Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature

Iatrogenically Acquired Mycobacterium abscessus Infection in an Indwelling Intercostal Drainage In Situ in a Patient With Alcoholic Liver Disease and Bilateral Hepatic Hydrothorax: A Report of a Rare Case

A 47-year-old male, a known case of alcoholic chronic liver disease with portal hypertension, presented with complaints of abdominal distension and shortness of breath. A provisional diagnosis of ethanol-related compensated chronic liver disease (CLD) with portal hypertension and splenomegaly, gross ascites with bilateral hepatic hydrothorax was made. The left-sided pleural effusion subsided after three pleural taps, but the right-sided effusion kept refilling even after four to five days of repeated therapeutic taps, so a pigtail catheter was left in situ. The pleural fluid was sent for culture which did not grow any pathogenic organisms. Cartridge-based nucleic acid amplification tests where Mycobacterium tuberculosis complex (MTBC) was not detected, Ziehl-Neelsen staining was done in which acid-fast bacilli were not seen, and cytology was done where no malignant cells were seen. The patient was discharged with the pigtail in situ on the right side and, after 20 days, the patient again presented with shortness of breath, and imaging revealed moderate right-side pleural effusion. Draining of pleural fluid was done and sent for investigation which again revealed no infective etiology. The patient was admitted to the hospital for one month as the right-sided effusion did not resolve. Suddenly, the patient developed shortness of breath, and a chest X-ray was done, which showed pigtail blockage; pigtail flushing was done, and the bag was drained. The patient was empirically started on IV meropenem 500 mg TID, IV teicoplanin 400 mg BD, and inj polymyxin B 500,000 IU IV BD. The pleural fluid was sent continuously for investigation for the first two months which again did not reveal any infective etiology. After two months of pigtail in situ, the pleural fluid was sent for CBNAAT where MTBC was not detected, and ZN stain showed smooth acid-fast bacilli. The sample was cultured, and it grew acid-fast bacilli in 72 hours on blood agar, MacConkey agar, and Lowenstein-Jensen media. A line probe assay done from the isolate revealed it to be Mycobacterium abscessus subsp. abscessus which was resistant to macrolides and sensitive to aminoglycosides. Mycobacterium abscessus subsp. abscessus was isolated from repeated cultures of pleural fluid, and the patient was advised on a combination treatment of amikacin, tigecycline, and imipenem. The patient was discharged with the indwelling pigtail with the advised treatment; unfortunately, we lost patient follow-up as the patient never returned to us.

Nontuberculous mycobacteria infections of the pleura: A systematic review

BACKGROUND

Nontuberculous mycobacterial (NTM) pleuritis is an uncommon manifestation of NTM infection. Case reports and small case series have shown a variable clinical course and high mortality rates.

OBJECTIVE

To describe patients' characteristics, clinical presentation and outcomes of NTM pleural infections.

METHODS

A systematic review of cases of NTM pleural infections published in PubMed-indexed journals from 1980 to 2021.

RESULTS

A total of 206 cases of NTM pleural infections were found and analyzed. Fifty-eight percent of cases were males. The mean age was 57.5 yrs (range 9-87 yrs). Forty-three percent of patients were immunosuppressed, and 43% had a chronic lung disease; thirty-two percent had neither risk factor. In addition to the pleural infection, 67% of cases had a concurrent pulmonary NTM infection, and in 18 cases there was another extrapulmonary site of NTM infection. In 29% of cases the pleural infection was the sole manifestation of NTM disease. The most common isolated mycobacterium was Mycobacterium avium complex (65%). Fifty-three percent and 26% of patients required pleural effusion drainage and a surgical intervention, respectively, to treat the infection, in addition to anti-NTM chemotherapy. Forty percent of patients developed pneumothorax, 16% suffered from empyema, and 16.5% had broncho-pleural fistula. The reported mortality rate was 24%.

CONCLUSION

NTM pleural infections may arise in immunocompetent and immunosuppressed patients, with or without chronic lung disease or concurrent NTM pulmonary infection. These infections carry a poor prognosis and a high risk of complications requiring surgical interventions in addition to anti-NTM chemotherapy.

