672 Bolton-Maggs, Colman, Dixon, Myskow, Williams, Donnelly, Hind

steroids and the addition of chlorambucil per- date this approach has produced a good mitted withdrawal of steroids. She was response in these two patients. treated with chlorambucil for a year and was symptom free on no treatment at the time of 1 Saltzstein SL. Pulmonary malignant lymphomas and Thorax: first published as 10.1136/thx.48.6.672 on 1 June 1993. Downloaded from reporting.3 A review of 15 cases of pulmonary pseudolymphomas: classification, therapy and progno- lymphoproliferative conditions including sis. Cancer 1963;16:928-55. 2 Gibbs AR, Seal ME. Primary lymphoproliferative condi- three originally defined as "pseudolym- tions of the lung. Thorax 1978;33:140-52. phoma" showed monoclonality in 13 (includ- 3 Herbert A, Wright DH, Isaacson PG, Smith JL. Primary malignant lymphoma of the lung. Hum Pathol 1984;15: ing all three pseudolymphomas). Patients 415-22. with diffuse or patchy lung shadowing on 4 Addis BJ, Hyjek E, Isaacson PG. Primary pulmonary lym- radiography had been treated with a mixture phoma: a reappraisal of its histogenesis and its relation- ship to pseudolymphoma and lymphoid interstitial of chemotherapy regimens containing pneumonia. Hisroparhology 1988;13:1-17. steroids, two receiving steroids and chloram- 5 Li G, Hansmann M-L, Zwingers T, Lennert K. Primary lymphomas of the lung: morphological, immunohisto- bucil alone. One of these was lost to follow chemical and clinical features. Histopathology 1990;16: up and the other had a clinical response with 519-31. no change in the radiographic appearance.4 6 Robbins R, Peale AR, Al-Saleem T. Pseudolymphomas. AJYR 1970;108:149-53. Insufficient detail is given in this and other 7 Isaacson PG, Wright DH. Extranodal malignant lym- reports8 to evaluate the regimens used. Two phoma arising from mucosa-associated lymphoid tissue. Cancer 1984;53:2515-24. of a reported series of 13 patients with lym- 8 Kennedy JL, Nathwani NB, Burke JS, Hill RL, Rappaport phocytic interstitial pneumonitis were treated H. Pulmonary lymphomas and other pulmonary lym- with chlorambucil and steroids with improve- phoid lesions. Cancer 1985;56:539-52. 9 Herbert A, Walters MT, Cawley MID, Godrey RC. ment in one.'0 There is no consensus estab- Lymphocytic interstitial pneumonia identified as lym- lished for the treatment of these conditions. phoma of mucosa associated lymphoid tissue. Y Pathol 1985;146: 129-38. As histologically these patients have low 10 Strimlan CV, Rosenow EC, Weiland LH, Brown LR. grade lymphoma, we chose to treat our two Lymphocytic interstitial pneumonitis. Review of 13 with steroids and cases. Ann Inten Med 1978;88:616-21. patients chlorambucil, 11 Goldman JM. The lymphomas. In: Hoffbrand AV, Lewis agents well tried and effective for other types SM, eds. Postgraduate haematology. 3rd edn. Oxford: of low grade B cell lymphoma and chronic Heinemann, 1989:502-29. 12 Krikorian JG, Portlock CS, Cooney DP, Rosenberg SA. lymphatic leukaemia and used successfully in Spontaneous regression of non-Hodgkin's lymphoma: a some patients with "pseudolymphoma". To report of nine cases. Cancer 1980;46:2093-9.

