little information on the presence of the Mycobacterium avium-Intracellulare (MAC) complex in Peru. Five cases of MAC infection are described in patients with HIV/AIDS at the National Hospital Dos de Mayo, Lima - Peru. The patients presented, mainly, persistent fever, chronic diarrhea, consumptive syndrome, pancytopenia and citofagocitosis. In all of them, resistant acid-alcohol bacilli were identified in feces, so they received antituberculous treatment. The culture of feces was negative for Mycobacterium tuberculosis and, later, in all cases MAC was identified using a molecular test (genotype) in the culture of feces. Three patients received treatment for MAC right after identification; however, they all died. Before presentations similar to the reported, we suggest the use of higher performance methods (blood culture, myeloculture, molecular tests), as well as early associating drugs with activity for MAC to antitubercular scheme with the intention of improving the prognosis of this group of patients.

Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient

Abstract A 37-year-old man with AIDS presented with altered mental status four weeks after stopping his medications for Mycobacterium avium-intracellulare (MAI). He had low CD4 cell count and severe hypercalcemia. Bone marrow biopsy revealed bone marrow infiltration by granulomas positive for acid-fast bacilli and cultures grew MAI. His hypercalcemia continued to worsen with the initiation of MAI therapy but we were able to treat it successfully with pamidronate and calcitonin.

Infección pulmonar por Mycobacterium avium en paciente VIH/SIDA: Primer reporte en Perú / Mycobacterium avium lung infection in HIV/AIDS patient: First report in Peru

El complejo Mycobacterium avium (MAC) es un patógeno que se encuentra en el medioambiente y causa infecciones tanto en pacientes inmunocompetentes como inmunocomprometidos. Se presenta el caso de un paciente VIH positivo varón de 38 años infectado por P. jirovecii y aparentemente infectado por Mycobacterium tuberculosis desde el año 2009, el cual fue tratado con antibioticoterapia para pneumocistosis y terapia antituberculosis (TB) logrando mejoría parcial. En el año 2012 se le realizó nuevamente examen de cultivo y un nuevo tratamiento anti TB, frente a la sospecha de estar en presencia de una cepa de TB multidrogorresistente se recomienda realizar la identificación micobacteriana. El examen de cultivo fue positivo y el resultado genotípico resultó positivo para MAC. Se reporta el primer caso de un paciente VIH/SIDA con infección pulmonar por MAC en el Perú, así como una breve revisión de los aspectos epidemiológicos, clínicos y de tratamiento.

The Mycobacterium avium complex (MAC) is a pathogen found in the environment which causes infections in immunocompetent and immunocompromised patients. One case is presented: an HIV positive, 38 year old male patient, infected with P. jirovecii and apparently infected with Mycobacterium tuberculosis since 2009. He was treated with antibiotic therapy for pneumocystosis and antituberculosis (TB) therapy, which achieved a partial improvement. In 2012, the patient underwent a culture test and new anti TB treatment. Upon suspicion of a drug resistant TB strain, it was recommended to perform the mycobacterial identification. The culture test was positive and the genotypic result was positive for MAC. The first case of an HIV/AIDS patient with MAC lung infection in Peru is reported, as well as a brief review of the epidemiological, clinical and treatment aspects to the case.

Mycobacterium avium lung disease combined with a bronchogenic cyst in an immunocompetent young adult

We report a very rare case of a bronchogenic cyst combined with nontuberculous mycobacterial pulmonary disease in an immunocompetent patient. A 21-year-old male was referred to our institution because of a cough, fever, and worsening of abnormalities on his chest radiograph, despite anti-tuberculosis treatment. Computed tomography of the chest showed a large multi-cystic mass over the right-upper lobe. Pathological examination of the excised lobe showed a bronchogenic cyst combined with a destructive cavitary lesion with granulomatous inflammation. Microbiological culture of sputum and lung tissue yielded Mycobacterium avium. The patient was administered anti-mycobacterial treatment that included clarithromycin.

Mediastinitis and pericardial effusion in a patient with AIDS and disseminated Mycobacterium avium infection: a case report / Mediastinite e derrame pericárdico em um paciente com AIDS e infecção disseminada por Mycobacterium avium: um relato de caso

We report the case of a 36-year-old man who had acquired immune deficiency syndrome and developed suppurative mediastinitis extending over the left lung and anterior thoracic wall around the sternum, pericardial effusions, splenomegaly, and mesenteric and periaortic lymphadenomegaly due to Mycobacterium avium (genotype I). The organism was isolated from an axillary lymph node and the bone marrow. Mediastinitis associated with disseminated M. avium complex infection is uncommon and, to the best of our knowledge, this manifestation has not reported before.

Relatamos o caso de um paciente de 36 anos vivendo com AIDS que desenvolveu mediastinite supurativa com extensão ao pulmão esquerdo e à parede anterior do tórax ao redor do esterno, derrame pericárdico, esplenomegalia e adenomegalia mesentérica e periaórtica, devido ao Mycobacterium avium genótipo I, isolado de linfonodo axilar e da medula óssea. A mediastinite associada à infecção pelo Mycobacterium avium é rara e, até onde conhecemos na literatura publicada, esta forma de apresentação ainda no foi relatada.

