Disseminated coinfection with Mycobacterium Avium complex and Mycobacterium Kansasii in a patient with idiopathic CD4+ lymphocytopenia: A case report.

Simultaneously disseminated coinfection with two species of nontuberculous mycobacteria (NTM) is extremely rare and had been reported only in immunocompromised individuals. Here, we report a 59-year-old Thai man, previously healthy. He presented with a 2-month history of prolonged fever, constitutional symptoms, and hepatosplenomegaly. His chest and abdomen computed tomography illustrated multiple enlarged mediastinal lymph nodes accompanied with multifocal crazy-paving appearance in both lungs and hepatosplenomegaly. Endobronchial ultrasound-guided transbronchial needle aspiration was performed on the mediastinal nodes. The pathologic findings were necrotizing granulomatous lymphadenitis with numerous AFB-positive bacilli. Blood culture subsequently isolated M. intracellulare, while BAL and lymph node culture isolated M. intracellulare and M. kansasii, which confirmed species by multiplex PCR and 16s rRNA sequencing. Idiopathic CD4+ lymphocytopenia (ICL) was diagnosed as the cause of secondary immune deficiency. Intravenous imipenem, amikacin, and azithromycin were administered as an empirical antibiotic regimen for 4 weeks, then substituted to oral rifampicin, clarithromycin, moxifloxacin, and ethambutol as definitive regimen. Unfortunately, it was found that he had died unexpectedly at home after 4 months of treatment, possibly related to this illness. In our view, patients with severe disseminated NTM disease should be evaluated to explore a secondary immune deficiency disorder. An ICL is a rare heterogenous syndrome but should be considered.

Isolated Tuberculous Transverse Myelitis Without Meningitis Among Patients With AIDS: A Case Report.

Acute transverse myelitis is an inflammatory disorder of the spinal cord, characterized by acute or subacute onset of paraparesis, bilateral sensory deficit, and impaired urinary bladder and sphincter tone function. Mycobacterium tuberculosis, a very rare cause of transverse myelitis, especially tuberculous myelitis without meningitis, is extremely rare. The main etiologic mechanism consists of an abnormal activation of the immune system against the spinal cord as well as the direct invasion by the bacillus. We present a 30-year-old Thai woman with AIDS, presenting with paraplegia for two days. Her MRI of the whole spine showed nodular enhancing intramedullary lesions involving the spinal cord at the T11-T12 level, and intramedullary enhancing lesion along the T12 spinal cord to the conus medullaris. Cerebrospinal fluid (CSF) examination revealed only a few white blood cells without hypoglycorrhachia or elevated CSF protein. CSF polymerase chain reaction (PCR) and culture for M. tuberculosis produced negative results. Other investigations did not demonstrate other organ involvement. Spinal cord biopsy at T12 was performed and exhibited diffuse epithelioid histiocytic proliferation admixed with small lymphocytes and plasma cells with numerous acid-fast bacilli (AFB)-positive bacilli organisms. PCR for M. tuberculosis was also detected in spinal cord tissue. Thus, acute transverse myelitis caused by isolated tuberculous myelitis without meningeal involvement was diagnosed. She had marked clinical improvement and neurologic recovery after treatment with anti-tuberculosis and intravenous steroid pulses. Isolated M. tuberculosis spinal tuberculous myelitis without meningitis is exceptionally uncommon and should be carefully considered, particularly in severely immunocompromised individuals residing in regions with a high tuberculosis burden.

Is Echocardiography Mandatory for All Streptococcus gallolyticus Subsp. pasteurianus Bacteremia?

BACKGROUND: Streptococcus gallolyticus, formerly known as one of the Streptococcus bovis group, is frequently associated with endocarditis. Current guidelines recommended diagnostic work-up for endocarditis among patients with S. gallolyticus bacteremia. However, S. gallolyticus subsp. pasteurianus, was found to be associated with neonatal sepsis and liver diseases and is less commonly associated with endocarditis compared with S. gallolyticus subsp. gallolyticus. Our study aimed to identify the risk factors for S. gallolyticus subsp. pasteurianus endocarditis to help select the patients for echocardiography. METHODS: In this retrospective cohort study, medical records from all adult patients with S. gallolyticus subsp. pasteurianus isolated from blood cultures at Phramongkutklao Hospital from 2009 to 2015 were reviewed. Patients who had mixed bacteremia or missing records were excluded from the study. RESULTS: During the study period, S. gallolyticus subsp. pasteurianus was isolated among 106 individuals. Mean age was 66.9±15.6 years. Most patients (61.3%) were male, with cirrhosis as the most common underlying diseases (46.2%), followed by malignancy and chronic kidney disease. Most common manifestations included primary bacteremia (44.3%), followed by spontaneous bacterial peritonitis (23.6%). Infective endocarditis was found among 9 patients. No patients with cirrhosis or single blood specimen of bacteremia had endocarditis (RR 0; p-value 0.003, and RR 1.35; p-value 0.079). The common complications associated with endocarditis were acute respiratory failure (RR 4.32; p-value 0.05), whereas acute kidney injury was a protective factor (RR 0; p-value 0.01). Among 76 patients who had records of 2-year follow-up, no new diagnosis of endocarditis or malignancy was observed. CONCLUSION: Among patients with S. gallolyticus subsp. pasteurianus bacteremia, echocardiography might not be needed among patients with cirrhosis and without sustained bacteremia.