Clinical significance of the isolation of rapidly growing mycobacteria

BACKGROUND: To assess the clinical significance of the isolates of rapid-growing mycobacteria in a Universitary hospital from Madrid (Spain). PATIENTS AND METHODS: Review of medical records from patients with isolates of rapid-growing mycobacteria identified between 1979 and 1996 in the Microbiology department of the Fundación Jiménèz Díaz (Madrid, Spain). RESULTS: Rapid-growing mycobacteria were isolated from 28 patients during the study period (13 M. chelonae, 10 M. fortuitum, 2 M. mucogenicum, 1 M. marinum, 1 M. smegmatis and 1 M. flavascens). Clinical records of 26 patients were reviewed, being the isolate significative in 10 cases (5 soft tissue infections, 2 peritonitis in patients undergoing Continuous Ambulatory Peritoneal Dialysis [CAPD], 1 urinary tract infection, 1 osteomyelitis and 1 catheter-related soft-tissue infection). No patient was HIV+. All infections cured except 2 of them (the urinary tract infection and the osteomyelitis). Catheter withdrawal was needed in 3 cases (peritonitis in CAPD and catheter-related soft-tissue infection), apart from proper antimicrobial therapy. CONCLUSION: The most frequent rapid-growing mycobacteria isolated were those of the M. fortuitum complex. In our experience, isolation of rapid-growing mycobacteria from skin and soft-tissue samples was usually clinically significant, while isolates from respiratory tract, gut and blood cultures are always nonsignificant.     

Variables affecting results of sodium chloride tolerance test for identification of rapidly growing mycobacteria

The sodium chloride tolerance test is often used in the identification of rapidly growing mycobacteria, particularly for distinguishing between Mycobacterium abscessus and Mycobacterium chelonae. This test, however, is frequently unreliable for the identification of some species. In this study we examined the following variables: medium manufacturer, inoculum concentration, and atmosphere and temperature of incubation. Results show that reliability is improved if the test and control slants are inoculated with an organism suspension spectrophotometrically equal to a 1 McFarland standard. Slants should be incubated at 35 degrees C in ambient air and checked weekly for 4 weeks. Growth on control slants should be critically evaluated to determine the adequacy of the inoculum; colonies should number greater than 50. Salt-containing media should be examined carefully to detect pinpoint or tiny colonies, and colonies should number greater than 50 for a positive reaction. Concurrent use of a citrate slant may be helpful for distinguishing between M. abscessus and M. chelonae. Molecular methodologies are probably the most reliable means for the identification of rapidly growing mycobacteria and should be used, if possible, when unequivocal species identification is of particular importance.     

Lameness and leg weakness in rapidly growing turkeys associated with hip lesions

A form of epidemic lameness affecting rapidly growing broadbreasted turkeys of different breeds was investigated in 16 flocks. The condition commenced when birds were between eight and 14 weeks old and was consistenly associated with the development of lesions in the hip. Affected birds first showed leg weakness and ataxia and later chronic postural changes involving the hip. The post mortem lesions were those of inflammation, oedema, ulceration, fibrosis and complensatory hypertrophy of localised areas associated with the hip articulation. The cause was not established but the anatomical features of affected birds, their nutritional status and their apparent freedom from recognised infectious diseased are discussed.     

Failure to recognize rapidly growing mycobacteria in a proficiency testing sample without specific request--a wider diagnostic problem?

Fifty participants in the Swiss External Quality Control Program in Bacteriology/Mycology received a diagnostic sample containing Mycobacterium fortuitum. Only 31 used some sort of acid-fast stains, and 13 reported the diagnosis of M. fortuitum or rapidly growing mycobacteria. We conclude that the presence of 'rapid growers' in routine bacteriology samples is underestimated, and that acid-fast stains should be performed on suspicious Gram-positive rods.     

Infections due to nontuberculous mycobacteria in children with leukemia

We reviewed the spectrum of infections due to nontuberculous mycobacteria (NTM) in children with leukemia. Three children acquired such infections. One patient developed pneumonia after the cessation of chemotherapy when Mycobacterium xenopi was identified in his lung biopsy specimen. He required 2 years of treatment with antituberculous agents and clarithromycin. Cultures of central and peripheral blood specimens from two patients yielded Mycobacterium fortuitum and Mycobacterium chelonae, respectively. Broviac catheters were likely the source of infection. Removal of the catheters and antibiotic treatment resulted in cure. Central venous catheters in leukemic children are potential sources of infection. For febrile neutropenic children with leukemia who do not respond to antibiotic therapy, cultures positive for diphtheroids or negative routine bacterial and fungal cultures should raise a suspicion for infections due to NTM. Systemic infections may require up to 2 years of therapy. Removal of the infected catheters during persistent or recurrent infections in necessary for control of the infection.     

