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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 56-58

Mycobacterium riyadhense lung infection in a patient with HIV/AIDS


Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Submission08-Nov-2013
Date of Acceptance16-Dec-2013
Date of Web Publication24-Mar-2014

Correspondence Address:
Musa Abubakar Garbati
Department of Medicine, Section of Infectious Diseases, King Fahad Medical City, Riyadh - 11525
Saudi Arabia
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  Abstract 

Mycobacterium riyadhense was first isolated in 2009. Five additional cases were reported since then. This is, however, the first case of M. riyadhense with human immunodeficiency virus coinfection in the literature. A 54-year-old male diabetic presented with 4 months history of diarrhea, productive cough, odynophagia, and dysphagia with progressive weight loss. He looked cachectic with oropharyngeal thrush, bilateral axillary lymph node enlargement and herpes zoster involving the first two thoracic dermatomes. He had right-sided consolidation on chest examination. He was anemic with a normal platelet count. Sputum examination was positive for acid-fast bacilli (AFB); however, deoxyribonucleic acid probe-detection assay for MTB (complex) was negative. The isolate was confirmed as M. riyadhense at the Bioscientia laboratories (Ingelheim, Germany). Stool was positive for Clostridium difficile toxins by polymerase chain reaction (PCR). Human immunodeficiency virus (HIV) test was also positive. The patient showed improvement in clinical, bacteriologic, and immunologic parameters with antituberculous and antiretroviral medications. The lesson from this case is for clinicians to suspect infection with atypical mycobacteria once mycobacterium tuberculosis (MTB) PCR is negative in a patient with a positive smear for AFB so that appropriate therapy for nontuberculous mycobacterial disease can be initiated early.

Keywords: Atypical mycobacteria, HIV/acquired immune deficiency syndrome, M. riyadhense


How to cite this article:
Garbati MA, Hakawi AM. Mycobacterium riyadhense lung infection in a patient with HIV/AIDS. Sub-Saharan Afr J Med 2014;1:56-8

How to cite this URL:
Garbati MA, Hakawi AM. Mycobacterium riyadhense lung infection in a patient with HIV/AIDS. Sub-Saharan Afr J Med [serial online] 2014 [cited 2019 Oct 20];1:56-8. Available from: http://www.ssajm.org/text.asp?2014/1/1/56/129324


  Introduction Top


Mycobacterium riyadhense a nonchromogenic, slowly growing nontuberculous mycobacterium (NTM), was first isolated in 2009 from maxillary sinus lavage fluid of a 19-year-old male with jaw swelling. [1] Five additional cases have been reported [2],[3],[4],[5] since then making this the seventh in the literature. M. riyadhense has established itself as an emerging pathogen with the potential to cause infection at both extrapulmonary and pulmonary sites, with six out of the seven cases manifesting as pulmonary infections.

M. riyadhense, M. szulgai, M. kansasii, and M. malmoense are closely related phylogenetically making them among the most pathogenic NTM. [6],[7] The pathogenicity of M. riyadhense has further been established with the presence of a region of difference 1 (RD1), a region harboring the early secretory antigen target (ESAT-6) and culture filtrate protein (CFP-10) genes, which are important virulence factors in M. tuberculosis[8],[9],[10] and thought to equally play a crucial role in the virulence of NTM, such as M. riyadhense. [9] Deletion of RD1 lowers the virulence of M. tuberculosis complex bacteria, [8],[11],[12] suggesting that this site is involved in pathogenesis.

We, hereby, report the first case of infection with M. riyadhense in a patient with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).


