- Email: [email protected]
Mycobacterium szulgai osteomyelitis in AIDS
M6d Mal Infect. 1996 ; 26, RICAI : 674-5
Mycobacterium szulgai osteomyelitis in AIDS* M. PULIK, E LETURDU, Ph. G E N E T
E L I O N N E T , Ch. P E T I T D I D I E R , a n d T. T O U A H R I * *
We report the first documented case of Mycobacterium szulgai osteomyelitis in a patient with AIDS. A 35-year-old woman, seroposifive for HIV since 1986, presented with an osteomyelitis of the fight tibia. The CD4 count was 8/pl. Bone biopsy yielded numerous acid fast bacilli identified as M. szulgai in culture. Therapy with isoniazid, rifampin, ethambutol and ofloxacin was initiated. The organism was susceptible to rifampin, rifabutin, ethambutol and clarithromycin, but showed resistance to isoniazid and pirazinamide. Isoniazid and ofloxacin were discontinued and clarithromyin was added. Clinical symptoms resolved. M. szulgai is a rare human pathogen that usually causes pulmonary disease. In AIDS patients, only 3 cases of M. szulgai infection have been reported.
SUMMARY
Key-words : AIDS - Mycobacterium szulgai - Osteomyelitis.
Mycobacterium szulgai is an unusual pathogen that, to our knowledge, has not been previously reported as a cause of osteomyelitis in an AIDS patient. We describe a 35-year-old intravenous drug user woman who presented with a one-month history of weight loss and pain in the right leg. She was seropositive for HIV since 1986. Her medical history was significant for oral candidiasis, and a CD4+ lymphocyte count of 50 x 106/1 in March 1994. She declined any prophylaxis or anti-retroviral therapy. In March 1995, she started to complain of pain in the right tibia. She was afebrile. Laboratory results disclosed normal erythrocyte sedimentation rate, C reactive protein, and calcemia, elevated alkaline phosphatase (170 UI/1), and a CD4 + count of 8 x 106/1. Bone roentgenograms revealed cortical osteolysis of the right tibia. This was further confirmed by bone CT scan. A bone scan demonstrated that the lesion was unique. Bone biopsy and aspirates were performed. Ziehl-Neelsen-stained smears revealed numerous acid-fast bacilli. Cultures from the bone grew a scotochromogenic mycobacterium, identified as M. szulgai. Biopsy specimen from bone lesion revealed granuloma with epithelioid and giant cells containing numerous acidfast bacilli. Chest roentgenograms revealed mediastinal * 15° R6unionIrlterdiscipfinafle de Chimioth6rapie Anti-Infectieuse. Paris, 7 et 8 d6cembre 1995. ** Departments of Haematologyand Bacteriology, Victor Dupouy Hospital, 69 rue du Lieutenant Colonel Prudhon - F-95107 Argenteuil.
lymphadenopathy and a nodule in the left upper lobe, and a sputum smear was positive for acid-fast bacilli. Results of repeated urine and stool cultures for mycobacteria were negative. Cultures of sputum and blood yielded M. szulgai. Therapy with isoniazid, rifampin, ethambutol, and ofloxacin was initiated. After one month of treatment the pain resolved. The organism was susceptible to rifampin, rifabutin, kanamycin, ethambutol, clarithromycin, and amikacin but showed resistance to isoniazid, pirazinamide, and streptomycin. Isoniazid and ofloxacin were discontinued and clarithromycin was added to the therapeutic regimen. She developed Pneumocystis carinii pneumonia 4 months after the diagnosis of M. szulgai infection.
M. szulgai is a rare human pathogen that has been described in less than 40 cases in the literature (1, 2). The organism usually causes pulmonal2¢ disease similar to that caused by Mycobacterium tuberculosis (1, 2, 3). In non HIV-infected patients, bone diseases due to M. szulgai have been reported twice: one patient developed cutaneous lesions and osteomyelitis while taking steroids (3); an other developed M. szulgai osteomyelitis at multiple sites following Salmonella paratyphi bacteremia (4). In AIDS patients, only 3 cases of M. szulgai infection have been reported (5, 6, 7). Pulmonary disease was the prominent feature in two (5, 7), renal and possibly non documented bone infection was reported in the other (6).