Paranasal sinus infection due to atypical mycobacteria in two patients with AIDS

Atypical mycobacteria, which are common opportunistic pathogens in patients with AIDS, have not been previously implicated in the pathogenesis of paranasal sinus infections; we describe two such patients. Clinical and radiographic evidence of bilateral maxillary and ethmoid sinusitis was observed for one patient; his infection proved resistant to therapy with conventional antimicrobials and decongestants. Endoscopic ethmoid sinus biopsy yielded a specimen containing acid-fast bacilli (AFB) that were later identified as Mycobacterium kansasii. Antimycobacterial therapy had not resulted in amelioration of the sinusitis > 2 months later, at which time he died of cerebral toxoplasmosis. The second patient presented with a tender right frontotemporal soft-tissue mass; a computed tomogram disclosed that it extended through the frontal bone to the frontal sinus. Inflamed tissue debrided from the sinus contained AFB; cultures first yielded M. kansasii and later Mycobacterium avium complex. Bacteremia due to both organisms was also demonstrated. Infection progressed despite therapy.     

Breast abscess with lethal septicemia due to Pseudomonas aeruginosa in a patient with AIDS

OBJECTIVE: The incidence of Pseudomonas aeruginosa in HIV-infected patients has increased over the last years. We describe a case of pseudomonal breast abscess complicated with fatal septicemia in an AIDS patient. CASE REPORT: A 21-year-old woman was admitted for fever, chills, nausea, vomiting and pain in the breast. She had a swelling in the right breast of 3 days duration. HIV infection had been confirmed 6 years earlier. CD4 count was 2/mm3. Surgical drainage produced a blue-green purulent discharge which grew Pseudomonas aeruginosa on culture. Despite cloxacilin, then ceftazidime and amikacin, initial improvement was followed 2 weeks later by nodular pulmonary infiltration with cavitation. P. aeruginosa was recovered from sputum and blood cultures, but stepwise resistance developed and the patient died 3 months after admission. DISCUSSION: Breast abscesses are infrequent in nonlactating women. P. aeruginosa is rarely involved, even in HIV patients. Due to the risk of resistance, prompt administration of appropriate antibiotics is required.     

Direct method to determine the antibiotic susceptibility of rapidly growing blood pathogens

Standardized direct disk diffusion antibiotic susceptibility testing on monomicrobial blood cultures is compared with the Food and Drug Administration method. The direct method yields acceptable data and may conserve 24 h in reporting results.     

Intrauterine growth retardation associated with hypoxia due to bronchiectasis

Two pregnancies in a young patient who had undergone lobectomy for bronchiectasis are described. Both were complicated by intrauterine growth retardation. The only abnormality detected was maternal hypoxaemia, and this was assumed to be causal.     

Headaches associated with nasal obstruction due to deviated nasal septum

A deviated nasal septum not only can cause a blocked nose, but may also be associated with headaches. This study evaluates the nature of these headaches, the effect of submucous resection of the nasal septum, and the factors associated with postoperative headache relief. Deviated nasal septa were corrected by submucous resection in 99 men and 17 women. Patients were studied at 4 to 48 months (mean 18 months) postoperatively. Fifty-five of the 116 patients studied (47.4%) had preoperative recurring headaches. Thirty-five of the 55 patients with headaches (63.6%) experienced relief (complete or partial) of their headaches at a mean follow-up period of 18 months. Patients were more likely to be relieved of their headaches following submucous resection if the headaches were most intense over the frontal region, pressurelike in nature, and if the submucous resection resulted in relief of nasal obstruction. It is possible that headaches recur in the long term, and it is postulated that central mechanisms play a role.     

Hyperthyroidism due to contamination of the alternative drug Ader-Rein (Vascu-Vitaal)

A 52-year-old woman developed hyperthyroidism due to the alternative Vascu-Vitaal pills. She was suffering from nephrotic syndrome due to membranoproliferative glomerulonephritis and subclinical hypothyroidism, possibly due to renal loss of thyroid hormone. For peripheral vascular disease she took the non-registered Vascu-Vitaal pills on her own initiative. According to the product information, these pills contain multiple vitamins, minerals, amino acids and tissue extracts of bovine adrenals, hypophysis and thymus. The patient developed hyperthyroidism after starting on a new batch of the preparation; it subsided after stopping the treatment. A technetium thyroid scan showed decreased uptake and subsequently the Vascu-Vitaal pills were found to contain both thyroxine and triiodothyronine. The thyroid hormone contamination was probably caused by bovine thyroid tissue. It is suggested to require a health warning statement on the package of alternative therapeutics stating that production and contents are not subject to governmental supervision.     

