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Mycobacterium Flavescens Le Infezioni in Medicina, n. 2, 95-99, 2003 Casi clinici Mycobacterium flavescens vertebral osteomyelitis Case report in an immunocompetent host Osteomielite vertebrale da Mycobacterium flavescens in un ospite immunocompetente Antonio Mastroianni Unità Operativa Malattie Infettive, Ospedale “G.B. Morgagni”, Forlì I INTRODUCTION upper lobe, and a CTscan of the thorax showed a small pleural-based lesion of 1-cm in diame- ycobacterium flavescens is an unusual ter. Bronchoscopy with bronchoalveolar lavage pathogen that, to our knowledge, has (BAL) and repeated CT-guided biopsies were Mnot been previously reported as a cause non-diagnostic. Abdominal ultrasonography of vertebral osteomyelitis. We wish to report a revealed no hepatosplenic lesion. Radiograph rare case of vertebral osteomyelitis caused by of the spine disclosed sclerosis and wedge- Mycobacterium flavescens in a subject with ap- shaped deformities of TH 10, TH 11 and TH 12. parent normal immune function, with a brief MRI showed massive spondylodiscitis of review of previous reports of human infection TH10/12, with paraspinal and intraspinal ab- caused by this atypical mycobacterium. This scess formation. Neurologic symptoms were case demonstrates that non-tuberculous my- absent. A purified protein derivative skin test cobacteria (NTM) vertebral ostemyelitis can oc- was negative. A bone debridement and a diag- cur not only in immunosuppressed patients but nostic bone biopsy were performed. Gram also in immunocompetent patients. staining of the purulent material from the ver- We have also reviewed the literature on vertebral tebral lesion showed no microorganims, while disease due to rapidly growing mycobacteria. acid fast stain revealed acid-fast bacteria. Ther- apy with isoniazid, rifampin, and streptomycin was initiated for suspected vertebral tubercu- I CASE REPORT lous osteomyelitis (Pott’s disease). After two consecutive months of treatment, the patient A 70-year-old man with a history of severe continued to experience low fever, lumbar pain, chronic ischemic cardiopathy and diabetes mel- night sweats, and fatigue. Mycobacterial blood litus was admitted to our hospital because of a and bone cultures drawn on admission proved 3-month history of fever, night sweats, fatigue, positive for Mycobacterium flavescens. This or- weight loss, and an increasing lower back pain ganism was susceptible to streptomycin and ri- and left-sided chest pain. On admission his fampin, and it was resistant to ethambutol and body temperature was 38 °C. Examination of isoniazid. Therapy was changed to rifampin, the joints revealed moderate signs of inflamma- ciprofloxacin and ethambutol, and the patient tory activity in the thoracic spine that was ten- improved rapidly. der to palpation. Results of laboratory tests in- Therapy was well tolerated for 13 months and cluded a leukocyte count of 89 x 109/l with neu- he completely recovered. trophils 69% and lymphocytes 32%, C-reactive protein and albumin of 120 mg/l and 28 g/l, re- spectively, and an ESR of 35 mm/h. Screening I DISCUSSION for HIV, syphilis and Brucella were negative. Lymphocytes subset analysis was normal. A Mycobacterial diseases cause substantial mor- chest radiograph showed an infiltrate in the left bidity and mortality throughout the world, and 97 2003 in recent years diseases caused by emergence of The diagnosis of infection due to rapidly grow- rapidly growing mycobacteria have been re- ing mycobacteria requires appropriate tissue ported from both developing and industrial- specimens to be obtained. Among the rapidly ized countries. Although most diseases due to growing mycobacteria found in abundance in pathogenic mycobacteria are caused by My- the environment, strains associated with hu- cobacterium tuberculosis, the rates of infections man disease are more frequently restricted to caused by NTM are increasingly reported in Mycobacterium fortuitum, Mycobacterium chelonae both healthy and immunocompromised pa- and Mycobacterium abscessus [1-3]. In addition, tients in the last decades. there are several saprophytic species of rapid NTM are ubiquitous organisms in our environ- growers documented as occasional etiological ment, ranging from harmless inhabitants of agents of disease, including Mycobacterium aquatic reservoirs and soil to species patho- phlei, Mycobacterium aurum, Mycobacterium genic to man and animals; in addition, NTM neoaurum, Mycobacterium flavescens, Mycobac- may also contaminate microbiological speci- terium vaccae, and the thermophilic species My- mens [1]. In recent years it has come to be ap- cobacterium thermoresistibile [1-3]. preciated that nosocomial transmission of these Extrapulmonary disease caused by NTM has a organisms is increasing [1]. broad spectrum of clinical