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Nontuberculous Mycobacterial Pulmonary Disease Secondary to Mycobacterium Szulgai Oztug Onal C* and Emel Kibaroglu 4Th Tuberculosis Dispensary, Ankara, Turkey

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Nontuberculous Mycobacterial Pulmonary Disease Secondary to Mycobacterium Szulgai Oztug Onal C* and Emel Kibaroglu 4Th Tuberculosis Dispensary, Ankara, Turkey ical C lin as C e f R o l e Oztug Onal and Kibaroglu, J Clin Case Rep 2014, 4:4 a p n o r r u t DOI: 10.4172/2165-7920.1000349 s o J Journal of Clinical Case Reports ISSN: 2165-7920 Case Report Open Access Nontuberculous Mycobacterial Pulmonary Disease Secondary to Mycobacterium Szulgai Oztug Onal C* and Emel Kibaroglu 4th Tuberculosis Dispensary, Ankara, Turkey Keywords: Mycobacterium szulgai; Tuberculosis; Non-pathogenic month of the treatment the patients sputum production had resolved and mycobacterium she couldn’t provide sputum for evaluation. At the end of third month of treatment there was no radiographic improvement. The patient was Introduction treated with 12 months of isoniazid, rifampicin, and ethambutol. By the Mycobacterium szulgai was first defined in 1972 as a non-pathogenic respiratory function test she has been diagnosed for asthma and started mycobacterium. It is a rarely seen nontuberculous mycobacterium to take inhaling steroids. No radiographic improvement occurred with (NTM or mycobacteria other than tuberculosis (MOTT)) and evidence treatment and a small pulmoner paranchimal tissue observed within of disease usually accompanies its isolation from clinical specimens the left lung. Left pneumonectomy was recommended and declined by [1]. The nontuberculous mycobacteria are accounted for significant the patient and she is currently being medically managed. morbidity in the immunocompetent and immunocompromised host. Discussion Mycobacterium szulgai is a slow growing mycobacterium which is rare in nature and humans. It has been isolated from environmental M. szulgai, M. simiae and M. malmoense are some of the sources such as aquariums, swimming pools, and tropical fish. mycobacteria which are difficult to diagnose. These organisms may Therefore, Mycobacterium szulgai disease has to be distinguished cause long-term cavitary disease of the lung, leading to significant from pseudoinfection because of contamination of samples in the morbidity. M. szulgai is a slow-growing, scotochromogenic NTM. It laboratory. A few cases have been reported since Mycobacterium szulgai was first described in 1972 and is responsible for n<0.5% of all human was defined. Several of these cases were the patients with acquired isolates of NTM [5-7]. Mycobacterium szulgai was named after Dr. immunodeficiency syndrome (AIDS) [2,3]. Three-drug therapy which T. Szulga, who played a role in the development of the lipid analysis is used in vitro susceptibilities as a guide for 12 to 18 months increases method that allowed its early distinction from other mycobacteria [8]. the probability for success [4]. Although it involves lungs most Although the natural reservoir of the mycobacterim is unknown, it has commonly, organ involvement and disseminated disease may rarely been isolated from snails and tropical fish [9,10] and in water, including occur. Herein, we present a case of M. szulgai pulmonary infection drinking water and hospital water supply [11,12]. Microbiological developed 24 years after an episode of pulmonary tuberculosis with a diagnosis can be difficult. Long culture period, potential contamination discussion of the difficulty for an accurate diagnosis and a review of the with environmental mycobacteria may be some of the reasons. M. relevant literature. szulgai may be misidentified with other NTM [13,14]. It was initially misidentified as M. gordonae and M. avium-intracellulare-scrofulaceum Case Report respectively. M. szulgai produces rough or smooth pigmented colonies Our female patient at the age of 39 referred to our center in July after two to four weeks [15]. Prolonged incubation of cultured material 2011 and she had 2-week history of cough, fever, night sweats, malaise, for at least four-week is necessary. The most common nontuberculous and a weight loss of 5-kg during the last 4 weeks. She had been treated mycobacteria to cause disease of the lung result from Mycobacterium for pulmonary tuberculosis in 1997 and in 2001. Her prior two avium complex. Classically, it causes an indolent tuberculosis like episodes have not been confirmed by sputum culture results. On her disease in the patients with chronic lung disease; however, it may chest examination; inspiratory rhonchi, fine rales and a few expiratory occur up to 30% of women with no obvious previous lung disease who wheezes were found in the right infraclavicular area. On the left have nodular infiltrates and bronchiectasis when seen [6,16]. Similar side there were no breath sounds. On the chest radiography, a right to other