Study of gastric emptying by dual isotopes. Corrections due to contamination

The evaluation of gastric emptying by the double isotope technique involves some methodologic conditioning. Among them contamination correction or interference in the energy windows of the activity of the two isotopes used in the marking of the solids and fluids of the test food are important. The results of an experiment in which a phantom was used to evaluate the contamination between indio 111 (DTPA-Ca111In) and technecium 99m (colloid99mTc). Three test studies were posteriorly performed in healthy volunteers and 27 studies in a control group (13 males, mean age of 33 years, mean body mass index 39.02 kg/m). In these studies the contamination was corrected with the acquisition, following an initial swallow of juice marked with 111In, of activity in the windows of both isotopes. The contamination of 111In (isotope of greatest radiation energy) in the window of 99mTc was 24% in the phantom and 20%, 23% and 26% in the three initial study tests. The mean contamination in the control group was of 22% with limits of 19% to 29% and a standard deviation of 3%. Despite the comparable results, the usefulness of the individualized contamination calculation in the studies of gastric emptying with dual isotope to minimize the methodologic errors of this technique is discussed.     

Pancytopenia due to vitamin B12 deficiency associated with Graves' disease

Pancytopenia has a broad differential diagnosis, which can be narrowed depending on the cellularity of the bone marrow. The authors describe a complex patient with a history of Graves' disease who presented with pancytopenia, initially suspected of being due to aplastic anemia. He was later diagnosed with Vitamin B12 deficiency as a result of pernicious anemia. The potentially striking hematologic effects of cobalamin deficiency and the autoimmune basis for concurrent Graves' disease and pernicious anemia are reviewed.     

Unique association of a rapidly growing right atrial myxoma in a child with double-outlet right ventricle

We have undertaken an analysis of semen from HIV infected men with regard to sperm counts and motility, non-spermatozoal cells, and viral nucleic acid. Regression analysis showed that sperm concentration and motility were positively associated with blood CD4 cell count. By contrast, non-spermatozoal cell concentration (round cells) was inversely related to CD4 count. Extracellular HIV RNA was detected in the majority of semen samples and proviral DNA in a minority. Percoll gradient washing of 12 semen samples yielded six samples containing adequate sperm concentration for analysis. This washing procedure reduced prewash extracellular RNA to below detectable limits in all cases; proviral DNA present in two of the six prewash samples was also reduced to below detectable limits after washing. We conclude that semen washing before artificial insemination may reduce the risk of HIV transmission from an infected man to an uninfected woman. However, further evidence from prospective analyses of such an approach is required.     

Esophagitis due to a herpesvirus associated with mortality in a psittacine aviary

In a disease outbreak at a psittacine aviary, eight Pionus sp. and Amazon parrots became sick. Three of four Amazon parrots died with severe esophagitis, and epithelial intranuclear inclusion bodies containing herpesvirus were prominent. Focal liver necrosis with rare hepatocyte intranuclear inclusion bodies were found in two of the dead Amazon parrots.     

Severe hypersensitivity syndrome due to sulfasalazine associated with reactivation of human herpesvirus 6

BACKGROUND: A severe adverse reaction to sulfasalazine therapy has been associated with hypersensitivity syndrome, the clinical features of which are similar to infectious mononucleosis. No serologic evidence of viral infections has been reported with this syndrome; however, human herpesvirus 6 infection has not been specifically investigated, which could cause an infectious mononucleosislike syndrome. OBSERVATIONS: We report 2 cases of hypersensitivity syndrome induced by the use of sulfasalazine. The clinical features of the syndrome appeared 18 and 32 days after administration of sulfasalazine. Clinical signs included a maculopapular rash progressing to exfoliate erythroderma, fever, and lymphadenopathy. Leukocytosis, atypical lymphocytes, liver dysfunction, and renal disturbance were also observed. In 1 patient, human herpesvirus 6 variant B was isolated from peripheral blood mononuclear cells, and in both patients anti-human herpesvirus 6 IgG titers increased considerably. CONCLUSIONS: Two cases of hypersensitivity syndrome due to sulfasalazine use were associated with the reactivation of human herpesvirus 6, which may be a required cause of hypersensitivity syndrome.