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Mori Y, Nakashima H, Funasaka T, Hori S, Kagajo M, Abe T, Ando M, Shindoh J. Utility of serum immunoglobulin A antibody against glycopeptidolipid core antigen in the diagnosis and management of hypersensitivity pneumonitis associated with Mycobacterium avium complex: A case report. Respir Med Case Rep 2022; 41:101790. [PMID: 36568320 PMCID: PMC9772834 DOI: 10.1016/j.rmcr.2022.101790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Measurement of the levels of serum immunoglobulin A antibody against glycopeptidolipid (GPL) core antigen, a cell surface antigen found in Mycobacterium avium complex (MAC), has been reported to be useful in the diagnosis and management of pulmonary MAC infection. However, evidence on its utility in hypersensitivity pneumonitis (HP) associated with MAC (i.e., "hot-tub lung") is limited. We herein report a case of HP associated with MAC in which the GPL core antibody levels were serially measured from diagnosis to treatment and thereafter. A 61-year-old man was suspected to have non-fibrotic HP based on the clinical course, laboratory findings, imaging pattern, bronchoalveolar lavage (BAL) lymphocytosis, and histopathological findings. Based on the history of whirlpool bath use, inhalation of aerosolized MAC was suspected as the cause of HP. The GPL core antibody level, measured using an enzyme-linked immunosorbent assay kit, was elevated, suggesting an immunological sensitization to MAC. A provocation test using the patient's whirlpool bath was positive. An identical MAC strain was isolated from the BAL fluid and bathtub. Accordingly, the patient was diagnosed with HP caused by the inhalation of aerosolized MAC from the whirlpool bath. The patient recovered after steroid treatment and discontinuation of the whirlpool bath. The GPL core antibody levels decreased with disease improvement. In conclusion, GPL core antibody levels could be elevated in HP associated with MAC and decrease with disease improvement. Thus, measurement of the GPL core antibody level may be useful for the diagnosis and management of HP associated with MAC.
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Key Words
- BAL, bronchoalveolar lavage
- CRP, C-reactive protein
- DLCO, diffusing capacity of the lung for carbon monoxide
- ELISA, enzyme-linked immunosorbent assay
- Enzyme-linked immunosorbent assay
- FVC, forced vital capacity
- GPL, glycopeptidolipid
- HP, hypersensitivity pneumonitis
- HRCT, high-resolution computed tomography
- Hot-tub lung
- Hypersensitivity pneumonitis
- MAC, Mycobacterium avium complex
- Mycobacterium avium complex
- PaO2, partial pressure of oxygen
- WBC, white blood cell
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Affiliation(s)
- Yuta Mori
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan,Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,Corresponding author. Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Harunori Nakashima
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takashi Funasaka
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Sho Hori
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Michiko Kagajo
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takashi Abe
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Morihide Ando
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Joe Shindoh
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
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Arish M, Naz F. Sphingosine-1-phosphate receptors 2 and 3 reprogram resting human macrophages into M1 phenotype following mycobacteria infection. Curr Res Immunol 2022; 3:110-117. [PMID: 35676924 PMCID: PMC9168381 DOI: 10.1016/j.crimmu.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/14/2022] [Accepted: 05/17/2022] [Indexed: 11/22/2022] Open
Abstract
Mycobacteria tuberculosis (M.tb) the causative agent for tuberculosis has been accredited for a high rate of morbidity and mortality worldwide. The rise in MDR and XDR cases has further created new obstacles in achieving the "End TB Strategy", which is aimed for 2035. In this article, we have demonstrated the potential of sphingosine-1-phosphate (S1P) analogs in providing an anti-mycobacterial effector response by altering macrophage polarity into M1. Among S1PR1 and S1PR3 analogs, S1PR2 analogs proficiently favor selective polarization of infected human macrophages into M1 phenotypes, marked by increased expression of M1 markers and decreased M2 markers. Furthermore, S1PR1-3 analogs treated macrophages were also able to decrease the secretion of anti-inflammatory cytokine IL-10 and can induce NO secretion in infected macrophages. Lastly, only S1PR2-3 analogs were able to restrict the growth of mycobacteria in human macrophages. Taken together our study reflects the potential of S1PR2-3 analogs in providing host defenses following mycobacterial infection by favoring M1 macrophage polarization.
