Clinicopathological study of cases with Mycobacterium szulgai infection

Pulmonary mycobacteriosis is usually caused by Mycobacterium tuberculosis, Mycobacterium avium complex, or Mycobacterium kansasii. There are, however, other slow-growing mycobacteria which can cause pulmonary infection. Mycobacterium szulgai, first reported in 1972, is a scotochromogenic species which can affect human lungs, although human-to-human spread of infection is thought to be unlikely. We have recently treated three cases of middle-aged to elderly persons (45-87 year-old), two of them had underlying diseases (one with intrapulmonary and the other with extrapulmonary). All patients had constitutional symptoms (cough, sputum, dyspnea), and chest roentgenograms demonstrated either cavitation with scattered nodules or peripheral infiltrates predominantly in upper lobes, resembling pulmonary tuberculosis. In two cases, M. szulgai was identified by using DNA-DNA hybridization method. The in vitro susceptibility of M. szulgai to antimycobacterial drugs was better than that of M. avium complex, and it was resistant only to paraaminosalicylate, cycloserine, and partially to isoniazid. Pulmonary disease of three patients were successfully treated with a combination of multiple antimycobacterial agents including rifampin, ethambutol, isoniazid, or streptomycin.     

Transverse sinus thrombosis and venous infarction of the brain following unilateral radical neck dissection

Mycobacterium szulgai is a scotochromogen mycobacterium that accounts for < 1% of all human isolates of non-tuberculous mycobacteria. We report the first case of osteomyelitis caused by Mycobacterium szulgai in an AIDS patient. Culture from tissue was needed for isolation and identification of the organism, which was initially misidentified as Mycobacterium gordonae. Susceptibility testing to a fluoroquinolone was carried out and is also reported here for the first time. This case demonstrates the pathogenic potential of M. szulgai in this setting, and illustrates the need to obtain tissue specimens for culture in infected immunosuppressed patients to make a specific microbiological diagnosis and institute appropriate therapy.     

Pulmonary hypertension. Response of vasoactive peptides to a nonionic contrast medium in patients undergoing pulmonary angiography

A 46-years-old male was admitted to our hospital because of productive cough and infiltrates on the chest roentogenogram. The patient had a history of left upper bullectomy ten years prior to the admission. The CT scan of the chest on admission showed infiltrats with cavitation in the left apex and multiple bullae in almost whole lung. Microscopical examination of smears of sputum and bronchoalveolar lavage fluid revealed acid-fast bacilli. They were identified as Mycobacterium szulgai by DNA-DNA hybridization method. The patient was treated with isoniazid, streptomycin and rifampicin. After treatment for about a month, the culture of sputum converted to negative for M. szulgai. After about three months hospitalization, the infiltrates decreased and the cavity wall became thin, and no recurrence sign has been observed after the discharge. There are a few case reports of pulmonary infection due to M. szulgai associated with bullous disease of the lung in Japan.     

Simulating binocular visual field status in glaucoma

A 73-year-old male was admitted to our hospital because of productive cough and infiltrate on the chest roentogenogram. The underlying diseases was found to be multiple myeloma. He received a physical examination in June, 1996. The chest X-ray and CT scan on admission showed an infiltrative shadow with multiple bulla in the left upper lung field. Internal use of antibiotics and drip infusion of IPM/CS were ineffective. The chest X-ray showed air-fluid level in left upper peripheral bullous lesion and a percutaneus needle aspiration of the lung was performed. The specimen was pus with blood and microscopical examination of smears revealed no acid-fast bacilli, but Mycobacterium szulgai was isolated and identified by DNA-DNA hybridization method. The patient was treated with isoniazid and rifampicin, and improved in a few months. There are a few case reports of pulmonary infection due to M. szulgai associated with emphysematous bulla of the lung in Japan. M. szulgai infection of the lung is similar to M. kansasii infection in respect to clinical features (improvement of chest abnormal shadow, efficacy of drug).     

Mycobacterium avium complex and Mycobacterium tuberculosis in patients infected with the human immunodeficiency virus

Primary care physicians play an important role in identifying and treating bacterial infections in adults infected with the human immunodeficiency virus (HIV). Mycobacterium avium complex and Mycobacterium tuberculosis are pathogens that can cause systemic or local infection in these patients. We review the epidemiology, pathogenesis, clinical presentation, and principles of treatment for these two mycobacterial pathogens. Because M tuberculosis disease is preventable and curable and yet communicable, physicians should maintain a high degree of suspicion for tuberculosis in HIV-infected adults. In comparison, the goal of treating M avium complex in patients with advanced HIV disease is to reduce constitutional symptoms and improve survival.     