  Case Report Top


A 54-year-old male diabetic, presented with productive cough, chronic diarrohea, and weight loss. Examination was positive for cachexia, oropharyngeal thrush, peripheral lymphadenopathy and herpes zoster of the left first and second thoracic dermatomes. His HIV screening and confirmatory tests were positive. [Table 1] shows his immunologic and virologic parameters with reference values compared to the local population. [13] Polymerase chain reaction (PCR) for respiratory viruses from bronchoalveolar lavage (BAL) fluid was negative. Stool examination was negative for parasites but positive for Clostridium difficile toxins by PCR.
Table 1: Virologic and immunologic parameters at baseline and follow-up

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Smears from BAL fluid were positive for acid-fast bacilli (AFB) and culture yielded mycobacterial species; however, deoxyribonucleic acid (DNA) probe-detection assay for Mycobacterium tuberculosis (MTB) complex was negative. Further speciation of the mycobacterium at the National Reference Centre for Mycobacteria, Borstel, Germany, using molecular methods identified the isolate as M. riyadhense. The identification was done by amplification of a fragment of the gene coding for 16S rRNA (1200bp) and sequenced. The resulting sequence-matched best with M. riyadhense, with 1 bp difference to the database sequence according to CLSI guidelines. [14]

Plain radiograph and computerized tomographic (CT) scan of the chest showed right apical cavitary disease. Conventional antituberculosis (ATT) regimen [Rifampin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E)] was started and followed with a highly active antiretroviral therapy (HAART) combination of truvada (emtricitabine and tenofovir) and efavirenz 4 weeks later with no adverse effects. Following full identification of the mycobacterium the regimen was changed to ethambutol, isoniazid and rifampicin (EHR) and clarithromycin during the intensive phase and ER and clarithromycin continued for a total duration of one year with complete resolution of radiologic features. Trimethoprim-sulphamethoxazole was added as primary prophylaxis until CD4 count level rose above 200 cells per micro liter for consecutive 3 months. Sputum conversion was achieved after 4 weeks of therapy. The patient has remained symptom-free 2 years after discontinuing antimycobacterial therapy. A Table summarizing all previously reported M. riyadhense infections has been included as [Table 2].
Table 2: Country of isolation, Year of publication, Site of infection, treatment and outcome of cases of Mycobacterium riyadhense infection

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  Discussion Top


Although this is the seventh case of infection with M. riyadhense in the literature, it is, however, the first to be coinfected with HIV. For a patient with suspected NTM lung disease, the following have to be met: (1) chest radiograph or, in the absence of cavitations, high resolution CT scan of the chest; (2) three or more sputum specimens for AFB analysis; and (3) exclusion of other disorders, such as TB. Several samples from sputum and BAL fluid were positive for AFB smear and culture, in addition to the consistent clinical and radiologic features, thus fulfilling the American Thoracic Society diagnostic criteria for NTM lung disease. [6] In the setting of typical symptoms and chest CT findings of fibronodular opacities or cavitary disease, a patient with one positive culture from bronchoalveolar lavage (or two positive cultures from sputum) now meet diagnostic criteria. [6]

The lack of commercially available kits, like DNA sequencing, to facilitate a timely and rapid diagnosis for new and emerging species of NTM including M. riyadhense often results in delayed diagnosis and initiation of standard ATT which could be insufficient. [1],[2],[3],[4] Whereas in vitro drug susceptibility tests are basically used for the choice of therapy for the rapid growers, the same cannot be said of the slow growers due to discrepancies arising from laboratory technical difficulties of drug susceptibility testing (DST), standardization of methods, and a lack of clinical validation. [6] It is, however, important to note that even though breakpoints for the susceptibility of M. riyadhense have not been established extrapolations can be made from results for M. kansasii (rifampicin) and M. avium complex (clarithromycin) as reported by van Ingen et al.,[15] in a recent review.


  Conclusion Top


Improved techniques for the identification of emerging NTM strains have led to the isolation of new members of this rapidly expanding bacterial group. This is the seventh case of M. riyadhense infection in the literature but the first to be coinfected with HIV. A combination of HAART and antituberculosis medications led to clinical, virologic, microbiologic, and radiologic improvement. The lesson from this case is that negative results of MTB (complex) PCR in a patient with positive smear should prompt a suspicion of infection due to NTM so that appropriate antimicrobials can be administered.