Mycobacterium Avium Complex Infection Presenting as an Endobronchial Mass in a Patient with Acquired Immune Deficiency Syndrome

Mycobacterium avium complex (MAC) infection is a common opportunistic infection in patients with AIDS (acquired immune deficiency syndrome). Pulmonary involvement of MAC may range from asymptomatic colonization of the respiratory tract to invasive parenchymal or cavitary disease. However, endobronchial lesions with MAC infection are rare in immunocompetent and immunosuppressed hosts. Here, we report MAC infection presenting as an endobronchial mass in a patient with AIDS.

Mycobacterium avium and Burkholderia pseudomallei (Melioidosis) coinfection in an HIV-positive patient.

A 29 year old HIV positive Thai female with CD4 count of 10 cells/mm3 presented with chronic diffuse abdominal pain, fever, weight loss, anemia and leucopenia. Ultrasonography demonstrated diffuse upper abdominal lymphadenopathy with ascites. Microbiological and molecular work up of the specimen obtained by ultrasound-guided lymph node aspiration revealed co-infection with Burkholderia pseudomallei and Mycobacterium avium. Indirect hemagglutination, IgM-indirect fluorescent antibody, and IgG-indirect fluorescent antibody to Burkholderia pseudomallei were < 1:20, < 1:50 and < 1:50, respectively, at nine months, four months before the culture diagnosis and two months, eight months after the culture diagnosis of Burkholderia pseudomallei infection. The patient was treated initially with two weeks of intravenous ceftazidime, followed by oral cotrimoxazole, doxycycline and chloramphenicol. Clarithromycin and ofloxacin were added after the identification of Mycobacterium avium and its susceptibility test. The patients demonstrated clinical improvement with decreasing abdominal pain and resolution of fever.

Micobacteriosis pulmonar en pacientes HIV negativos en la ciudad de Buenos Aires, años 2003-2004 / Pulmonary mycobacteriosis in non HIV patients, Buenos Aires City, 2003-2004

La enfermedad provocada por micobacterias ambientales es sospechada fundamentalmente en pacientesHIV positivos o con otras enfermedades de base. En nuestro país no hay información actualizadaacerca de la prevalencia, tratamiento y evolución de esta enfermedad en pacientes inmunocompetentes.Presentamos 10 casos de enfermedad pulmonar por micobacterias ambientales en pacientes inmunocompetentes:diagnóstico clínico-bacteriológico, tratamiento y evolución.

Pulmonary disease,due to Mycobacteria other than tuberculosis, is mainly suspected in HIV + patients, or underlyingother diseases. In our country, there is no updated information on the prevalence of this pulmonarydisease, its treatment and evolution in immucocompetent patients. We present 10 cases of pulmonary diseasedue to Mycobacteria other than tuberculosis in non HIV patients: clinical-bacteriological diagnosis, treatment andevolution.

Enfermedades micobacterianas diseminadas en pacientes con VIH/SIDA. Evaluación de los hemocultivos por método rápido / Disseminated mycobacterial infections in patients with HIV/AIDS. Evaluation of blood cultures

Mil cuarenta hemocultivos correspondientes a 451 enfermos uruguayos con SIDA y diagnóstico clínico de micobacteriosis diseminada fueron evaluados entre 1999 y 2003. Las muestras fueron procesadas en el Centro de Referencia Nacional para Micobacterias (Montevideo, Uruguay), utilizando el sistema de hemocultivos automatizado para micobacterias MB - BacT (BioMérieux). Se detectaron 45 muestras positivas (4,3%) correspondientes a 26 enfermos (promedio 2,3 muestras por paciente). En 10/26 casos se identificó M. avium complex (MAC) y en 13/26 el germen aislado fue M. tuberculosis. El tiempo medio de incubación fue de 12,4 días (intervalo 6-19 días) para MAC y de 22,6 días (intervalo 7-35 días) para M. tuberculosis. El hemocultivo ha demostrado ser la mejor muestra para la confirmación bacteriológica de las enfermedades micobacterianas diseminadas cuando se estudian por lo menos 2 muestras por paciente. La frecuencia de aislamientos de M. tuberculosis y MAC aislados en pacientes con SIDA en Uruguay, corresponde a la de un país con una moderada prevalencia de tuberculosis.

One thousand-forty blood cultures corresponding to 451 Uruguayan patients with AIDS and clinic diagnosis of disseminated mycobacterial infection were evaluated between 1999 and 2003. Samples were processed in the NationalReferenceCenter for Mycobacteria (Montevideo, Uruguay), using the automated blood culture system for mycobacteria MB -BacT (BioMérieux). Forty-five positive samples were detected (4.3%) corresponding to 26 patients with AIDS (average 2.3 samples per patient). In 10/26 patients M. avium complex (MAC) was identified and in 13/26 the isolated germ was M. tuberculosis. The average time of incubation was of 12.4 days (range 6-19 days) for MAC and of 22.6 days (range 7-35 days) for M. tuberculosis. Blood culture has demonstrated to be the best sample for the bacteriological confirmation of the disseminated mycobacterial infections when at least 2 samples by patient are studied. The frequency of isolates of M. tuberculosis and MAC in AIDS patients is according with a moderate prevalence of tuberculosis in Uruguay.

