Letter to the Editor Mixed Bronchial Infection due intracellulare in an AIDS Patient
to Mycobacterium tuberculosis and Mycobacterium avium-
Pulmonary involvement is common in patients with AIDS. The spectrum of disease includes opportunistic infections, Kaposi's sarcoma, lymphoid interstitial pneumonitis, non-specific interstitial pneumonitis, adult respiratory distress syndrome and other diseases [1,2]. Mycobacterial infection is an emergent manifestation of AIDS [3]. Tuberculosis in AIDS patients presents unusual features such as extrapulmonary and disseminated localizations [4,5]. Another unusual finding that has recently been reported in these patients is endobronchial tuberculosis [6--8]. Mycobacterium avium-intraceUulare (MAI) also produces pulmonary and extrapulmonary diseases [3]. Recently, endobronchial MAI infection in three patients with AIDS has been reported in USA [9,10]. Thus far there have been no reports of endobronchial mixed infections with Mycobacterium tuberculosis and MAI in the literature. A 31-year-old male drug addict, anti-HIV positive, was admitted to our Department of Infectious Diseases with a one-week history of fever (39.5°C), unproductive cough, thoracic pain and progressive dyspnoea. Parenteral antibiotics administered for one week prior to his admission provided no relief. On admission laboratory findings were as follows: anti-HIV positive (ELISA and Western blot methods), leukocytes 2,500 mm 3, with total lymphocyte count of 250/mm 3, T-helper population 2/mm 3, T-cytotoxic-suppressor cells 100/mm 3, ratio 0.02. A chest X-ray revealed bilateral diffuse fine interstitial infiltrates. A Ziehl-Neelsen stain of sputum was negative. Induced sputum was also negative for Pneumocystis carinii. Fiberoptic bronchoscopy showed an endobronchial lesion obstructing the airway of the left main bronchus. The lesion appeared as a white mass mimicking bronchogenic carcinoma. Biopsy of the lesion showed granuloma formation with intracellular acid-fast bacilli. Pulmonary biopsy showed unspecific interstititial pneumonia. A PPD skin test was non-reactive. The patient underwent oesophago-gastroduodenoscopy and colonoscopy, which revealed the presence of oesophageal candidiasis and disseminated granuloma formation with intracellular acid-fast bacilli in the intestinal mucosa. AIDS diagnosis was formulated (CDC criteria). Cultures of bronchoalveolar lavage (BAL) fluid and tissue samples grew Mycobacterium tuberculosis and Mycobacterium aviumintracellulare. Therapy with rifampicin (600 mg/day), isoniazid (500 mg/day), ethambutol (1.5 gjday), imipenem (3 g/day) and amikacin (1 gJday) was started and the fever disappeared after three weeks. Three months later repeated fiberoptic bronchoscopy showed a complete resolution of the
62 / 298
bronchial lesion. The patient died six months later: CMV encephalitis, cerebral toxoplasmosis and disseminated atypical mycobacteriosis (intestinal, liver and lymphadenopathy) were found. Endobronchial tuberculosis is an unusual occurrence in AIDS patients. Endobronchial MAI infection has been reported only rarely [6-8]. The most common port of entry for endobronchial mycobacterial infection includes implantation of organisms from infected sputum and lymphatic spread to the peribronchial region [7]. Other mechanisms that have been proposed include direct extension from a parenchymal source, erosion of a lymph node through a bronchus and hematogenous spread [7]. As in our case, infection with MAI in AIDS patients is usually a dis~minated disease, with endobronchial, liver and intestinal involvement [3]. In rare cases granuloma formation is prominent in MAI infection, and the histopathological features are indistinguishable from the lesions of tuberculosis [3]. Clinical and radiographic findings are often difficult to ascribe to MAI [3,9]. In this case report, we describe a young man with AIDS with cndobronchial mass due to MAI and M. tuberculosis. Initially, he had an unproductive cough and progressive dyspnoea with atypical radiographic presentation. In such patients, fiberoptic bronchoscopy is necessary for an aetiologic diagnosis. The lesion contained granulomas with acid-fast organisms in macrophages. Tissue cultures from our patient subsequently grew MAI and M. tuberculosis. No other pathogens were isolated. Our patient's infection was probably a case of "primary" tuberculosis with MAI superinfection. Endobronchial mycobacteriosis can mimic bronchogenic carcinoma, with rapid progression of the radiographic findings and deterioration of the clinical status prior to the institution of specific chemotherapy [3,8,9]. It is very important in HIV-positive patients with progressive dyspnoea, unproductive cough, fever and other respiratory symptoms with atypical or normal chest X-ray to suspect an endobronchial mycobacterial infection.