 
  References Top

1.van Ingen J, Al-Hajoj SA, Boeree M, Al-Rabiah F, Enaimi M, de Zwaan R, et al. Mycobacterium riyadhense sp. nov., a nontuberculous species identified as Mycobacterium tuberculosis complex by a commercial line-probe assay. Int J Syst Evol Microbiol 2009;59:1049-53.  Back to cited text no. 1
    
2.Godreuil S, Marchandin H, Michon AL, Ponsada M, Chyderiotis G, Brisou P, et al. Mycobacterium riyadhense pulmonary infection, France and Bahrain. Emerg Infect Dis 2012;18:176-8.  Back to cited text no. 2
    
3.Choi JI, Lim JH, Kim SR, Lee SH, Park JS, Seo KW, et al. Lung infection caused by mycobacterium riyadhense confused with mycobacterium tuberculosis: The first case in Korea. Ann Lab Med 2012;32:298-303.  Back to cited text no. 3
    
4.Tortoli E, Rogasi PG, Fantoni E, Beltrami C, De Francisci A, Mariottini A. Infection due to a novel mycobacterium, mimicking multidrug-resistant Mycobacterium tuberculosis. Clin Microbiol Infect 2010;16:1130-4.  Back to cited text no. 4
    
5.Henderson J, Genes S, Young Z, Kaplan P. Mycobacterium riyadhense causing pulmonary infection in human. Am J Respir Crit Care Med 2012;185:A6113.  Back to cited text no. 5
    
6.Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. ATS Mycobacterial Diseases Subcommittee, American Thoracic Society, Infectious Disease Society of America. An Official ATS/IDSA statement: Diagnosis, treatment, and prevention of non-tuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367-416.  Back to cited text no. 6
    
7.van Ingen J, Boeree MJ, de Lange WC, de Haas PE, Dekhuijzen PN, van Soolingen D. Clinical relevance of mycobacterium szulgai in the Netherlands. Clin Infect Dis 2008;46:1200-5.  Back to cited text no. 7
    
8.Lewis KN, Liao R, Guinn KM, Hickey MJ, Smith S, Behr MA, et al. Deletion of RD1 from mycobacterium tuberculosis mimics bacilli calmette-guerin attenuation. J Infect Dis 2003;187:117-23.  Back to cited text no. 8
    
9.van Ingen J, de Zwaan R, Dekhuijzen R, Boeree M, van Soolingen D. Region of difference 1 in non-tuberculous mycobacterium species adds a phylogenetic and taxonomical character. J Bacteriol 2009;191:5865-7.  Back to cited text no. 9
    
10.Berthet, FX, Rasmussen PB, Rosenkrands I, Andersen P, Gicquel B. A Mycobacterium tuberculosis operon encoding ESAT-6 and a novel low molecular-mass culture filtrate protein (CPF-10). Microbiology 1998;144:3195-203.  Back to cited text no. 10
    
11.Mostowy S, Cousins D, Behr MA. Genomic interrogation of the dassie bacillus reveals it as a unique RD1 mutant within the Mycobacterium tuberculosis complex. J Bacteriol 2004;186:104-9.  Back to cited text no. 11
    
12.Pym AS, Brodin P, Brosch R, Huerre M, Cole ST. Loss of RD1 contributed to the attenuation of the live tuberculosis vaccines Mycobacterium bovis BCG and Mycobacterium microti. Mol Microbiol 2002;46:709-17.  Back to cited text no. 12
    
13.Al Qouzi A, Al Salamah A, Al Rasheed R, Al Musalam A, Al Khairy K, Kheir O, et al. Immunophenotyping of peripheral blood lymphocytes in Saudi men. Clin Diagn Lab Immunol 2002;9:279-81.  Back to cited text no. 13
    
14.Clinical and Laboratory Standards Institute: Interpretive criteria for identification of bacteria and fungi by DNA target sequencing. Approved standard MM18-A, 1 st ed. Wayne: Clinical and Laboratory Standards Institute; 2008.  Back to cited text no. 14
    
15.van Ingen J, Boeree MJ, van Soolingen D, Mouton JW. Resistance mechanisms and drug susceptibility testing of non-tuberculous mycobacteria. Drug Resist Updat 2012;15:149-61.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2]



 

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