Mycobacterium avium intracellularae complex associated extrapulmonary axillary lymphadenitis in a HIV-seropositive infant--a rare case report.

Opportunistic infections by Mycobacterium avium intracellulare complex in HIV infected patients, though common in adults, are rarely seen in infants. We herewith report an interesting case of an eight month old infant presenting with isolated axillary lymphadenitis, later on diagnosed to be tubercular lymphadenitis by Mycobacterium avium intracellulare and finally proved to be seropositive for HIV infection born to previously undetected HIV seropositive parents.

Postmortem pathology of opportunistic infection in a HIV positive patient--a case report.

An autopsy case of HIV positive patient with multiple opportunistic infections is described. We received heart, lungs, spleen and both the kidneys along with pieces of cerebrum for anatomy and histopathological examination. Histology of organs revealed disseminated non-granulomatous necrotizing type of tissue reaction with superadded infection with Cryptococcus neoformans (C. neoformans) in liver and brain. Pneumocysts carini (P. carini) induced pneumonia in lungs, disseminated mycobacterial infection in spleen, lungs, liver and kidneys and acute fibrinous meningitis with superadded infection with C. neoformans in brain. Special stains were carried out to demonstrate different organisms.

Mycobacterium avium-intracellulare in stool in HIV-seropositive man.

Mycobacterium tuberculosis is the predominant acid-fast bacillus causing diarrhea in HIV-seropositive patients in India. We report a 27-year-old HIV-seropositive man with diarrhea in whom M. avium-intracellulare was isolated on stool culture.

Mycobacterium Avium Arthritis with Extra-articular Abscess in a Patient with Mixed Connective Tissue Disease

A case of Mycobacterium avium arthritis in a 39-year-old female patient with mixed connective tissue disease (MCTD) was reported. An extra-articular abscess had formed outside the knee joint and extended down the calf. A culture was taken of the abscess and synovial fluid disclosed Mycobacteriun avium. This was resistant to most anti-tuberculosis agents. A combination of anti-tuberculosis drugs followed a total resection of the abscess. We concluded that M avium septic arthritis could insidiously develop into an extra-articular abscess. A combination of anti-tuberculosis drugs with a total resection of the abscess was an effective treatment.

Clinical and laboratory findings of disseminated Mycobacterium avium complex infection (DMAC) in a pair matched case-control study

A pair matched case/control study was conducted from January 1991 to 30 June 1992 in order to define clinical and laboratory findings associated with DMAC infection in AIDS patients. Since DMAC infection is usually associated with advanced immunodeficiency, and therefore also with other opportunistic illnesses, in addition to the number of CD4+ lymphocytes, cases and controls were matched using the following criteria: date of AIDS diagnosis and antiretroviral therapy, number and severity of associated opportunistic infections and, whenever possible, type of Pneumocystis carinii prophylaxis, age and gender, in this order of relevance. Cases (defined as patients presenting at least one positive culture for MAC at a normally sterile site) and controls presented CD4+ lymphocyte counts below 50 cel/mm3. A significantly higher prevalence of general, digestive and respiratory signs, increased LDH levels, low hemoglobin levels and CD4+ cell counts were recorded for cases when compared to controls. Increases in gammaGT and alkaline phosphatase levels seen in cases were also recorded for controls. In conclusion, the strategy we used for selecting controls allowed us to detect laboratory findings associated to DMAC infection not found in other advanced immunossupressed AIDS patients without DMAC

Micobacterias no tuberculosas en pacientes con fibrosis quistica / Nontuberculous mycobacteria in patients with cystic fibrosis

En los últimos años hubo un aumento en el aislamiento de micobacterias no tuberculosas (MNT) en muestras de tracto respiratorio de pacientes adultos con fibrosis quística (FQ) siendo la prevalencia en los distintos centros de EE.UU., Inglaterra, Suecia e Irlanda entre 12.5 y 19.5 por ciento. El objetivo de este estudio fue investigar la presencia de MNT en los pacientes atendidos en nuestro Centro Provincial de Fibrosis Quística. Se estudiaron 92 muestras de esputo y/o contenido gástrico provenientes de 40 pacientes com FQ, de edades comprendidas entre 4 meses y 25 años, obtenidas durante una exacerbación aguda o en los controles de seguimiento. En 6 pacientes com afectación clínica moderada o severa se aisló complejo Mycobacterium avium-intracellulare, 5 de ellos se interpretaron como casos de colonización y un paciente se consideró con enfermedad micobacteriana activa y recibió tratamiento. El índice de contaminación de las muestras fue muy alto en la primera etapa del estudio (57 por ciento), descendiendo al 2.8 por ciento con el cambio de método utilizado en el procesamiento de las muestras. Concluimos que la presencia de MNT es relativamente frecuente en pacientes con FQ, aun en los niños con afectación moderada o severa, por lo que debería investigarse sistemáticamente ante la posibilidad de que desarrollen enfermedad activa.