Osteoarticular Mycobacterium xenopi infection

BACKGROUND: Mycobacterium xenopi is a potential pathogen for man and can cause bone and joint infections, particularly spondylodiscitis. Most cases of infection occur in fragilized patients and are found more and more often in AIDS patients. CASE REPORT: A 41-year-old HIV+ woman developed cervical spondylodiscitis due to Mycobacterium xenopi infection. The strain was isolated from a discovertebral biopsy and was resistant to several antibiotics. Outcome was unfavorable. DISCUSSION: Most of the cases reported to date have involved spondylodiscitis of the thoracic or lumbar spine. To our knowledge, this is the first report of cervical spondylodiscitis dut to Mycobacterium xenopi in an HIV+ patient. Antibiotic combinations using fluoroquinolones and new macrolides are usually prescribed. Such protocols may provide cure of these opportunistic infections in immunodeficient patients.     

Disease caused by Mycobacterium kansasii in patients with HIV infection

BACKGROUND: To describe the clinical features and response to therapy in Mycobacterium kansasii disease among HIV infected patients, an increasing problem in our setting. METHODS: A retrospective survey of all charts from patients with HIV infection with Mycobacterium kansasii infection recorded between April 1985 and December 1991. RESULTS: A total of 13 patients were identified. All of them had clinically significant respiratory tract samples with a definite M. kansasii isolation. Only three had disseminated disease. In all but two cases, CD4 cell count at diagnosis time was lower than 200/mm3. Chest X-ray films showed interstitial pattern (8 cases) or alveolar condensation (3 cases) and lung cavities were seen in 4 patients. All patients with lung disease and one with disseminated disease responded well to anti-tuberculous therapy. CONCLUSION: Mycobacterium kansasii produces disease in advances stages of HIV-induced immunosuppression. The most common primary location is pulmonary, but disseminated forms can also be seen. The infection can be controlled with standard anti-tuberculous therapy.     

Bacteriology of mycobacteria: taxonomic and morphological characteristics

Bacteriological characteristics of organisms belonging to Genus Mycobacterium which involves more than 60 species are described. Mycobacterial organisms can be divided into the following groups having differential characteristics, on the basis of the results of biological, biochemical, and genetic investigations, including lipid analysis, DNA probe test, and comparative 16S ribosomal RNA sequencing. First, Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis, M. africanum, etc.). Second, cultivable but slowly growing nontuberculous mycobacteria, including photochromogens (Runyon Group I) such as M. kansasii, M. marinum, M. simiae, M. intermedium, and M. asiaticum, scotochromogens (Runyon Group II) such as M. scrofulaceum, M. szulgai, M. injectum, M. lentiflavum, and M. gordonae, nonphotochromogenens (Runyon Group III) such as M. avium, M. intracellulare, M. xenopi, M. malmoense, M. genavense, M. celatum, and M. gastri. Third, cultivable rapidly growing nontuberculous mycobacteria (Runyon Group IV) including M. fortuitum, M. chenolae, M. abscessus, M. phlei, and M. smegmatis. Fourth, noncultivable mycobacteria including M. leprae. About 30 species of Mycobacterium cause pulmonary, dermal, lymphatic, and disseminated infections in human beings. This paper mainly deals with the taxonomic, morphological, and other biological characteristics of these mycobacterial organisms.     

Osteomyelitis due to Mycobacterium haemophilum in a patient with AIDS

A case of osteomyelitis resulting from infection with Mycobacterium haemophilum in a patient with the Acquired Immunodeficiency Syndrome (AIDS) and Hodgkin's disease is described. The clinical features and response to therapy are examined and compared to previous reported cases. Mycobacterium haemophilum infection in immunocompromised patients usually results in cutaneous lesions but osteomyelitis may be the presenting feature. Tissue samples should be obtained early for microbiological examination and treatment should consist of surgical debridement and appropriate antimicrobial therapy.     

Echocardiographic evidence of aortopulmonary collaterals in premature infants after closure of ductus arteriosus

Aortopulmonary collaterals occur in a variety of congenital heart diseases, in chronic pulmonary infection and abscesses, in association with lung tumors, and after multiple pulmonary emboli. In patients with congenital cyanotic heart disease aortopulmonary collaterals mainly occur in conditions with reduced pulmonary blood flow. We investigated 12 preterm low-birth-weight infants, gestational age 29.3+/-3.3 weeks, with respiratory failure who suffered from moderate to severe chronic lung disease after a period of mechanical ventilation. All patients developed aortopulmonary collaterals after closure of a patent ductus arteriosus. Aortopulmonary collaterals could be displayed clearly by color Doppler echocardiography and originated mainly from the descending aorta or the aortic arch. Hypoxic and hypercapnic episodes favored the development of aortopulmonary collaterals, which disappeared after pulmonary hemodynamics and respiratory function had improved. In only one patient coiling of a large col lateral vessel had to be performed. Systemic-to-pulmonary collateral vessels potentially aggravate chronic lung disease by increasing collateral pulmonary blood flow and reducing lung compliance. We conclude that aortopulmonary collaterals occur in bronchopulmonary dysplasia and can cause major problems in ventilated premature infants. Echocardiographic evaluation is important to prevent aggravation of chronic lung disease of infants at risk.     