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Affiliation(s)
- Mohd Arish
- JH-Institute of Molecular Medicine, Jamia Hamdard, New Delhi, India
| | - Farha Naz
- Centre of Interdisciplinary Research in Basic Science (CIRBSc), Jamia Millia Islamia, New Delhi, India
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Pennington KM, Vu A, Challener D, Rivera CG, Shweta FNU, Zeuli JD, Temesgen Z. Approach to the diagnosis and treatment of non-tuberculous mycobacterial disease. J Clin Tuberc Other Mycobact Dis 2021; 24:100244. [PMID: 34036184 PMCID: PMC8135042 DOI: 10.1016/j.jctube.2021.100244] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Non-tuberculous mycobacteria (NTM) is a collective name given to a group of more than 190 species of Mycobacterium. The clinical presentation for most NTM infections is non-specific, often resulting in delayed diagnosis. Further complicating matters is that NTM organisms can be difficult to isolate. Medications used to treat NTM infection can be difficult for patients to tolerate, and prolonged courses of anti-mycobacterial therapy are often required for adequate suppression or eradication. Herein, we review different NTM syndromes, appropriate diagnostic tests, and treatment regimens.
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Key Words
- ADR, adverse drug reactions
- AFB, acid fast bacilli
- AST, antimicrobial-susceptibility testing
- ATS, American Thoracic Society
- BCG, Bacille Calmette-Guerin
- CLSI, Clinical and Laboratory Standards Institute
- COPD, chronic obstructive pulmonary disease
- ECG, electrocardiogram
- EMB, ethambutol
- Erm, erythromycin ribosomal methylase
- FDA, Food and Drug Administration
- HIV, human immunodeficiency virus
- HRCT, high resolution computed tomography
- IDSA, Infectious Disease Society of America
- INF-γ, interferon- γ
- INH, isoniazid
- MAC, Mycobacterium avium complex
- MALDI-TOF, matrix-assisted laser desorption ionization time-of-flight mass spectrometry
- MGIT, mycobacteria growth indicator tube
- MIC, minimum inhibitory concentrations
- Mycobacterium abscessus
- Mycobacterium avium
- NTM, non-tuberculous mycobacteria
- Non-tuberculous mycobacteria
- PCR, polymerase chain reaction
- PFT, pulmonary function test
- TB, tuberculosis
- TDM, therapeutic drug monitoring
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Affiliation(s)
- Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic Rochester, MN, USA
| | - Ann Vu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic Rochester, MN, USA
| | - Douglas Challener
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, MN, USA
| | | | - F N U Shweta
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, MN, USA
| | - John D Zeuli
- Department of Pharmacy, Mayo Clinic Rochester, MN, USA
| | - Zelalem Temesgen
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Rochester, MN, USA
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Iitoh E, Tominaga M, Okamoto M, Sakazaki Y, Nakamura M, Kinoshita T, Kawayama T, Hoshino T. A case of pulmonary Mycobacterium heckeshornense infection in a healthy Japanese man. Respir Med Case Rep 2020; 30:101093. [PMID: 32489849 PMCID: PMC7256317 DOI: 10.1016/j.rmcr.2020.101093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 10/29/2022] Open
Abstract
A 72-year-old man, healthy, smoker, with long-standing cough, was referred to our hospital and his chest X-ray (CXR) revealed a cavity lesion in the right upper lobe. Direct sputum smears, but not culture in solid medium, were positive for acid-fast bacilli (AFB) without tuberculosis DNA. The preliminary diagnosis was of a non-tuberculosis infection that progressed slowly, and the CXR showed the condition to worsen daily. Four years later, a commercialized mycobacteria growth indicator tube system was used to culture the colonies of AFB successfully in liquid medium, and the species Mycobacterium heckeshornense was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry. The patient responded well to triple therapy with rifampicin, ethambutol, and clarithromycin, the sputum cultures remained negative and the roentgenogram showed minor improvement over the following 6 months.
