Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Acknowledgements
Authors’ reply
Book Review
Book Reviews
Classics In Indian Medicine
Clinical Case Report
Clinical Case Reports
Clinical Research Methods
Clinico-pathological Conference
Clinicopathological Conference
Conferences
Correspondence
Corrigendum
Editorial
Eminent Indians in Medicine
Errata
Erratum
Everyday Practice
Film Review
History of Medicine
HOW TO DO IT
Images In Medicine
Indian Medical Institutions
Letter from Bristol
Letter from Chennai
Letter From Ganiyari
Letter from Glasgow
Letter from London
Letter from Mangalore
Letter From Mumbai
Letter From Nepal
Masala
Medical Education
Medical Ethics
Medicine and Society
News From Here And There
Notice of Retraction
Notices
Obituaries
Obituary
Original Article
Original Articles
Review Article
Selected Summaries
Selected Summary
Short Report
Short Reports
Speaking for Myself
Speaking for Ourselve
Speaking for Ourselves
Students@nmji
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Acknowledgements
Authors’ reply
Book Review
Book Reviews
Classics In Indian Medicine
Clinical Case Report
Clinical Case Reports
Clinical Research Methods
Clinico-pathological Conference
Clinicopathological Conference
Conferences
Correspondence
Corrigendum
Editorial
Eminent Indians in Medicine
Errata
Erratum
Everyday Practice
Film Review
History of Medicine
HOW TO DO IT
Images In Medicine
Indian Medical Institutions
Letter from Bristol
Letter from Chennai
Letter From Ganiyari
Letter from Glasgow
Letter from London
Letter from Mangalore
Letter From Mumbai
Letter From Nepal
Masala
Medical Education
Medical Ethics
Medicine and Society
News From Here And There
Notice of Retraction
Notices
Obituaries
Obituary
Original Article
Original Articles
Review Article
Selected Summaries
Selected Summary
Short Report
Short Reports
Speaking for Myself
Speaking for Ourselve
Speaking for Ourselves
Students@nmji
View/Download PDF

Translate this page into:

Clinical Case Reports
36 (
2
); 93-94
doi:
10.25259/NMJI_646_21

Disseminated Mycobacterium abscessus infection in a patient on haemodialysis

Department of Microbiology, Kasturba Medical College, Lighthouse Hill Road, Hampankatta, Mangalore 575001, Karnataka, India
Department of Nephrology, Columbia Asia Referral Hospital, Yeshwanthpur, 26, Brigade Gateway, 4, 1st Main Rd, Malleswaram, Bengaluru 560055, Karnataka, India
Department of Internal Medicine, Columbia Asia Referral Hospital, Yeshwanthpur, 26, Brigade Gateway, 4, 1st Main Rd, Malleswaram, Bengaluru 560055, Karnataka, India
Correspondence to ANISHA FERNANDES; ferndale25@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

[To cite: Fernandes A, Chitralli DK, Srividya S, Sreekumar G. Disseminated Mycobacterium abscessus infection in a patient on haemodialysis. Natl Med J India 2023;36:93–4. DOI: 10.25259/NMJI_646_21]

Abstract

We report a 46-year-old woman with disseminated Mycobacterium abscessus infection who was on maintenance haemodialysis for chronic glomerulonephritis. Prolonged blood cultures yielded growth of a rapid-growing nontubercular Mycobacterium. Diagnosis to a species level guided empirical therapy while we awaited antimicrobial susceptibility results. The patient was treated successfully with a multidrug regimen.

THE CASE

A 46-year-old woman with end-stage renal disease (ESRD) secondary to chronic glomerulonephritis and on maintenance haemodialysis through an arteriovenous fistula, presented with low-grade, intermittent fever with chills, myalgia and polyarthralgia of 6 weeks’ duration. Examination was unremarkable except for pallor. Initial blood and urine cultures were negative. High-resolution CT scan showed mild bilateral pleural effusion. She was treated with broad-spectrum antibiotics. Positron emission tomography scan showed a few cavitating pulmonary nodules (Fig. 1). Empirical first-line antitubercular drugs were started. However, she was re-admitted 2 weeks later with worsening fever, non-productive cough, weight loss and erythematous non-itchy macular rashes over the face, neck and arms (Fig. 2). Transoesophageal echocardiography showed mitral and tricuspid regurgitation without vegetations. A bone marrow biopsy was unremarkable.