Thorax 1993;48:672-673 http://thorax.bmj.com/

patients with acquired immunodeficiency Culture of syndrome (AIDS),' and the M avium com- plex is the most frequently isolated subtype.2 Mycobacterium kansasii There are few reports of isolation of non- tuberculous mycobacteria from blood cul- in the blood of an HIV tures in non-HIV patients.3 We report a

young man with a familial myelodysplasia and on September 24, 2021 by guest. Protected copyright. negative patient persistent Epstein-Barr virus infection who developed widespread M kansasii infection with isolation of the organism from blood cul- D Veale, D Fishwick, J E S White, tures. A D Gascoigne, K Gould, P A Corris Case report Abstract A 23 year old man developed fever and Department of A 23 year old man with a congenital rigours five weeks after returning from a holi- Respiratory Medicine disorder and in He then a D Veale myelodysplastic fibrosing day Spain. developed cough D Fishwick lung disease received treatment with with clear sputum and nausea. In his past J E S White prednisolone. After nine months his con- history he had suffered severe varicella and A D Gascoigne dition deteriorated and Mycobacterium recurrent herpes simplex infections and a per- P A Corris kansasii was isolated from blood cultures sistent Epstein-Barr virus infection from the Department of Microbiology and lymph node biopsy specimens. He age of 20 years. An older brother had died of K Gould responded to antituberculous treatment. refractory anaemia with excess lymphoblasts. Freeman Hospital, M kansasii has not previously been iso- Genetic studies had determined familial dys- Newcastle upon Tyne lated from the blood stream ofHIV nega- plasia with constitutional inversion of NE7 7DN tive patients. chromosome 1.4 Immunological studies had Correspondence to: a Dr D Veale shown leucopenia with profound lympho- Reprints will not be (Thorax 1993;48:672-673) penia but no other abnormality. On examina- available tion he had gross digital clubbing and Received 6 April 1992 generalised lung crackles. White blood cell Returned to authors 23 June 1992 Mycobacterial bacteraemia with organisms count (WBC) was o09 x 109/1 and he was Revised version received other than M tuberculosis other HIV Chest 27 July 1992 (mycobacteria antibody negative. radiography Accepted 30 July 1992 than tuberculosis, MOT) is not unusual in showed diffuse patchy parenchymal shadow- Culture ofMycobactenium kansasii in the blood ofan HIV negative patient 673

ing. He was treated with broad spectrum causes other than HIV showed no isolation of antibiotics but showed no clinical response MOTT.' Disseminated infection with M and was referred to the regional respiratory kansasii has been reported in patients with centre. Open lung biopsy samples showed AIDS.10 Pierce et al isolated MOTT from desquamative pneumonitis typical of blood in eight patients with non-HIV related Thorax: first published as 10.1136/thx.48.6.672 on 1 June 1993. Downloaded from Hamman-Rich syndrome. Specimens were immunodeficiency, all of whom were on long cultured and examined on a weekly basis, but term steroids for a variety of conditions there was no evidence of fungi, mycobacteria, including preleukaemia,3 but in none of these or pneumocystis pneumonia after eight was the organism M kansasii. weeks. He was treated with high dose steroids Bacteraemia with mycobacteria other than and showed an immediate clinical and func- M avium complex is a rare event and occurs tional improvement. most commonly in immunosuppressed Twelve months later, while taking 20 mg patients.' Isolation of M kansasii from blood prednisolone and acyclovir 200 mg three is rare in HIV patients and previously times a day, he became unwell and had a unknown in non-HIV patients. It may be that recurrence of fever. No lymph nodes were the organism is seldom present in blood, but palpable but he had persistence of lung crack- it is most probably because blood culture les. His haemoglobin was 92 g/dl and his specimens are taken too infrequently. WBC 1-4 x 109/1. One week later repeat Technical inadequacies may also play their chest radiography showed the new develop- part, but the development of radiometric ment of mediastinal adenopathy and a diag- detection methods may improve the yield of nosis of Epstein-Barr driven lymphoma was positive results." 12 suspected. Large fleshly lymph nodes were As MOTT in immunosuppressed patients found at mediastinoscopy, and histological may well be more responsive to treatment in examination revealed numerous acid fast non-HIV patients"3 than in those with HIV, it bacilli which proved to be M kansasii on cul- is important to culture specimens including ture. He also developed a large pericardial frequently obtained blood samples for a pro- effusion which required drainage. He was longed period with appropriate media in rele- initially treated with standard antituberculous vant clinical situatlons. chemotherapy comprising rifampicin, ison- We wish to thank the Respiratory Pathogens section of the iazid, and pyrazinamide. He deteriorated, Public Health Laboratory, Newcastle upon Tyne, for their however, on this regimen and treatment was help with the isolation and identification of the mycobacteria. therefore changed to rifabutin, isoniazid, ethambutol, and ciprofloxacin with gradual and sustained M was improvement. kansasii 1 Peters M, Schurmann D, Mayr AC, Hetzer R, Pohle HD, isolated from blood cultures, sputum, peri- Ruf B. Immunosuppression and mycobacteria other http://thorax.bmj.com/ cardial fluid, and mediastinal tissue. All speci- than Mycobacterium tuberculosis; results from patients with and without HIV infection. Epidemiol Infect 1989; mens were inoculated onto Lowenstein 103:293-300. Jensen slopes and tissue specimens into 2 Green JB, Sidhu GS, Lewin S, Levine JF, Masur H, Simberkoff MS, et al. Mycobactenium avtum- Kirchner's broth. Blood cultures were inocu- intracellulare: a cause of disseminated life-threatening lated directly into the broth, then saponised. infection in homosexuals and drug abusers. Ann Intern The organism was sensitive to rifabutin, Med 1982;97:539. 3 Pierce PF, DeYoung DR, Roberts GD. Mycobacteremia rifampicin, ethionamide, ciprofloxacin, capreo- and the new blood culture systems. Ann Intern Med