M. Libanore, R. Bicocchi, F. Ghinelli Received: 22 April l~,~2/Revision accepted: 3 August 1992 Dr. M. Libanore, Dr. R. Bicocchi, Dr. /~: Ghinelli, Divisione Malattie Infettive, Arcispedale S. Anna, C.so Giovecca 203, 1--44100 Ferrara, Italy.
Infection 20 (1992) No. 5 © MMV Medizin Verlag GmbH M~nchen, M~inchen 1992
M. Libanore et al.: M, tuberculosis and MAI in an AIDS Patient
References 1. Murray, J. F., Mills, J.: Pulmonary infectious complications of human immun~eficiency virus infection. Part 1. Am. Rev. Respir. Dis. 141 (1990) 1356-1372. 2. Murray, J. F., Mills, J.: Pulmonary infectious complications of human immunodeficiency virus infection. Part II. Am. Rev. Respir. Dis. 141 (1990) 1582-1598. 3. Fourni~, A. M., Dickinson, C. M., Erdfrocht, 1. It., Clear-y,T., Fischl, M. A.: Tubercul~is and non tubercul~is rnycobacteriosis in patients with AIDS. Chest 93 (1988) 772-775. 4. Chaisson, R. E., ~hecter, G. F., Theuer, C. P., Rutherford, G. F., Echenberg, D. F., H~,~ell, P. C.: Tuberculosis in patients with the acquired immunodeficiency syndrome. Am. Rev. Respir. Dis. 136 (1987) 570-574. 5. Flora, G. S., Modieleisky, T., Antoniskis, D., Barnes, P. F.: Undiagnosed tuberculosis in patients with human immunodeficiency virus infection. Chest 98 (1990) 1056--1059.
6. Maguire, G. P., De Lorenzo, L. J., Brown, R. B., Davidlan, M. M.: Case Report: endobronchial tubercuk~is simulating bronchogenic carcinoma in a patient with the a~uired immunodeficiency syndrome. Am. J. Med. Sci. 294 (1987) 42-44. 7. Ip, M. S., So, S. Y., Lain, W. K., Molt, C. K.: Endobronchial tuberculosis revisited. Chest 89 (1986) 727-730. 8~ Wasser, L S., Shaw, G. W., Talavara, W.: Endobronchial tubercul~is in the acquired immunodeficien~ s~yndrome. Chest 94 (1988) 1240-1244. 9. Mehle, M. E., Adamo, J. P., Mehta, A. C.: Endobronchial Mycobacterium avium-mtracellulare infection in a patient with AIDS. Chest 96 (1989) 199-201. 10. Palter, S. J., Cesario, T., Williams, J. It.: Mycobacteriurn avium complex infection presenting as endobronchial lesions in immunosuppressed patients. Ann. Intern. Med. 109 (1988) 389-393.