FIG 1.
PET CT scan showing a pulmonary nodule with cavitation
FIG 2.
Erythematous macular rashes on arm

As the usual protocol of 5 days incubation using automated blood culture system BD BACTECTM FX yielded negative results on previous samples, the protocol was extended to 21 days. On day 12, blood cultures collected in two aerobic bottles grew acid-fast bacilli suggesting atypical Mycobacteria. Growth obtained on blood and chocolate agar was identified as Mycobacterium abscessus by BRUKER Biotyper MALDI-TOF (Matrix-Assisted Laser Desorption/Ionization-Time of Flight) using Formic Acid, Acetonitrile extraction protocol with 0.5 mm zirconia beads1 and interpreted with MALDI Biotyer Compass Software 4.1 with MBT Mycobacteria Library 3.0 with a confidence value of 2.23. Antimicrobial susceptibility testing by Broth Microdilution using Thermofisher SensititreTM showed sensitivity to amikacin and clarithromycin with MICs of 1 and 0.12 μg/ml, respectively and interpreted using CLSI (Clinical and laboratory standards institute) guidelines.2 The isolate was resistant to amoxycillin/clavulanic acid, ceftriaxone, cefepime and ciprofloxacin with MICs of >64/32, >64, >32 and >4, respectively. She was treated with a combination of amikacin and clarithromycin for one month followed by continuation with clarithromycin. As the patient had already developed ESRD and was on haemodialysis, there was no risk of further nephrotoxicity and hence dose modification was not needed. Renal parameters were repeatedly tested throughout the course of the treatment and thrice-weekly maintenance dialysis, and remained stable. Blood cultures repeated after 4 weeks were sterile. At the time of writing she was on clarithromycin and asymptomatic for the past 6 months.

DISCUSSION

Mycobacterium abscessus is ubiquitous in water and soil.3 It can withstand harsh environmental conditions and various disinfectants, thereby persisting in hospital water systems.3 Outbreaks have been reported in haemodialysis centres.3

Impaired cellular immunity in ESRD predisposes to mycobacterial infections.3 Among rapid-growing Mycobacteria (RGM), M. fortuitum and M. chelonae are common causative agents, often presenting as peritonitis.3 M. abscessus usually causes pulmonary, skin and soft tissue infections.4 Disseminated infections are rare and often fatal. Rash is commonly seen in disseminated disease,4 as in our patient. We are aware of only two reports of disseminated M. abscessus in patients on dialysis.5,6

Diagnosis of M. abscessus requires clinical, radiological and microbiological evidence. Negative cultures are common and hence require multiple sampling.4 In non-resolving infections on antimicrobials, prolonged incubation of cultures has shown to improve yield.5 Biopsy of skin lesions often demonstrates acid-fast bacilli in smear and culture. RGM isolated in blood should be considered true pathogens after ruling out contamination.7 Molecular methods and MALDI-TOF have made identification of non-tubercular mycobacteria to a species level easier and quicker. A recent study evaluating MALDITOF MS in the identification of non-tuberculous mycobacterial1 revealed that a threshold score of >2.00 gave a valid identification of M. abscessus at the species level. A limitation of our study is that identification to a subspecies level was not done, which would require DNA sequencing.

M. abscessus displays resistance to most antibiotic classes.8 Subspecies identification is useful to guide treatment before availability of susceptibility patterns. Currently, there are no clear guidelines on antimicrobials and combinations, duration and use of newer antimicrobials. Multidrug regimens with i.v. agents are advised, with at least three active agents, including macrolides, if susceptible.8 Cocktails of macrolides, amikacin, linezolid, tigecycline in the form of induction and continuation phase up to 6–9 months have been used with success.

Conflicts of interest.

None declared

References

  1. , , . Evaluation of MALDI Biotyper interpretation criteria for accurate identification of nontuberculous mycobacteria. J Clin Microbiol. 2020;58:e01103-e01120.
    [CrossRef] [PubMed] [Google Scholar]
  2. . Performance standards for susceptibility testing of mycobacteria, Nocardia spp. and other aerobic actinomycetes In: CLSI document M62 (1st ed). Wayne, PA: Clinical and Laboratory Standards Institute; .
    [Google Scholar]
  3. , . Mycobacterial infections in patients with chronic kidney disease and kidney transplantation. Adv Chronic Kidney Dis. 2019;26:35-40.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , . General overview of nontuberculous mycobacteria opportunistic pathogens: Mycobacterium avium and Mycobacterium abscessus. J Clin Med. 2020;9:2541.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Disseminated Mycobacterium abscessus infection in a peritoneal dialysis patient. ID Cases. 2017;9:6-7.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , . The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review. Nephrology (Carlton). 2011;16:174-9.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , . Current significance of the Mycobacterium chelonae-abscessus group. Diagn Microbiol Infect Dis. 2019;94:248-54.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , , . Mycobacterium abscessus complex infections in humans. Emerg Infect Dis. 2015;21:1638-46.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
14,080

PDF downloads
35
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections