Fatal pulmonary cavitary disease secondary to Mycobacterium xenopi in a patient with sarcoidosis

Long-term Findings in Bullous Sarcoidosis: A Case Report and Literature Review

Pulmonary sarcoidosis may occasionally present with large bullae, but the clinical implications of this finding remain unclear. We herein report the complete clinical course of a case of pulmonary bullous sarcoidosis. Chest computed tomography initially showed subpleural and peribronchovascular lung opacities, and bullae spontaneously developed in adjacent less-affected regions, probably via a retraction mechanism. Bullae progression was refractory to corticosteroid treatment and associated with deterioration of respiratory symptoms. The later phase involved repeated bacterial and fungal infections of the bullous lungs, eventually causing respiratory failure and mortality. Postmortem examinations revealed aggressive pulmonary Mycobacterium avium infection and diffuse alveolar damage.

Pulmonary Cavitary Disease Secondary to Mycobacterium xenopi Complicated by Respiratory Failure

Non-tuberculous mycobacteria (NTM) are a significant cause of pulmonary infection worldwide and can be clinically challenging. Mycobacterium xenopi (M. xenopi) has low pathogenicity and usually requires either host immune impairment, as in the case of a human immunodeficiency virus infection, or a structural lung disease to cause a clinical disease. Comorbidities have an essential role in M. xenopi occurrence. Herein, we present a rare case of pulmonary cavitary disease caused by M. xenopi complicated by respiratory failure and superinfection in a patient with a chronic obstructive pulmonary disease. An 81-year-old woman presented to the hospital with the chief concerns of shortness of breath and productive cough lasting a few weeks before presentation. A computed tomography scan of the chest showed a right upper lobe, thick-walled, cavitary lesion measuring 2.1 cm x 4.3 cm x 3.1 cm with associated bronchiectasis and pleural parenchymal scarring. One year ago, the patient underwent bronchoscopy for a right upper lobe cavitary lesion, which revealed M. xenopi on bronchoalveolar lavage culture. During the current admission, she was started on rifampin, isoniazid, ethambutol, and clarithromycin because the M. xenopi was clinically significant and fulfilled the American Thoracic Society diagnostic criteria for NTM lung disease. A diagnosis of NTM pulmonary disease does not necessarily suggest that treatment is required. The distinction between colonization and illness may be difficult upon the isolation of M. xenopi. A patient-centered approach is essential given that M. xenopi is often considered a commensal pathogen. When treatment is required, a multidrug approach with an individualized, optimal duration of therapy should be considered.