Erratum Infection 20 (1992) no. 4 Letter to the Editor W. G. Boersma, Y. Holioway: "Clinical Relevance of Pneumococcal Antigen Detection in Urine", pages 240-241. Table 1, next to the last line should read: Lower respiratory tract infection 0/I 1 0/45 0/20 0/1
Infection 20 (1992) No. 5 © MMV Medizin Verlag GmbH Miinchen, Mtinchen 1992
299 / 63
to Mycobacterium tuberculosis and Mycobacterium avium-
Pulmonary involvement is common in patients with AIDS. The spectrum of disease includes opportunistic infections, Kaposi's sarcoma, lymphoid interstitial pneumonitis, non-specific interstitial pneumonitis, adult respiratory distress syndrome and other diseases [1,2]. Mycobacterial infection is an emergent manifestation of AIDS [3]. Tuberculosis in AIDS patients presents unusual features such as extrapulmonary and disseminated localizations [4,5]. Another unusual finding that has recently been reported in these patients is endobronchial tuberculosis [6--8]. Mycobacterium avium-intraceUulare (MAI) also produces pulmonary and extrapulmonary diseases [3]. Recently, endobronchial MAI infection in three patients with AIDS has been reported in USA [9,10]. Thus far there have been no reports of endobronchial mixed infections with Mycobacterium tuberculosis and MAI in the literature. A 31-year-old male drug addict, anti-HIV positive, was admitted to our Department of Infectious Diseases with a one-week history of fever (39.5°C), unproductive cough, thoracic pain and progressive dyspnoea. Parenteral antibiotics administered for one week prior to his admission provided no relief. On admission laboratory findings were as follows: anti-HIV positive (ELISA and Western blot methods), leukocytes 2,500 mm 3, with total lymphocyte count of 250/mm 3, T-helper population 2/mm 3, T-cytotoxic-suppressor cells 100/mm 3, ratio 0.02. A chest X-ray revealed bilateral diffuse fine interstitial infiltrates. A Ziehl-Neelsen stain of sputum was negative. Induced sputum was also negative for Pneumocystis carinii. Fiberoptic bronchoscopy showed an endobronchial lesion obstructing the airway of the left main bronchus. The lesion appeared as a white mass mimicking bronchogenic carcinoma. Biopsy of the lesion showed granuloma formation with intracellular acid-fast bacilli. Pulmonary biopsy showed unspecific interstititial pneumonia. A PPD skin test was non-reactive. The patient underwent oesophago-gastroduodenoscopy and colonoscopy, which revealed the presence of oesophageal candidiasis and disseminated granuloma formation with intracellular acid-fast bacilli in the intestinal mucosa. AIDS diagnosis was formulated (CDC criteria). Cultures of bronchoalveolar lavage (BAL) fluid and tissue samples grew Mycobacterium tuberculosis and Mycobacterium aviumintracellulare. Therapy with rifampicin (600 mg/day), isoniazid (500 mg/day), ethambutol (1.5 gjday), imipenem (3 g/day) and amikacin (1 gJday) was started and the fever disappeared after three weeks. Three months later repeated fiberoptic bronchoscopy showed a complete resolution of the
62 / 298
bronchial lesion. The patient died six months later: CMV encephalitis, cerebral toxoplasmosis and disseminated atypical mycobacteriosis (intestinal, liver and lymphadenopathy) were found. Endobronchial tuberculosis is an unusual occurrence in AIDS patients. Endobronchial MAI infection has been reported only rarely [6-8]. The most common port of entry for endobronchial mycobacterial infection includes implantation of organisms from infected sputum and lymphatic spread to the peribronchial region [7]. Other mechanisms that have been proposed include direct extension from a parenchymal source, erosion of a lymph node through a bronchus and hematogenous spread [7]. As in our case, infection with MAI in AIDS patients is usually a dis~minated disease, with endobronchial, liver and intestinal involvement [3]. In rare cases granuloma formation is prominent in MAI infection, and the histopathological features are indistinguishable from the lesions of tuberculosis [3]. Clinical and radiographic findings are often difficult to ascribe to MAI [3,9]. In this case report, we describe a young man with AIDS with cndobronchial mass due to MAI and M. tuberculosis. Initially, he had an unproductive cough and progressive dyspnoea with atypical radiographic presentation. In such patients, fiberoptic bronchoscopy is necessary for an aetiologic diagnosis. The lesion contained granulomas with acid-fast organisms in macrophages. Tissue cultures from our patient subsequently grew MAI and M. tuberculosis. No other pathogens were isolated. Our patient's infection was probably a case of "primary" tuberculosis with MAI superinfection. Endobronchial mycobacteriosis can mimic bronchogenic carcinoma, with rapid progression of the radiographic findings and deterioration of the clinical status prior to the institution of specific chemotherapy [3,8,9]. It is very important in HIV-positive patients with progressive dyspnoea, unproductive cough, fever and other respiratory symptoms with atypical or normal chest X-ray to suspect an endobronchial mycobacterial infection.
