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Mediquest - April '08 Edition |
Mycobacterium fortuitum(non tuberculous mycobacteria)infection complicating lipoid pneumonia
Dr Susan Verghese, Dr S Ramesh, Dr CN Paramasivan, Dr G Kubendiran, Dr D Vijayasekaran
Dr Susan Verghese MD, PhD
Consultant Microbiologist
International Center for Cardio thoracic & Vascular Diseases
Dr S Ramesh, MD, DCH,
Consultant Physician
BRS Hospital
Dr CN Pramasivan PhD, DSc,
Senior Deputy Director
Tuberculosis Research Center
Dr G Kubendiran PhD
Microbiologist
Tuberculosis Research Center
Dr D Vijayasekaran MD, DCH, PhD, FIAP
Pediatrician & Pulmonologist
Institute Of Child Health
Word Count : 1093
No of references: 7
Category: Case Report
Figures: 2
Address:
International Center for Cardiothoracic & Vascular Diseases
Frontier Life Line Pvt Ltd
R 30C Ambattur Estate Rd
Mogappair , Chennai 600101
E mail <susan_verghese2001@yahoo.com>
The genus Mycobacterium has more than 100 well characterized species, and with the exception of Mycobacterium leprae and tuberculosis the other members are normal inhabitants of natural fresh waters, drinking water , soil and their aerosols. These mycobacteria formerly known as Atypical mycobacteria, are now called Non Tuberculous Mycobacteria (NTM). NTMs are noncommunicable; there is virtually no human to human spread. Disease from these organisms usually develops in setting of immunosuppression or trauma or surgical disruption of skin and mucous membranes. Human disease due to NTMs is classified into four distinct clinical syndromes: chronic pulmonary disease , lymphadenitis, cutaneous disease( non-healing ulcers and surgical site infections) and disseminated disease. Of these, chronic pulmonary disease is most commonly encountered clinically. We report an unusual case of lipoid pneumonia complicated by infection with M fortuitum.
Case Report : A 13 years old previously healthy female was forced to consume gingelly oil orally during a ceremony. She got choked and developed an intense bout of coughing for nearly 1 ½ hours. Five days after the episode she developed high grade fever and productive cough for which she was evaluated in a hospital elsewhere, where she was diagnosed to have bilateral basal pneumonitis based on a chest X ray. As the fever persisted, she was admitted in the hospital of the 2nd author , five weeks after the episode of choking.
On examination, she had pallor, was not tachypnoeic, had minimal lung signs and had no requirement for oxygen. Her cardiovascular and abdominal examination was normal. Her course in the hospital was characterized by continuous high grade fever (102 to 104oF) with minimal lung signs, but with persistent infiltrates on chest X ray (Fig: 1) and a productive cough. Investigations revealed a total WBC count of 21,000cells/ cmm, with predominance of neutrophils. ESR done on two separate occasions was 43 and 110 at the end of 1 hour respectively. HIV and Mantoux test were negative. Fiber optic bronchoscopy revealed no intra bronchial pathology.
Sputum for smear for AFB was positive (Grade I+). Atypical mycobacteria (rapid grower) was grown within 4 days on both Lowenstein Jenson media and the isolated strain was sent to Tuberculosis Research Centre, Chennai for confirmation of it’s identification, where it was identified as M. fortuitum. (TRCNo: RF 9859) based on mycolic acid analysis for species identification by high performance liquid chromatography (HPLC), as per the method of Butler et al with slight modifications.1,2 There was no other bacterial or fungal pathogens isolated from the sputum. CT scan showed cavitating consolidation in all segments of the left lower lobe and inferior lingual segment. Cavitating consolidation was also seen in the right middle and lower lobe.
She was commenced on a treatment regimen of Isoniazid 5mg /kg, Rifampicin 10 mg /kg, Ethambutol 25mg/kg for 2 months and subsequently 15 mg/kg, Clarithromycin 15mg/kg and injection Amikacin 15mg/kg was given thrice weekly . Amikacin was discontinued after 2 months and other drugs were continued for another 10 months.
On review after 6 months with appropriate treatment , she was found to be asymptomatic, had gained weight and chest X ray showed near complete clearance of the infiltrates. Sputum for AFB was negative. Her treatment was continued for a total period of one year.
Discussion :
The clinical presentation of exogenous lipoid pneumonia (ELP) is nonspecific and ranges from a totally asymptomatic patient with incidental radiological findings to a patient with acute or chronic symptoms attributable to pneumonia, pulmonary fibrosis, or cor pulmonale.3 Mineral oils, of all types stimulate a chronic granulomatous inflammation, which tends to be located mostly in the lower or middle lobes.
Lipoid pneumonia should be considered in the differential diagnosis of 'non-resolving' pneumonias in communities where the cultural practice of infant feeding with castor oil is prevalent. Bronchoscopy with brochoalveolar lavage can be successful in establishing the diagnosis of ELP by demonstration of a high lipid-laden macrophage index although this specific test was not done in our case.
Treatment of ELP in children is generally supportive and radiographic abnormalities resolve within months after stopping the use of mineral oil.
Patients with lipoid pneumonia are at risk for super infection with non-tuberculous mycobacterial (NTM) infections because lipids impede phagocytosis by the host's macrophages and thereby enhance the growth of these organisms.4 Esophageal achalasia or other swallowing disorders complicated by lipoid pneumonia have been reported to be associated with pulmonary infections caused by rapidly growing NTMs such as M. fortuitum, M. chelonae and other rapid growers.
The isolation rate of NTM`s from India has been reported to range from 0.5 percent to 8.6 percent. Mycobacteria fortuitum and M chelonae, common rapidly growing mycobacteria , have been associated with peritonitis in patients undergoing continuous ambulatory peritoneal dialysis, catheter related infections in patients with cancer and disseminated infections and surgical site infections. Frequently, the source is contamination of the wound, directly or indirectly, with colonized tap water; however, nosocomial infections have also been associated with contaminated gentian violet used for skin marking in plastic surgery.
Mortality from localized M fortuitum infection and nonhealing ulcers and surgical site infections caused by M chelonae is rare. Death may result from extensive pulmonary or disseminated disease. Morbidity largely depends on the site of infection. Localized skin lesions may eventually heal without therapy or surgical intervention. At other sites, chronic infection is common.
The following drugs have been used in the medical management of NTM viz Amikacin, Doxycycline, Imipenem, Ciprofloxacin, , Cefoxitin , Clarithromycin , Trimethoprim and sulphamethaxozole and Azithromycin.
Duration of medical treatment ranges from 18 months to two years or at least for one year after cultures are negative. In disseminated disease and in the immunocompromised patients, lifelong treatment needs to be given.
References:
1. Butler,WR., Floyd MM and Silcox.V et al. 1999. Mycolic acid pattern standards for HPLC identification of mycobacteria. Centers for Disease Control and Prevention, Atlanta, GA.pp 22-23.
2. Vanitha.DJ, Immanuel C, Szponar B, Larsson L and Paramasivan C.N. Identification of a group of nontuberculous mycobacteria isolated from the South Indian BCG trial area by HPLC. Current Science, 2002; 82 (2): 189-191.
3.
Hari P, Bandla R., Davis SH and Hopkins NE. Lipoid Pneumonia: A silent complication of mineral oil aspiration. Pediatrics. 1999; 103 : 19.
4. Cox EG, Heil SA, Kleiman MB .Lipoid pneumonia and Mycobacterium smegmtis. Pediatr Infect Dis J. 1994; 13: 414-415.
5. Hadjiliadis D, Adlakha A, Prakash UB. Rapidly growing mycobacterial lung infection in association with oesophageal disorders.
Mayo Clin Proc. 1999; 74 :744-75.
6. Paramasivan CN, Herbert D, Prabhakar R. Non-tuberculous mycobacteria: an
overview. Lung India 1986; 4: 7-12.
7.
Wallace RJ, Glassroth J, Griffith EF, Olivieer KN, Cook JL Gordin F. Diagnosis and treatment of disease caused by NTM. Am J Respir Crit Care Med 1997; 156:S1-25.
