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Mycobacterium Gordonae from a Patient with Pulmonary Disease

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Mycobacterium Gordonae from a Patient with Pulmonary Disease Int J Clin Exp Pathol 2016;9(7):7733-7738 www.ijcep.com /ISSN:1936-2625/IJCEP0024186 Case Report Who is the criminal? Isolates of Mycobacterium tuberculosis, Mycobacterium abscessus and Mycobacterium gordonae from a patient with pulmonary disease Jianhao Wei1,2*, Yi Jiang1,3*, Guilian Li1,3*, Qian Guo1,2, Haican Liu1,3, Donglei Xu1,3, Jianghua Zheng2, Kanglin Wan1,3 1State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, P. R. China; 2Department of Clinical Laboratory, Shanghai Public Health Clinical Center, Shanghai, P. R. China; 3Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, P. R. China. *Equal contributors. Received January 16, 2016; Accepted March 26, 2016; Epub July 1, 2016; Published July 15, 2016 Abstract: Few reports have described pulmonary disease caused by multi-pathogen infections with mycobacteria. We report a well-documented case of a unique pulmonary disease that resulted from infections with M. tuberculo- sis, M. abscessus and M. gordonae in an adult woman who was not immunodeficient. Combining her medical his- tory and the drug sensitivities of the M. abscessus and M. gordonae isolates, the patient was treated with amikacin, cefoxitin and clarithromycin. Her symptoms and physical status were relieved up to February 2015. Keywords: Mycobacterium tuberculosis, mycobacterium abscessus, mycobacterium gordonae, multiple infection, pulmonary disease Introduction Previous case history: The patient had no family history of any lung diseases and never smoked, Non-tuberculous mycobacteria (NTM) diseases but had been diagnosed with tuberculous pleu- are likened to the Sword of Damocles, no one ritis in 2006. She said she had received regular knows why, when or where, the unfortunate treatment for more than 12 mouths until cured. infection will happen, nor who the unfortunate She worked as a teacher in a middle school of person that succumbs to the misery will be. Beijing and was not an immunocompromised Because there are many different species of patient. NTM, standardized treatments of NTM infec- tions may not be sticky enough. An even worse In December 2012, the patient suffered fever, scenario comprises the existence of multi- rigor, tussiculation and nausea, with no obvious infections. Here, we report a well-documented causes, for 6 days and was diagnosed with case of a unique pulmonary disease, caused by pneumonia at Beijing Shijitan Hospital. Based an infection with Mycobacterium (M.) tubercu- on this diagnosis, she was treated with moxi- losis, M. abscessus and M. gordonae. The floxacin and ambroxol hydrochloride until she patient was an adult woman who was not was discharged from the hospital. immunodeficient, but who had a history of On September 2013, the patient was admitted tuberculous pleuritis. We present the develop- to the 309th hospital of the Chinese People’s ments of the infection and the treatment of the Liberation Army, because of cough, sputum and patient. dyspnea, for 3 weeks. Scattered high-density Case presentation nodules and calcifications in both of her lungs and bronchiectasis in the lingual segment of A 37-year-old woman was referred to our labo- the upper lobe of her left lung were observed ratory in November 2014 because of the unsat- using chest computed tomography (CT) (Figure isfactory treatment of her pulmonary disease. 1A). Sputum samples were found positive for Mycobacterium and pulmonary disease Figure 1. A 37-year-old woman with a multi-infection of M. tuberculosis, M. abscessus and M. gordonae. A: Comput- ed tomography (CT) in September 2013 showing the scattered high-density nodules and calcifications in the lungs and bronchiectasis in the lingual segment of the upper lobe of her left lung. Sputum samples were found positive for M. tuberculosis. B: CT in May 2014 showing some improvement in the left lung. Some patchy shadows had dis- solved, but a new cavity had appeared in the right lung, which was previously a tubercle shadow. M. abscessus was first isolated in March 2014, and after two months of therapy with pasiniazid, linezolid, pyrazinamide and rifapen- tine, M. abscessus was still found positive in the patient’s sputum samples. C: CT in October 2014 showing the new lesions and localized pleural thickening adhesion that appeared in the patient’s left lung, some previously patchy shadows had dissolved, the diameter of the cavity in the right lung had become smaller and the bronchiectasis in the lingual segment of the upper lobe of the patient’s left lung remained. Both M. abscessus and M. gordonae were isolated from the patient at this time. acid-fast bacilli (AFB), and a sample obtained the patient went to the hospital several times by bronchoscopy was similarly positive. Isolates as an outpatient and sputum smears tested for from the samples were identified as M. tuber- AFB were still found positive. No data of any culosis. Routine laboratory testing revealed her other tests performed at this stage