M. Libanore, R. Bicocchi, F. Ghinelli Received: 22 April l~,~2/Revision accepted: 3 August 1992 Dr. M. Libanore, Dr. R. Bicocchi, Dr. /~: Ghinelli, Divisione Malattie Infettive, Arcispedale S. Anna, C.so Giovecca 203, 1--44100 Ferrara, Italy.
Infection 20 (1992) No. 5 © MMV Medizin Verlag GmbH M~nchen, M~inchen 1992
M. Libanore et al.: M, tuberculosis and MAI in an AIDS Patient
References 1. Murray, J. F., Mills, J.: Pulmonary infectious complications of human immun~eficiency virus infection. Part 1. Am. Rev. Respir. Dis. 141 (1990) 1356-1372. 2. Murray, J. F., Mills, J.: Pulmonary infectious complications of human immunodeficiency virus infection. Part II. Am. Rev. Respir. Dis. 141 (1990) 1582-1598. 3. Fourni~, A. M., Dickinson, C. M., Erdfrocht, 1. It., Clear-y,T., Fischl, M. A.: Tubercul~is and non tubercul~is rnycobacteriosis in patients with AIDS. Chest 93 (1988) 772-775. 4. Chaisson, R. E., ~hecter, G. F., Theuer, C. P., Rutherford, G. F., Echenberg, D. F., H~,~ell, P. C.: Tuberculosis in patients with the acquired immunodeficiency syndrome. Am. Rev. Respir. Dis. 136 (1987) 570-574. 5. Flora, G. S., Modieleisky, T., Antoniskis, D., Barnes, P. F.: Undiagnosed tuberculosis in patients with human immunodeficiency virus infection. Chest 98 (1990) 1056--1059.
6. Maguire, G. P., De Lorenzo, L. J., Brown, R. B., Davidlan, M. M.: Case Report: endobronchial tubercuk~is simulating bronchogenic carcinoma in a patient with the a~uired immunodeficiency syndrome. Am. J. Med. Sci. 294 (1987) 42-44. 7. Ip, M. S., So, S. Y., Lain, W. K., Molt, C. K.: Endobronchial tuberculosis revisited. Chest 89 (1986) 727-730. 8~ Wasser, L S., Shaw, G. W., Talavara, W.: Endobronchial tubercul~is in the acquired immunodeficien~ s~yndrome. Chest 94 (1988) 1240-1244. 9. Mehle, M. E., Adamo, J. P., Mehta, A. C.: Endobronchial Mycobacterium avium-mtracellulare infection in a patient with AIDS. Chest 96 (1989) 199-201. 10. Palter, S. J., Cesario, T., Williams, J. It.: Mycobacteriurn avium complex infection presenting as endobronchial lesions in immunosuppressed patients. Ann. Intern. Med. 109 (1988) 389-393.
Erratum Infection 20 (1992) no. 4 Letter to the Editor W. G. Boersma, Y. Holioway: "Clinical Relevance of Pneumococcal Antigen Detection in Urine", pages 240-241. Table 1, next to the last line should read: Lower respiratory tract infection 0/I 1 0/45 0/20 0/1
Infection 20 (1992) No. 5 © MMV Medizin Verlag GmbH Miinchen, Mtinchen 1992
299 / 63