Nontuberculous mycobacterial cutaneous infection confirmed by biochemical tests, polymerase chain reaction-restriction fragment length polymorphism analysis and sequencing of hsp65 gene

We report a woman in whom a slow-growing scotochromogenic strain of Mycobacterium was cultured from skin lesions. According to its phenotypic and biochemical characteristics we could predict only that it might be M. szulgai, M. scrofulaceum or M. gordonae. Polymerase chain reaction amplification of the hsp65 gene and subsequent restriction fragment length polymorphism analysis on the isolated strain showed that its restriction pattern differed from both M. scrofulaceum and other scotochromogenic species. Ninety-nine per cent similarity was detected between the isolated strain and M. gordonae by sequencing of the hsp65 gene. This result suggests that the isolated strain may be either a slow-growing scotochromogenic Mycobacterium most resembling M. gordonae or a novel mycobacterial species.     

Cavitary pulmonary lesions in patients infected with human immunodeficiency virus

The differential diagnosis of cavitary pulmonary lesions in individuals infected with human immunodeficiency virus (HIV) is broad, especially in patients with advanced disease. In patients with Pneumocystis carinii pneumonia, cavitation is an uncommon manifestation of a common disease. It is unusual in patients with pulmonary cryptococcosis, coccidioidomycosis, and histoplasmosis but occurs frequently in patients with invasive pulmonary aspergillosis. In patients with pulmonary tuberculosis, cavities are more common during earlier stages of HIV disease, when cellular immunity is relatively preserved. Mycobacterium avium complex is an uncommon cause of lung disease and infrequently produces cavities. However, Mycobacterium kansasii, is often associated with cavitation. Cavities can complicate any bacterial pneumonia and are especially common with pneumonia due to Pseudomonas aeruginosa, Nocardia asteroides, and Rhodococcus equi. Noninfectious causes of cavitary lesions are rare, but cavitary lesions caused by pulmonary Kaposi's sarcoma and non-Hodgkin's lymphoma have been reported. Because of the broad differential diagnosis and because most cavities are caused by treatable opportunistic infections, a definitive diagnosis is essential.     

Pediatric osteomyelitis in Panama

Two hundred forty-one children who had osteomyelitis during a 19-year period, 1974 through 1992, were identified by chart review. Acute osteomyelitis or chronic osteomyelitis was the diagnosis for 221 (92%) and 20 (8%) of the children, respectively. Bacteriologic etiology was documented in 137 (57%) of the cases. Staphylococcus aureus, Pseudomonas aeruginosa, Salmonella species organisms, and Haemophilus influenzae type b were isolated from 97 (40%), 10 (4%), 8 (3%), and 7 (3%) of the children, respectively. S. aureus was the predominant microorganism in all age groups, whereas H. influenzae occurred only in children younger than 2 years of age. P. aeruginosa was recovered predominantly from children with a penetrating injury of the foot, while salmonella bone infections were diagnosed in patients with sickle cell disease. These data provide guidelines for the initial work-up for and management of osteomyelitis in children living in developing Latin American countries.     

MRI appearance of spinal lesions: metastatic tumors or infections?

Three patients with pathologically verified spinal osteomyelitis and another three with metastatic tumors of the spine were investigated. MRI of th spine of four patients showed several unusual findings. The preservation of intervertebral discs and endplates did not predict accurately the diagnosis of either infections or tumors. The "pepper and salt" appearing feature may also occur in a metastatic tumor. Plain radiographs, CT, and radioisotope bone scans were less sensitive than MRI to disclose the lesions. In cases of osteomyelitis, the systemic sources of infections were frequently not found, and the responsible microorganisms could not be identified even from the surgical specimens of two patients. However, mycobacterium tuberculosis was found in the surgical specimen of a patient with cervical spinal lesion whose MRI was indistinguishable from a metastatic tumor. Surgicopathological diagnosis was therefore crucial and mandatory in these instances.     

Mycobacterium bovis osteomyelitis involving a hip arthroplasty after intravesicular bacille Calmette-Guérin for bladder cancer

Bacille Calmette-Guérin (BCG), an attenuated strain of Mycobacterium bovis, is one of the most effective agents in the treatment of superficial bladder cancer. BCG osteomyelitis is an infrequent complication of intravesicular BCG therapy; only five cases of BCG vertebral osteomyelitis have been reported in the literature. Similarly, the infection of an indwelling extravascular device by BCG is rare; there is only one previous report documenting infection associated with an automated implantable cardiac defibrillator. We report a case of BCG osteomyelitis involving a hip arthroplasty that occurred after intravesicular administration of BCG for bladder cancer, and we review the risk factors predisposing to such infections and their treatment.     