were pro- white-cell count, CD4+ T cells and hemoglobin vided to us. levels were normal, the C-reactive protein level was 21.47 mg/L, and she tested negative for During March 2014, the patient was admitted the antibodies against the human immunodefi- to the Beijing Chest Hospital (BCH) for treat- ciency virus. In combination with her history of ment of the stubborn disease. M. abscessus tuberculous pleuritis in 2006, the patient was was cultured from the bronchial lavage fluid diagnosed with secondary (reactivation) tuber- and there was no evidence of M. tuberculosis, culosis and bronchiectasis, but the data of the so her treatment was changed to pasiniazide, treatment given at this stage were not avail- linezolid, pyrazinamide and rifapentine. On May able. From December 2013 to February 2014, 2014, she was reexamined using CT; most of 7734 Int J Clin Exp Pathol 2016;9(7):7733-7738 Mycobacterium and pulmonary disease the characteristic lesions in her left lung had We also used monoclonal isolates to confirm improved, some patchy shadows had dissolved, the pathogen (s), because M. tuberculosis and and the tubercle shadow in her right lung had M. gordonae had previously been isolated from become a new cavity (Figure 1B). Isolates from the patient. Subcultures were prepared on her sputum were identified as M. abscessus 7H10-OADC plates to separate the single colo- again, so a new therapy with clarithromycin, nies. Three different orange colonies and 144 ethambutol, levofloxacin, and rifapentine was cream-smooth morphological colonies were initiated. The patient’s condition continued to found in the subcultures of the sample from 13 improve, except for intermittent tussiculation. November after incubation for 12 days. The molecular tests were then repeated on the Unfortunately the patient’s disease relapsed in monoclonal isolates. The cream-smooth mor- October 2014. Due to the tussiculation and phological and the orange colonies were identi- weight loss (nearly 10 kg over the previous fied asM. abscessus and M. gordonae, respec- eight months), she was admitted to the BCH. tively. The presence of M. tuberculosis was fur- The CT showed new lesions and localized pleu- ther excluded via an additional PCR-IS6110 ral thickening adhesion had appeared in her test [5]. left lung (Figure 1C). Surprisingly, of the six pos- itive cultures from the induced sputum taken The susceptibilities of the isolates to thirty-six between 4 October and 30 October, most were antimicrobial agents (purchased from Sigma- identified as M. abscessus and two contained Aldrich) were tested in accordance with the both M. abscessus and M. gordonae. In addi- guidelines from the Clinical and Laboratory tion, the cultures grown from another bronchial Standards Institute (CLSI) [6]. Table 1 shows lavage fluid sample (of the lower lobe of her the minimum inhibitory concentrations (MICs) right lung) on 17 October were identified as M. of each drug against the isolates of M. absces- gordonae. The patient was considered to have sus and M. gordonae, respectively. Based on a multi-infection with M. abscessus and M. gor- the drug susceptibility tests, amikacin was donae. Rifapentine was replaced with cefoxitin included in the therapeutic regimen for the in her therapeutic regimen. Then, her doctor patient; until February 2015, she was treated contacted us and referred her to our laboratory with intravenous (IV) amikacin (400 mg qd), IV for further examination. cefoxitin (60 mg/kg bid), and oral clarithromy- cin (300 mg tid). The patient’s symptoms Assessment and treatment at our laboratory: showed some improvement and the last three During November 2014, we collected ten spu- sputum cultures were negative for AFB. tum samples by sputum induction; samples from four of the days (5, 6, 13 and 17 November) Discussion were found positive for AFB via sputum smear With the development of molecular biological microscopy. After four days of incubation by the techniques, more than 150 NTM species have BACTEC MGIT 960 system, three of the sam- been described [7]. Some NTM species are ples (collected 5, 13, and 17 November, respec- known pathogens in patients with pulmonary tively) were found positive for culture; these diseases [8], including M. abscessus and M. isolates were tolerant of 10 mg/ml 2-thiophen- gordonae, although they are rare. Such NTM ecarboxylic acid hydrazide and 500 mg/ml species are increasingly being recognized as p-nitro benzoic acid. The isolates were deter- pathogens responsible for respiratory tract mined to be mycobacterial species using 16S infections as well. Multi-infections with M. rRNA gene PCR-sequencing. The sequences tuberculosis, M. abscessus and M. gordonae showed 100% similarity with M. abscessus, have not been described before. In this report, according to the basic local alignment search the patient met the diagnostic criteria of the tool (BLAST) online database. As we knew that American Thoracic Society and the Infectious the 16S rRNA gene is not a sufficient criterion Disease Society of America, published for NTM for the identification of species in theM.
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