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Mycobacterium Abscessus Urinary Tract Infection: Case Report Infecção Urinária Por Mycobacterium Abscessus: Relato De Caso

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Mycobacterium Abscessus Urinary Tract Infection: Case Report Infecção Urinária Por Mycobacterium Abscessus: Relato De Caso CASE REPORT | RELATO DE CASO Mycobacterium abscessus urinary tract infection: case report Infecção urinária por Mycobacterium abscessus: relato de caso Authors ABSTRACT RESUMO 1 Jadson Soares Laudelino Urinary tract infection is a serious public Infecção do trato urinário é um sério Flávio Teles Farias Filho1 health issue that predominantly affects problema de saúde pública que acomete André Falcão Pedrosa Costa1 women. In men, it is more often associated predominantemente as mulheres. Em Vitorino Modesto Santos2,3 with prostatic hyperplasia and bladder homens, está mais relacionada com catheterization. Urogenital tuberculosis hiperplasia prostática e cateterismo presents with nonspecific with nonspecific vesical. A tuberculose urogenital cursa com 1 Universidade Estadual de symptoms and the diagnosis can be made sintomas inespecíficos e o diagnóstico pode Ciências da Saúde de Alagoas, in the presence of sterile leukocyturia ser aventado na presença de leucocitúria Maceió, AL, Brasil. 2 Hospital das Forças Armadas, and recurrent infection with acid urine. estéril, e infecção recorrente com urina Brasília, DF, Brasil. Non-tuberculous mycobacteria or ácida. Micobactérias não tuberculosas 3 Universidade Católica de other non-tuberculosis mycobacteria ou mycobacteria other than tuberculosis Brasília, Taguatinga, DF, Brasil. are opportunistic pathogens that são patógenos oportunistas que habitam inhabit the soil, water or environment o solo, a água ou superfícies do meio surfaces, and usually cause diseases ambiente, e geralmente causam doenças in immunocompromised individuals. em imunodeprimidos. Mycobacterium Mycobacterium abscessus is an agent that abscessus é um agente que causa infecções causes lung, skin and soft tissue hospital nosocomiais, pulmonares, de pele e de infections. Urinary tract infections by this tecidos moles. Infecção urinária decorrente pathogen are rare. desse patógeno é considerada rara. Keywords: Mycobacterium Infections, Palavras-chave: Infecções por Micobacté- Nontuberculous; Urinary Tract Infec- ria não Tuberculosa; Infecções Urinárias; tions; Tuberculosis. Tuberculose. INTRODUCTION and there may be pyuria and microscopic he- maturia.3 The UGTBC is based on the growth Urinary tract infections (UTIs) are caused of the pathogen in urine culture, sown in a by several microorganisms, and the main specific medium and, rarely, on pathology pathogen involved is Escherichia coli, fol- findings. lowed by Klebsiella pneumoniae, Proteus Non-tuberculosis mycobacteria (NTM), mirabilis, Enterococcus faecalis and are those that do not belong to the Staphylococcus saprophyticus.1,2 Women Mycobacterium tuberculosis (M. tuberculo- are more often affected than men, a phe- sis and M. bovis) complex, and M. leprae.4 nomenon explained by various factors More than 125 NTM species that cause dis- - anatomical or behavioral; in men, pros- eases in humans have already been identi- tatic hyperplasia and urinary instrumenta- fied.4 These pathogens are usually isolated Submitted on: 12/16/2018. tion are factors that favor the occurrence Approved on: 03/06/2019. from soil and from natural or treated water of UTIs. sources.4 There is no evidence of human- Urogenital tuberculosis (UGTBC) animal or inter-human transmission, and the Correspondence to: should be considered a differential diag- Vitorino Modesto Santos. disease results from environmental exposure, E-mail: [email protected] nosis of UTIs; the clinical symptoms are although the source of infection is not usu- nonspecific, the most common symptoms DOI: 10.1590/2175-8239-JBN-2018-0260 ally identified.4 In developed countries, the are dysuria, polaquiuria and back pain, 124 Urinary tract infection by Mycobacterium abscessus incidence rate ranges from 1 to 2 cases per 100,000 Figure 1. Abdominal CT (A) and Ultrasound (B) scan images showing mild renal pelvis ectasia and prostate calcifications. inhabitants; however, since non-tuberculous myco- bacterioses are not compulsorily notifiable diseases, their true incidence is unknown.4 Chronic lung infec- tion is the most frequent clinical manifestation, ac- counting for 90% of the cases, followed by dissemi- nated disease, lymph node infection and skin or soft tissue infection.4 We report a case of an adult man with urinary infection by M. abscessus, a microor- ganism that has been rarely described as an etiologic agent of UTI. CASE REPORT 50-year-old man, accountant, from a town in the countryside of Alagoas. He sought medical attention two years before a nephrological evaluation, complai- ning of pain in the right iliac and suprapubic fossa, nausea, vomiting and intense