Mycobacterial chylous ascites: report of three cases and systematic review

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

BACKGROUND

Mycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare.

CASE PRESENTATION

A 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient's general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30.

CONCLUSIONS

We report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.

Disseminated Mycobacterium avium Infection Complicated with Chylous Ascites in a Patient with Neutralizing Autoantibodies to Interferon-γ

A 68-year-old man visited our hospital due to anorexia, weight loss and a fever. We diagnosed the patient with disseminated Mycobacterium avium complex (MAC) and confirmed the presence of interferon (IFN)-γ neutralizing autoantibodies (IFN-γAb). His lesions improved following antibiotic therapy, but chylous ascites (CA) developed seven months after treatment. CA was able to be controlled by subcutaneous octreotide and diet therapy. IFN-γAb is recognized as having a critical role in the pathogenesis of disseminated MAC disease, but its clinical features are not fully understood. CA may be a complication that develops during the treatment of disseminated MAC infection.

Disseminated Mycobacterium avium subsp. hominissuis infection and ascites in an FIV-positive cat

A domestic shorthair cat was presented to the Veterinary Teaching Hospital at The University of the West Indies with a history of anorexia, ataxia, and lethargy. On physical examination, moderate abdominal distension and a palpable abdominal fluid wave were noted. Dark yellow, cloudy fluid was collected via abdominocentesis. Fluid analysis indicated that the effusion was a transudate containing low numbers of macrophages and occasional neutrophils. Some of the macrophages contained rod-shaped nonstaining structures of variable length (2-4 um). These structures were also seen extracellularly in low numbers. The morphology of the structures was suggestive of Mycobacterium. The cat's condition continued to deteriorate, and it died within a few hours of being admitted. Further diagnostic tests revealed feline immunodeficiency virus (FIV) infection with concurrent Mycobacterium avium subsp hominissuis infection. To the authors' knowledge, this is the first reported case of nontubercular mycobacterial-related ascites in a cat.

Cytomorphology of Mycobacterium avium intracellulare-associated ascites

Ascites due to Mycobacterium avium intracellulare (MAI) infection is extremely rare and associated with a poor outcome. The cytomorphology of this condition has not been previously reported. We present a unique case of a 45-year-old woman with iatrogenic immunodeficiency who developed MAI-associated chylous ascites. The ascitic fluid cytology showed numerous lymphocytes and foamy histiocytes with abundant intracytoplasmic MAI organisms. The diagnosis was confirmed by tissue biopsy showing MAI mesenteritis. It is important to consider MAI-associated ascites in the differential diagnosis whenever ascitic fluid shows a predominant population of lymphocytes and macrophages, especially in immunocompromised patients.