mycobacteria, M. szulgai also leads to a wide spectrum of upper lobe calcific infiltrate was identified. Left lung was completely disease. Besides the initial report that described oleacronon bursitis, involved with fibro-cavitary infiltrated from previous tuberculosis. cervical adenitis in a child and pulmonary infection [8] a subsequent There was a new cavitary lesion in the fibrotic left base. In 1991 and review [17] reported osteomyelitis, tenosynovitis, cutaneous infection, in 2001, she was administered isoniazid, ethambutol rifampicin, and and disseminated disease. Recently, meningitis due to M. szulgai was pyrazinamide for assumed pulmonary tuberculosis for six months and suggested by the isolation of this organism from the cerebrospinal later developed pulmonary sequelae. Subsequently, she had repeated fluid of a 6-year-old girl who had altered sensorium and low-grade lung infections with rapid recovery 1-2 weeks after initiation of broad- fever [18]. Mycobacterium szulgai lung disease usually manifests spectrum antibiotics. Acid-fast bacilli (AFB) studies of her sputum at presentation was smear positive for AFB. As a result of positive AFB and new pulmonary cavity the patient was diagnosed as probable *Corresponding author: Oztug Onal C, 4th Tuberculosis Dispensary/Ankara, recurrent tuberculosis and started on isoniazid, rifampicin, ethambutol, Turkey, Tel: 00-90--312-3091224; E-mail: [email protected] pyrazinamide and streptomycin. In the second month of treatment, Received January 28, 2014; Accepted February 21, 2014; Published February cultures were positive for Mycobacterium szulgai and confirmed by dot 24, 2014 blot hybridization. No immunological deficiency that may cause NTM Citation: Oztug Onal C, Kibaroglu E (2014) Nontuberculous Mycobacterial infection identified. Rapid drug resistance testing resulted as sensitive Pulmonary Disease Secondary to Mycobacterium Szulgai. J Clin Case Rep 4: 349. doi:10.4172/2165-7920.1000349 for rifampicin, ethambutol and streptomycin and resistant for isoniazid. She continued to take isoniazid, ethambutol, rifampicin, pyrazinamide Copyright: © 2014 Oztug Onal C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits and streptomycin for 2 months. In November 2011 treatment was unrestricted use, distribution, and reproduction in any medium, provided the reorganized with isoniazid, rifampicin, and ethambutol. After the first original author and source are credited. J Clin Case Rep Volume 4 • Issue 4 • 1000349 ISSN: 2165-7920 JCCR, an open access journal Citation: Oztug Onal C, Kibaroglu E (2014) Nontuberculous Mycobacterial Pulmonary Disease Secondary to Mycobacterium Szulgai. J Clin Case Rep 4: 349. doi:10.4172/2165-7920.1000349 Page 2 of 2 with long-term weight loss and cough and, radiography reveals Mycobacterium szulgai in a patient with AIDS. Clin Infect Dis 18: 1022-1023. cavitary upper lobe infiltrates. Thus, the illness appears similar to 3. Zamboni M1, Igreja RP, Bonecker C, Torres Filho HM (1992) [Mycobacterium the traditional pulmonary disease resulted from M. avium complex szulgai infection in a patient with hemophilia and AIDS]. Rev Assoc Med Bras or other nontuberculous mycobacteria and recurrent tuberculosis 38: 150-152. [4]. Our patient reported in this case has had 2 previous lung disease 4. Benator DA1, Kan V, Gordin FM (1997) Mycobacterium szulgai infection of the episodes treated as pulmoner tuberculosis. We couldn’t reach her lung: case report and review of an unusual pathogen. Am J Med Sci 313: 346- sputum culture results for prior lung diseases in 1991 and 2001. It is 351. clear that culture results are very important for a proper diagnosis and 5. O’Brien RJ, Geiter LJ, Snider DE Jr (1987) The epidemiology of nontuberculous treatment. Previously healed or active tuberculosis is a well-defined mycobacterial diseases in the United States. Results from a national survey. Am Rev Respir Dis 135: 1007-1014. predisposition to nontuberculous mycobacterial diseases of the lung. Therefore, it was not surprising that the patient developed M. szulgai 6. Rosenzweig DY (1996) Nontuberculous mycobacterial disease in the immunocompetent adult. Semin Respir Infect 11: 252-261. infection 24 years after treatment for pulmonary tuberculosis. In two of the cases reported first in the literature, death was attributed to M. 7. (1990) Ad Hoc Committee of the Scientific Assembly on Microbiology, Tuberculosis, and Pulmonary Infections. Diagnosis and treatment of disease szulgai infection, despite chemotherapy [9], but no such deaths have caused by nontuberculous mycobacteria. Am Rev Respir Dis; 142: 940-953. been described since then. Seventeen of 18 patients with M. szulgai pulmonary infection whose outcome is described [2,17,19] responded 8. Marks J, Jenkins PA, Tsukamura M (1972) Mycobacterium szulgai--a new pathogen. Tubercle 53: 210-214. to antituberculous chemotherapy. Most of the reported patients were treated with at
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