mycin, ethambutol, and cycloserine but resis- 1983;99:786-9. on September 24, 2021 by guest. Protected copyright. tant to 4 Paul B, Reid MM, Davison EV, Abela M, Hamilton PJ. isoniazid, streptomycin, and Familial myelodysplasia: progressive disease associated pyrazinamide. No synergy tests were per- with emergence of monosomy 7. Br J Haematol 1987; formed. He did not suffer any relapse of 65:321-3. 5 Joyson DM. Water; the natural habitat of M kansasii. symptoms following completion of 12 months Tubercle 1979;60:77. antituberculous treatment. The dosage of 6 Banks J, Hunter AM, Campbell IA, Jenkins PA, Smith prednisolone was gradually reduced and he PA. Pulmonary infection with M kansasii in Wales, 1970-9; review of treatment and response. Thorax 1983; has returned to active sports. 38:271. 7 Palmer JA, Watanakunakom C. Mycobacterium kansasii pericarditis. Thorax 1984;39:876-7. 8 Koch M, Rabinowitsch L. Die tuberkulose der vogel und Discussion ihre beziehungen zur sangertiertuberkulose. Virchows M kansasii has been isolated from many envi- Arch PatholAnat 1907;190:246. 9 Zakowski P, Fligiel S, Berlin OGW, Johnson BL Jr. ronmental sources including tap water5 and Disseminated Mycobacterium avium-intracellulare infec- grows best at 37°C. It is usually sensitive to tion in homosexual men dying of acquired immuno- deficiency. JAMA 1982;248:2980. rifampicin and ethambutol.6 In immunocom- 10 Sherer R, Sable R, Sonnenberg M, Cooper S, Spencer P, petent patients treatment for between three Schwimmer S, et al. Disseminated infection with and 24 months resulted in cure in all Mycobacterium kansasii in the acquired immuno- cases deficiency syndrome. Ann Intern Med 1986;105:710-2. with no relapses after a mean follow up of five 11 Salfmnger M, Stool ED, Piot D, Heifets L. Comparison of years. M kansasii has been recorded in peri- three methods for recovery of Mycobacterium avium complex from blood specimens. Y Clin Microbiol 1988; cardial effusion in one previous report.7 26:1225-6. Disseminated infection with MOAr was 12 Kiebn T, Cammarata R. Comparatve recoveries of first reported by Koch and Rabinowitsch in Mycobacterium avium-M intracellulare from isolator lysis- centrifugation and BACTEC 13A blood culture sys- 1907.8 There have been numerous reports of tems. J7 Clin Microbiol 1988;26:760-1. disseminated M avium complex infection in 13 Horsburg CR, Mason UG, Farhi DC, Iseman MD. Disseminated infection with Mycobacterium avium-intra- patients with AIDS,29 but a study of 134 cellulare: a report of 13 cases and a review of the litera- patients who were immunosuppressed from ture. Medicine 1985;64:36-48.