Musculoskeletal complications of varicella

Varicella, commonly known as chickenpox, is a common viral infection in children. An estimated 3.5 million cases occur annually in the United States. Serious musculoskeletal complications such as osteomyelitis and necrotizing fasciitis, although uncommon, can be life and limb-threatening. The purpose of the current study was to determine the association between varicella and serious musculoskeletal complications necessitating operative treatment and to characterize these infections in otherwise healthy children. We retrospectively reviewed the records of all patients who had been admitted to the Children's Hospital in San Diego because of varicella and its complications during the eleven-year period from 1984 through 1994. All records with an inpatient discharge diagnosis code for varicella were identified. Twenty-seven (6 per cent) of the 417 admissions for varicella were for musculoskeletal complications of the disease necessitating operative treatment. There were seven admissions for osteomyelitis, four for septic arthritis, five for necrotizing fasciitis, ten for a deep-tissue abscess, and one for toxic shock syndrome leading to multiple limb amputations. Seventy-nine (19 per cent) of the 417 admissions occurred in 1994. Eleven (41 per cent) of the twenty-seven musculoskeletal complications that led to operative treatment occurred in 1994, representing a significant increase in the number of such complications compared with the numbers in previous years of the study (p < 0.01). Bacterial pathogens were identified as the cause of twenty-five of the twenty-seven complications that led to operative treatment. Of these twenty-five, twenty-one (84 per cent) were found, on culture, to be caused by group-A beta-hemolytic streptococcus. This pathogen was the cause of the infection in five of the seven patients who had osteomyelitis while Staphylococcus aureus was the cause in only one. Group-A beta-hemolytic streptococcus was also the causative organism in two of the four patients who had septic arthritis, three of the five who had necrotizing fasciitis, and all ten who had a deep-tissue abscess. Nine of the eleven musculoskeletal complications leading to operative treatment in 1994 had group-A beta-hemolytic streptococcus as the causative organism. An understanding of the trends of and a high level of suspicion for potentially serious secondary infections in children who have varicella is necessary for prompt recognition and appropriate treatment.     

Rapid development of resistance to clarithromycin following monotherapy for disseminated Mycobacterium chelonae infection in a heart transplant patient

Mycobacterium chelonae (formerly known as M. chelonae subspecies chelonae) is a rapidly growing mycobacterium that can cause disseminated infections, especially in immunocompromised hosts. The bacterium is typically resistant to antimicrobial agents; less than 20% of M. chelonae isolates are susceptible to trimethoprim-sulfamethoxazole, doxycycline, erythromycin, or ciprofloxacin. Findings in a recent study suggested that clarithromycin may be the drug of choice for the treatment of cutaneous (disseminated) disease due to M. chelonae. We describe a 60-year-old heart transplant patient with disseminated M. chelonae infection for whom monotherapy with clarithromycin failed because of the rapid development of resistance to the drug.     

Three cases of Pasteurella multocida infection in the respiratory tract

Pasteurella multocida (P. multocida) is well recognized as "normal flora" in the upper respiratory tract of cats, dogs and other animals. Recently, various infections due to P. multocida in human have been noted as pulmonary infections in the patients with chronic pulmonary diseases as well as skin abscesses or septicemia after an animal bite or scratch. We report here three cases of respiratory tract infections caused by P. multocida. The first two patients had acute exacerbation of bronchiectasis caused by P. multocida and the other patients with pulmonary emphysema developed pneumonia. These three patients improved by antibiotic therapy. In Japan, P. multocida respiratory tract infection is rare, but it may become more common in the future. Therefore, it seems to be important to take this pathogen into consideration in the management of chronic lung disease.     

Mycobacterium genavense infection presenting as a solitary brain mass in a patient with AIDS: case report and review

Patients with AIDS are prone to developing infections with opportunistic pathogens. Recently, a new mycobacterium, Mycobacterium genavense, has been found to cause infection in patients with AIDS. Previously published reports indicate that patients who are infected with this organism present with the same clinical features as do patients with disseminated infection due to organisms of the Mycobacterium avium complex. We describe an unusual case of a patient with AIDS who presented with grand mal seizures and a mass lesion in his brain, which was found to be caused by infection with M. genavense. No evidence of disseminated infection could be found in this patient. We discuss the microbiology of this organism and review the literature on M. genavense infections. Clinicians should be aware of this organism so that efforts at culture and identification will be made.