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Case Report Mycobacterium Kumamotonense in the Cervical Region in an Immunocompetent Patient, Clinical Case Report in Mexico

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Case Report Mycobacterium Kumamotonense in the Cervical Region in an Immunocompetent Patient, Clinical Case Report in Mexico Case Report Mycobacterium kumamotonense in the cervical region in an immunocompetent patient, clinical case report in Mexico Alejandro Hernández-Solis1, Maribel González-Villa2, José Ernesto Ramírez-González2, Yesenia Colin- Muñoz1, Raúl Cicero-Sabido1 1 Unit of Pulmonology and Surgery of Thorax, General Hospital of Mexico “Dr. Eduardo Liceaga”, Mexico City, Mexico 2 Institute of Epidemiological Diagnosis and Reference (InDRE), Ministry of Health, Mexico City, Mexico Abstract Non-tuberculous mycobacterial infection has increased significantly in recent years, especially in emerging countries. We present the case of a 25-year-old male patient, immunocompetent, with cervical lymphadenopathy, identifying Mycobacterium kumamotonense, a rare species in extrapulmonary forms and with a high drug resistance index. Key words: Non-tuberculous mycobacteria; cervical lymphadenopathy; Mycobacterium kumamotonense. J Infect Dev Ctries 2019; 13(12):1165-1169. doi:10.3855/jidc.11935 (Received 18 August 2019 – Accepted 14 November 2019) Copyright © 2019 Hernández-Solis et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction simiae were isolated [7]. In previous studies of patients Non-tuberculous mycobacteria (MNT) are those with cervical lymphadenopathy, MNT have been unrelated to the Mycobacterium tuberculosis and reported only in 6.6% of cases, identifying M. Mycobacterium leprae complex. Approximately 170 intracellulare, M. gordonae and M. fortuitum [3]. species known to cause disease in humans are known The Mycobacterium terrae complex (MTC) is the [1]. These mycobacteria are part of the environment, group of mycobacteria that has been linked as the being identified in soil, water, animals and food causative agent of bone and joint infections. Among the products [2]. The pulmonary form is the most frequent main species identified in this complex are in adults, while cervical lymphadenopathies represent Mycobacterium kumamotonense, M. senuense, M. the most common extrapulmonary form in children. In paraterrae, M. strain, M. engbaekii, M. longobardum, patients with HIV / AIDS, disseminated tuberculosis is M. heraklionense, M. virginiense and M. arupense [8]. the main presentation form [1,3]. The incidence and In 2006, a new mycobacterial species, M. prevalence of pathologies triggered by NTMs have kumamotonense, was proposed, which has the insertion been increasing especially in emerging countries, while of 14 nucleotides, which is distinctive of the M. terrae in industrialized countries there is a rate that varies from complex in the 16S rRNA gene [9,10]. 1 to 1.8 cases per 100,000 inhabitants [4]. The Here below is the report of a clinical case in which commonly involved agents are Mycobacterium avium the presence of M. kumamotonense in an complex, Mycobacterium gordonae and immunocompetent patient with no history of pulmonary Mycobacterium xenopi [5]. Extrapulmonary forms pathology and HIV negative is identified. predominate in the female gender with an average age of 50 years, and they are more frequent in skin and soft Clinical case tissues, followed by disseminated disease and cervical We present the case of a 25-year-old male patient, lymphadenopathy [6]. without a history of immunodeficiencies, who goes to a In Mexico there are no epidemiological data or concentration hospital in Mexico City for presenting a typification of the species involved. There are some 3-month clinical picture characterized by a fever of 38 case reports in patients with HIV / AIDS in whom M. ° C, loss 5 kg in weight, accompanied by cervical avium, M. kansasii, M. gordonae, M. fortuitum and M. ganglion growth of approximately 3 cm in diameter, Hernández-Solis et al. – Mycobacterium kumamotonense in the cervical region J Infect Dev Ctries 2019; 13(12):1165-1169. hard, non-painful, asthenia and adynamia. HIV Elisa tree was made based on the sequences of the hsp65 gene test was performed and reported negative and imaging under the method of the nearest neighbor (Figure 3). studies, in which chest image was found without lung involvement data. The neck CAT (Computed axial Figure 1. A. Homogeneous calcified image, 1 cm in diameter, tomography) scanned multiple enlarged cervical in the right hilar region. B. Node conglomerate in left ganglion chains (Figure 1). Excisional biopsy of supraclavicular space and paratracheal region which compress lymphadenopathy was performed finding the carotid. C. Displaced carotid by node conglomerate. granulomatous reaction and caseous necrosis in the histopathological study (Figure 2). Ziehl-Neelsen staining was performed identifying the presence of acid-alcohol resistant bacilli. In order to confirm the diagnosis of tuberculosis, culture was carried out in a liquid medium for the detection of M. tuberculosis with the diagnostic Becton Dickinson kit, Sparks, MD, USA, observing positive growth at 32 days. Subsequently, DNA was extracted with a phenol chloroform method and PCR technique was performed to amplify a 440 bp fragment corresponding to the hsp65 fragment using primers TB11: 5'-ACCAACGATGGTGTCCAT-3 'and TB12: 5'- CTTGTCGAACCGCATACCCT-3. This procedure was performed using ABI PRISM_ 3130xl Genetic Analyzer (Applied Biosystems, Foster City, CA, USA). The phylogenetic analysis was carried out with MEGAv.6.0 software (distance Neighbor Joining method) using the database for MNT species reported by Escamilla-Escobar [11], including the sequences with ID: KX077601 (strain study), KF432567, KF432807 , AB239920, AJ307656, AF547879, GU564405, FJ268582, JN571203, JN571202, KF432509, KT185529obtained from GenBank. In the results of the protein PCR thermal shock restriction analysis, 65 genes were consistent with those of Mycobacterium kumamotonense. The phylogenetic Figure 2. Histological section of cervical lymph node showing chronic granulomatous inflammation with the presence of caseous necrosis with HE staining. 10X. 1166 Hernández-Solis et al. – Mycobacterium kumamotonense in the cervical region J Infect Dev Ctries 2019; 13(12):1165-1169. Once the diagnosis was confirmed, the patient and bronchiectasis are shown. Unlike what was found received treatment with Isoniazide, Rifampicin and in the literature, our patient is male, under 35 years old, Etambutol. After three months of treatment, a favorable with extrapulmonary condition, without relevant risk evolution was observed, with the disappearance of the factors and has no respiratory compromise [6,14]. febrile symptoms and a marked decrease in the volume The clinical picture of lymphadenopathy is similar of the cervical nodes. There were no recurrences after between different species of mycobacteria. These are one year of follow-up. presented as persistent local inflammation, with few general symptoms, indurated chains of gradual growth Discussion and rarely form fistulas, such as those observed in our Mycobacterium kumamotonense is a slow-growing patient. In cervical lymphadenopathies, surgical mycobacterium, which belongs to the M. terrae excision is associated with high cure rates, in complex. Data on the incidence of this species are combination with antimycobacterial therapy. In our limited globally. It was first isolated in sputum material case, we had an adequate response to treatment without from an immunocompetent patient . The condition of the presence of disease recurrences, possibly because subjects carrying HIV by MNT occurs after the CD4 the patient was not immunocompromised and did not count is < 200 cells / mm3. In the opposite case, present a multidrug resistant drug strain. In the interferon-specific (IFN) γ and interleukin (IL) -12 literature, antimicrobial therapy with macrolides is mutations have been associated in non-HIV-bearing recommended and preferably drug sensitivity studies to subjects. The incidence of MNT disease is high in initiate specific treatment to avoid a chronic clinical patients suffering from immunosuppression, connective picture and relapse [13,14,15]. tissue diseases, diabetes mellitus or using steroid The identification of MNTs is of the utmost corticosteroids. Mortality is significantly increased in importance to establish an adequate treatment. patients older than 65 years, of the female gender and Currently, various methods for such identification have co-infection with HIV / AIDS [12,13]. been described, however, the results remain uncertain In the literature, cases reported about the human due to the limited experience with this type of condition of M. kumamotonense are rare, so the clinical mycobacteria. Both, thin layer chromatography and characteristics are still very variable. Clinically, these gas-liquid chromatography have been considered for cases are characterized by presenting pulmonary the identification of various species of mycobacteria symptoms and in the CAT scan nodular images, caverns because their cell wall has a rich lipid component. On Figure 3. Phylogenetic tree constructed with hsp65 gene sequences. Strain HGM_145-12 (black framed) was identified as M. kumamotonense due to its phylogenetic relationship with this cluster. 1167 Hernández-Solis et al. – Mycobacterium kumamotonense in the cervical region J Infect Dev Ctries 2019; 13(12):1165-1169. the other hand, mass spectrometry has also been used, 2. Gupta RS, Lo B, Son J (2018) Phylogenomics and comparative although one of its main limitations is the lack of genomic studies robustly
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