dysuria. He had no he- maturia, fever, or weight loss. After consultation with an urologist, he used ciprofloxacin and tamsulosin for seven days. With no symptom improvement, the tre- atment regimen with ciprofloxacin was extended for another 14 days. The following exams were ordered in the investigation: urinary tract ultrasonography, prostate-specific antigen dosage and urodynamics, (+), sodium citrate (-), fructose fermentation (-), man- which results remained within the normality range. nitol fermentation (-); picric acid (+) and Tween 80 Urinalysis showed a pH of 7 and numerous pyocytes; hydrolysis (+). and the erythrocyte sedimentation rate was 75 mm/1st We started treatment with clarithromycin (500 mg hour. Computed tomography and ultrasound images twice daily) and amikacin (15 mg/day), for 18 months. of the abdomen revealed discrete renal pelvic ectasia In the fifth month of treatment, the patient remained and prostate calcifications (Figures 1A and B). with urinary symptoms; however, in the tenth month The initial physical examination of the nephrologi- he already showed important improvements. In the cal evaluation did not detect significant alterations be- eighteenth month of outpatient follow-up, there was sides discomfort to deep palpation in the hypogastric no clinical complaint and two urocultures for myco- region. Inflammatory markers, uroculture and EAS bacteria were negative. were requested for control purposes. Inflammatory markers were altered, leukocyturia persisted in the DISCUSSION EAS, and uroculture was repeatedly negative. In this Tuberculosis continues to represent a serious glo- way the possibility of M. tuberculosis urinary infec- bal health problem,5 and extra pulmonary involve- tion was raised and specific culture was requested for ment can occur in approximately 15% of the cases.6 this infectious agent. Two months later, the patient UGTBC is the second site of this type of involvement returned for consultation complaining of persistent and manifests as an insidious clinical picture with no dysuria, bladder discomfort (pressure), voiding ur- specific symptoms, generally leading to late diagno- gency and nocturia. The uroculture resulted positive ses.7 Diagnostic confirmation is established by finding for M. abscessus. In the Löwenstein-Jensen solidified M. tuberculosis in urine culture or by pathology exa- medium, fast-growing mycobacteria formed acromo- mination of tissue samples. genic colonies with rough-to-smooth morphology. The reported patient had UTI with many symp- The biochemical tests revealed a reduction of nitrate toms, and did not respond to treatment with the rou- (-), -glycosidase (-), 5% tolerance to sodium chloride β tinely used antibiotics. Considering the persistence of 125 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(1):124-127 Urinary tract infection by Mycobacterium abscessus the symptoms in the presence of sterile uroculture, tis- bacteria (including M. fortuitum and M. abscessus) sue calcifications and discrete anatomical alteration do not usually respond to drug therapy, and treatment of the right pelvis, the hypothesis of UGTBC was pro- should be based on drug sensitivity tests.4 Amikacin, posed and uroculture was requested in a specific me- clarithromycin, quinolones, doxycycline, imipenem, dium. The result was positive for M. abscessus, one linezunide, sulfamethoxazole, and tigecycline should of the nontuberculous mycobacteria that have very be tested.4 M. abscessus is a species of rapid growth rarely been described as the etiology of UTIs. and multidrug resistance that causes nosocomial in- NTMs are environmental opportunistic pathogens fections.14,15 Pulmonary, skin and soft tissue infections living in soil and drinking water systems.8 There are are the main forms of clinical presentation of the dis- reports of hospital contamination, including epidemic ease.16 Contamination may occur after inoculation of outbreaks.9 There is no record of transmission from the pathogen into skin lesions during small traumas animals to humans, nor among humans.4 Shower or during surgical procedures.17 Disease outbreaks af- water, soil material or pool water may be sources of ter invasive procedures have been described in the lit- infection.10 NTMs are believed to be acquired from erature, related to different medical procedures: post- the environment by ingestion, inhalation, or skin arthroscopy, laparoscopy and abdominoplasty.14 The contact.10 Opportunistic infection is related to immu- main hypotheses proposed for these cases of infection nocompromised patients, such as those infected with are poor sterilization and the use of contaminated wa- HIV, individuals with chronic obstructive pulmonary ter to clean the equipment.14 disease, cystic fibrosis, and sequelae of pulmonary In the treatment of infections caused by this agent, tuberculosis.9,11 it is mandatory to remove foreign bodies such as pros- Diagnosis
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