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Key Words
- AFB, acid-fast bacilli
- CAM, clarithromycin
- CT, computed tomography
- CXR, chest x-ray
- DDH, DNA–DNA hybridization
- EB, ethambutol
- M, Mycobacterium
- MAC, Mycobacterium avium complex
- MALDI-TOF MS
- MALDI-TOF MS, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry
- MGIT, mycobacteria growth indicator tube
- MIC, minimum inhibitory concentration
- MTB, Mycobacterium tuberculosis
- Matrix assisted laser desorption ionization-time of flight mass spectrometry
- Mycobacterium heckeshornense
- Mycobacterium xenopi
- NTM, nontuberculous mycobacteria
- Non-tuberculous mycobacterium infection
- PCR, polymerase chain reaction
- RE, rifampicin plus ethambutol
- RFP, rifampicin
- rRNA, ribosomal RNA
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Affiliation(s)
- Eriko Iitoh
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Masaki Tominaga
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Masaki Okamoto
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Yuki Sakazaki
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Masayuki Nakamura
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Takashi Kinoshita
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
| | - Tomoaki Hoshino
- Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Fukuoka, 830-0011, Japan
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Katano T, Hagiwara E, Arai H, Sato M, Yamaya T, Tajiri M, Ogura T. A case of intrathoracic desmoid tumor with pulmonary Mycobacterium abscessus disease. Respir Med Case Rep 2020; 29:101001. [PMID: 32015958 PMCID: PMC6992532 DOI: 10.1016/j.rmcr.2020.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 12/02/2022] Open
Abstract
A 68-year-old man who was on treatment for pulmonary Mycobacterium avium complex complained a worsening of sputum. Although he archived negative sputum culture two months ago, sputum culture tests revealed the newly isolation of Mycobacterium abscessus repeatedly. Chest computed tomography showed newly-appeared extra-pulmonary mass lesion in contact with a cyst at the bottom of his right lung. From the results of contrast-enhanced magnetic resonance imaging, we first suspected loculated pleural effusion due to Mycobacterium abscessus infection. A thoracoscopic examination was performed as the right pneumothorax developed, and the pleural lesion was successfully resected and diagnosed as an intrathoracic desmoid tumor. Intrathoracic desmoid tumor is very rare, and this is the first report of a case with pulmonary Mycobacterium abscessus disease.
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Affiliation(s)
- Takuma Katano
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hiromasa Arai
- Department of General Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Midori Sato
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takafumi Yamaya
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Michihiko Tajiri
- Department of General Thoracic Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Ghio AJ, Smith GS, DeFlorio-Barker S, Messier KP, Hudgens E, Murphy MS, Maillard JM, Stout JE, Hilborn ED. Application of diagnostic criteria for non-tuberculous mycobacterial disease to a case series of mycobacterial-positive isolates. J Clin Tuberc Other Mycobact Dis 2019; 17:100133. [PMID: 31867444 PMCID: PMC6904831 DOI: 10.1016/j.jctube.2019.100133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have provided guidelines to assist in the accurate diagnosis of lung disease caused by nontuberculous mycobacteria (NTM). These microbiologic, radiographic, and clinical criteria are considered equally important and all must be met to make the diagnosis of NTM lung disease. To assess the significance of the three criteria, each was evaluated for its contribution to the diagnosis of NTM lung disease in a case series. Laboratory reports of any specimen positive for NTM isolation were collected between January 1, 2006 and December 31, 2010 at a university medical center. Medical records were reviewed in detail using a standardized form. The total number of patients with a culture from any site positive for NTM was 297 while the number from respiratory specimens during the same period was 232 (78%). Samples from two of these patients also yielded M. tuberculosis complex and were excluded. While 128 of the remaining 230 patients (55.7%) in the cohort met the microbiologic criterion for diagnosis of NTM lung disease, 151 (65.6%) and 189 (78.3%) met the radiologic and clinical criteria respectively. Only 78 patients (33.9%) met all three criteria provided by the ATS/IDSA for diagnosis of NTM lung disease. This evaluation reaffirms that defining NTM lung disease using either one or two of the criteria provided by the 2007 ATS/IDSA guidelines may significantly overestimate the number of cases of NTM lung disease. Based on the experience of defining NTM lung disease in this case series, recommendations for modification of the ATS/IDSA guidelines are provided which include expansion of both radiologic patterns and the list of symptoms associated with NTM lung disease.
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Affiliation(s)
- Andrew J Ghio
- Human Studies Facility, US Environmental Protection Agency, 104 Mason Farm Road, Chapel Hill, NC 27514, USA
| | - Genee S Smith
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Stephanie DeFlorio-Barker
- Human Studies Facility, US Environmental Protection Agency, 104 Mason Farm Road, Chapel Hill, NC 27514, USA
| | | | - Edward Hudgens
- Human Studies Facility, US Environmental Protection Agency, 104 Mason Farm Road, Chapel Hill, NC 27514, USA
| | | | | | | | - Elizabeth D Hilborn
- Human Studies Facility, US Environmental Protection Agency, 104 Mason Farm Road, Chapel Hill, NC 27514, USA
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Affiliation(s)
- Rathan Reddy
- Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Umangi Patel
- Methodist Dallas Medical Center, Dallas, Texas, USA
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Inoue T, Tsunoda A, Nishimoto E, Nishida K, Komatsubara Y, Onoe R, Saji J, Mineshita M. Successful use of linezolid for refractory Mycobacterium abcessus infection: A case report. Respir Med Case Rep 2017; 23:43-45. [PMID: 29234594 PMCID: PMC5723375 DOI: 10.1016/j.rmcr.2017.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 11/06/2022] Open
Abstract
A 51-year-old male patient was receiving treatment for Mycobacterium abscessus infection for approximately 10 years. However, as his condition gradually progressed to type II respiratory insufficiency, he was referred to our hospital, which was near his home. Computed tomography on his first visit revealed an abscess in the right lower lobe. Because respiratory insufficiency was evident, he was admitted the same day. We began treatment with meropenem, amikacin, and clarithromycin, but his symptoms did not improve. In accordance with the 2007 American Thoracic Society/Infectious Diseases Society of America statement, we administered linezolid, which resulted in gradual improvement in his physical status and imaging findings.
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Key Words
- AMK, amikacin
- ATS/IDSA, American Thoracic Society/Infectious Diseases Society of America
- CAM, clarithromycin
- CRP, C-reactive protein
- CT, Computed tomography
- FRPM, faropenem
- IPM, imipenem
- LZD, linezolid
- Linezolid
- MAC, Mycobacterium avium complex
- MEPM, meropenem
- Mycobacterium abscessus
- Nontuberculous mycobacterium
- STFX, sitafloxacin
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Affiliation(s)
- Teppei Inoue
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Akihito Tsunoda
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Eriko Nishimoto
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Kohei Nishida
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Yuka Komatsubara
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Rintaro Onoe
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
| | - Junko Saji
- Division of Respiratory Disease, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, 1-30-37 Syukugawara, Tama-Ku, Kawasaki-Shi, Kanagawa-Ken 214-8525, Japan
| | - Masamichi Mineshita
- Division of Respiratory Disease, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa-Ken 216-8511, Japan
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Working S, Tyser A, Levy D. Mycobacterium avium complex olecranon bursitis resolves without antimicrobials or surgical intervention: A case report and review of the literature. IDCases 2015; 2:59-62. [PMID: 26793457 DOI: 10.1016/j.idcr.2015.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/02/2015] [Accepted: 04/05/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Nontuberculous mycobacteria are an uncommon cause of septic olecranon bursitis, though cases have increasingly been described in both immunocompromised and immunocompetent hosts. Guidelines recommend a combination of surgical resection and antimicrobials for treatment. This case is the first reported case of nontuberculous mycobacterial olecranon bursitis that resolved without medical or surgical intervention. Case presentation A 67-year-old female developed a painless, fluctuant swelling of the olecranon bursa following blunt trauma to the elbow. Due to persistent bursal swelling, she underwent three separate therapeutic bursal aspirations, two involving intrabursal steroid injection. After the third aspiration, the bursa became erythematous and severely swollen, and bursal fluid grew Mycobacterium avium complex. Triple-drug antimycobacterial therapy was initiated, but discontinued abruptly due to a rash. Surgery was not performed. The patient was observed off antimicrobials, and gradually clinically improved with a compressive dressing. By 14 months after initial presentation, clinical exam revealed complete resolution of the previously erythematous bursal mass. Discussion This is the first reported case of nontuberculous mycobacterial olecranon bursitis managed successfully without surgery or antimicrobials. Musculoskeletal nontuberculous mycobacterial infections are challenging given the lack of clinical data about optimal duration and choice of antimicrobials or the role of surgery. Additionally, the potential toxicity and drug interactions of antimycobacterials are not insignificant and warrant close monitoring if treatment is pursued. Conclusion This case raises an important clinical question of whether close observation off antimicrobials is appropriate in select cases of immunocompetent patients with localized atypical mycobacterial disease of soft tissue and skeletal structures.
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