manifestations refer- More than 65 different species have been recog- able to almost any organ system, although the nized, but many of the NTM are isolated as lab- spine is rarely affected. NTM infections of the oratory contaminants or colonizers, and infre- bones may occur following surgical proce- quently as true pathogens. Indeed, only a hand- dures, trauma, penetrating injuries or following ful of NMT are usually associated with diseases the injection of steroids. in clinical practice in humans. NTM osteomyelitis may be a complication of It has been reported that among the most com- skin and soft tissue infections most frequently mon risk factors associated with disease due to associated with a history of penetrating injury NTM are smoking, chronic lung disease, HIV or surgery. Moreover, extrapulmonary tubercu- infection, alcoholism, and less often immuno- losis due to NTM with involvement of the spine suppressive therapy, malignancy, connective remains an uncommon entity. The rarity of this tissue disease, previous Mycobacterium tubercu- condition was emphasized in recent articles [4, losis infection, leprosy, and diabetes [1-3]. 5]. NTM have been categorized into different Through an extensive literature search by groups based on characteristic colony morphol- means of MEDLINE consultation, we have ogy, growth rate, and pigmentation; growth identified only 20 cases of atypical mycobacte- rates have remained a practical means for ria vertebral osteomyelitis reported in the cur- grouping species within the laboratory [1-3]. rent English literature from 1955 to 2001 [4-7]. The rapidly growing mycobacteria include The study population consisted of 10 men and eight taxonomic groups of non-pigmented and 10 women with a mean age of 47 years (range pigmented organisms, also known as Runyon 16-79). group IV; these organisms exhibit growth in < 7 Of these cases, 5 were due to Mycobacterium days under optimal conditions in agar plates. xenopi, 4 were due to Mycobacterium avium-in- The most common disease associated with tracellulare, 4 were due to Mycobacterium fortui- these organisms is cutaneous disease associated tum, 3 were due to Mycobacterium abscessus, and with a penetrating wound or foreign body, but the remaining episodes were due to Mycobac- nosocomial infections can also occur [1-3]. terium simiae, Mycobacterium kansasii, Mycobac- Rapidly growing mycobacteria may also be as- terium bovis BCG and an atypical, non-classi- sociated with respiratory tract colonization or fied, mycobacterium. infection and surgical infections, while they are Vertebral infection caused by NTM involves the only occasionally associated with infections re- anterior inferior portion of the vertebral body, lated to hemodialysis, peritonitis in patients un- is adjacent to an intervertebral disk, and dergoing peritoneal dialysis, injection-associ- spreads under the anterior longitudinal liga- ated cutaneous and joint infections, and in- ment to involve the adjacent vertebrae, as de- travascular catheter infections [1-3]. These scribed for vertebral osteomyelitis due to My- pathogens are rarely transmitted by human-to- cobacterium tuberculosis. human contact and are resistant to common an- The most common clinical predisposing events tituberculosis drugs. preceding the diagnosis of vertebral os- 98 2003 teomyelitis included systemic lupus erythema- with chronic granulomatous disease [8-10]. tous and steroid therapy in four patients, and This was the first report of Mycobacterium back injury in 4 other patients. Other underly- flavescens disseminated infection. ing conditions included intravenous drug Mycobacterium flavescens was also cultured from abuse, HIV disease, hypertension, breast cancer the CSF of 4 patients with atypical clinical and and tamoxifen therapy, mental retardation, CSF profiles [11]. In a trial performed to test the achalasia, chronic granulomatous disease, iso- efficacy of BCG vaccination in the prevention of niazid prophylaxis for positive PPD and previ- tuberculosis in the Chingleput district of ous laminectomy. Madras state, South India, NTM were obtained Therapy included both surgical and antimy- from 8.6% of 16,907 sputum specimens; the cobacterial therapy. The final outcome was con- species isolated most frequently were Mycobac- sidered favorable in 13 (65%) patients. Two pa- terium avium, Mycobacterium terrae and Mycobac- tients died of aspiration pneumonia, and one terium scrofulaceum, while those species ac- other patient died of cor pulmonale. counting for 8-5% of all NTM were Mycobac- Two patients were able to walk with aid, in one terium fortuitum, Mycobacterium chelonae, My- patient there was evidence of persistent lower cobacterium gordonae, Mycobacterium vaccae and back pain, and one other patient suffered from
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