A rare pulmonary pathology complicated with an unusual condition

A 73-year-old male presented to the emergency department complaining about fatigue, night sweats, lack of appetite and weight loss for the past 2 months. His baseline weight was 47 kg and his height was 1.78 m (body mass index of 14.83 kg·m⁻²), while at presentation he weighed 39 kg. From his history, he underwent gastrectomy 31 years ago for stomach cancer. He was a smoker (55 pack-years), with no history of alcohol consumption or any other known pathological condition. Despite his gastrectomy, he did not suffer from symptoms suggesting reflux disease. 2 years ago, his daughter suffered from pulmonary tuberculosis, but he was not checked at that time with either a Mantoux test or chest radiograph. Physical examination revealed crackles in both lungs. His heart rate and blood pressure were normal. Because of his gastrectomy, he was on treatment with B12 and folic acid supplements and on presentation he did not reveal megaloblastic anaemia. From his laboratory examinations, his white blood cells were normal (9780 cells·μL⁻¹ (68.4% neutrophils, 21.7% lymphocytes)) while his C-reactive protein was elevated (8.87 mg·dL⁻¹). Despite his obviously impaired nutritional status his serum albumin was slightly above the lower normal level (3.67 g·dL⁻¹). His chest computed tomography (CT) revealed infiltrations bilaterally, signs of incipient pulmonary fibrosis with thickened interlobular septa, centrilobular nodules and loss of volume of the left lower lobe (figure 1). His blood gas analysis revealed hypoxaemia; therefore, he was admitted to hospital and initiated intravenous antibiotic treatment with ampicillin/sulbactam plus azithromycin.

Differential diagnosis should never be limited to the obvious diagnoseshttp://ow.ly/ybTM30obh6H

Pleurisy Caused by Mycobacterium abscessus in a Young Patient with Dermatomyositis: A Case Report and Brief Review of the Literature

M. abscessus is a rapidly growing mycobacteria (RGM) and is the most common cause of pulmonary RGM infection. M. abscessus pleurisy is extremely rare. We herein report the case of a young patient with M. abscessus pleurisy without any lung lesions. A laboratory analysis of the pleural effusion revealed lymphocyte predominance and increased adenosine deaminase, similar to the findings observed in tuberculous pleurisy. The patient was initially treated for tuberculous pleurisy, which resulted in the partial improvement of the patient's symptoms and pleural effusion. M. abscessus pleurisy should be considered, especially in immunocompromised individuals, even in the absence of pulmonary involvement.

TNF-α-mediated ER stress causes elimination of Mycobacterium fortuitum reservoirs by macrophage apoptosis

Mycobacterium fortuitum (MF), a rapidly growing nontuberculosis mycobacterium, is recognized as an important human pathogen. We investigated whether the endoplasmic reticulum (ER) stress response is associated with the apoptosis of MF-infected macrophages. The expression of ER molecular chaperones was significantly induced by MF infection. We found that MF-induced reactive oxygen species (ROS) generation plays a critical role in the induction of ER stress-mediated apoptosis. Excess TNF-α in the ER led to ER stress-mediated apoptosis during MF infection. The intracellular survival of MF was significantly increased by TNF-α knockdown compared with the control. This is the first report of MF-induced TNF-α as a cause of ER stress in macrophages. Furthermore, we found that TLR2-mediated ER stress response contributed to the elimination of intracellular MF in vivo. These results suggest that TNF-α-mediated ER stress during MF infection contributes to the suppression of intracellular survival of MF in macrophages. Our findings provide new insight into the importance of ER stress in mycobacterial infection.-Oh, S.-M., Lim, Y.-J., Choi, J.-A., Lee, J., Cho, S.-N., Go, D., Kim, S.-H., Song, C.-H. TNF-α-mediated ER stress causes elimination of Mycobacterium fortuitum reservoirs by macrophage apoptosis.