674
RESUME
O S T E O M Y E L I T E A MYCOBACTERIUM SZULGA1 A U C O U R S D U S I D A
Nous rapportons le premier cas d'ostdomyOlite document6e h Mycobacterium szulgai au cours du SIDA. Une patiente de 35 ans, infect6e par te VIH depuis 1986 et profond6ment immunoddprimde (CD4 : 8/~tl), pr6sente un tableau d'ost6omydlite du tibia. Une ponction biopsie met en 6vidence de tr6s nombreux bacilles acido-alcoolor6sistants identifi6s comme M. szulgai en culture. Un traitement associant 6thambutol, isoniazide, rifampicine, ofloxacine est d6but6. L'antibiogramme montre une sensibilit6 h la rifampicine, la rifabutine, l'6thambutol et la clarithromycine, mais une rdsistance ~ l'isoniazide et au pyrazinamide. L'isoniazide est remplac6 par la clarithromycine. L'6volution est favorable. M. szulgai est exceptiormellement responsable d'infection chez l'homme. L'atteinte pulmonaire est la plus habituelle. Au cours du SIDA, seules 3 observations d'infections ~ M. szulgai ont 6t6 rapport6es. M o t s - c l ~ s : S I D A - Mycobactdrie - Ost6omy61ite.
REFERENCES 1.
2.
3. 4.
M A L O N E Y J.M., G R E G G C.R., STEPHENS D.S., M A N I A N F.A., R I M L A N D D. - Infections caused b y Mycobacterium szulgai in humans. Rev Infect Dis. 1987 ; 9 : 1120-6. D Y L E W S K I J.S., Z A C K O N H.M., L A T O U R A.H., B E R R Y G.R. Mycobacterium szulgai : an unusual pathogen. Rev Infect Dis. 1987 ; 9 : 578-80. C R O S S G.M., M A R S H A L L A.G., A T O N J.K. - C u t a n e o u s Mycobacterium szulgai infection. Arch Dermatol. 1985 ; 121 : 247-9. GUR H., P O R A T S., H A A S H., N A P A R S T E K Y., E L I A K I M M. Disseminated mycobacterial disease caused by Mycobacterium szulgai.
675
5.
6.
7.
Arch Intern Med. 1984 ; 144 : 1861-3. N E W S H A N G., T O R R E S R.A. - P u l m o n a r y infection due to multidrug-resistant Mycobacterium szulgai in a patient with AIDS. Clin Infect Dis. 1994 ; 18 : 1022-3. ROIG P., NIETO A., N A V A R R O V., B E R N A C E R B., BORRAS R. Mycobacteriosis from Mycobacterium szulgai in a patient with human immunodeficiency virus infection. An Med Interna. 1993 ; 10 : 182-4. Z A M B O N I M., t G R E J A R.P., B O N E C K E R C., T O R R E S F I L H O H.M. - Mycobacterium szulgai infection in a patient with hemophilia and AIDS. Rev Assoc Med Bras. 1992 ; 38 : 150-2.
Mycobacterium szulgai osteomyelitis in AIDS* M. PULIK, E LETURDU, Ph. G E N E T
E L I O N N E T , Ch. P E T I T D I D I E R , a n d T. T O U A H R I * *
We report the first documented case of Mycobacterium szulgai osteomyelitis in a patient with AIDS. A 35-year-old woman, seroposifive for HIV since 1986, presented with an osteomyelitis of the fight tibia. The CD4 count was 8/pl. Bone biopsy yielded numerous acid fast bacilli identified as M. szulgai in culture. Therapy with isoniazid, rifampin, ethambutol and ofloxacin was initiated. The organism was susceptible to rifampin, rifabutin, ethambutol and clarithromycin, but showed resistance to isoniazid and pirazinamide. Isoniazid and ofloxacin were discontinued and clarithromyin was added. Clinical symptoms resolved. M. szulgai is a rare human pathogen that usually causes pulmonary disease. In AIDS patients, only 3 cases of M. szulgai infection have been reported.
SUMMARY
Key-words : AIDS - Mycobacterium szulgai - Osteomyelitis.
Mycobacterium szulgai is an unusual pathogen that, to our knowledge, has not been previously reported as a cause of osteomyelitis in an AIDS patient. We describe a 35-year-old intravenous drug user woman who presented with a one-month history of weight loss and pain in the right leg. She was seropositive for HIV since 1986. Her medical history was significant for oral candidiasis, and a CD4+ lymphocyte count of 50 x 106/1 in March 1994. She declined any prophylaxis or anti-retroviral therapy. In March 1995, she started to complain of pain in the right tibia. She was afebrile. Laboratory results disclosed normal erythrocyte sedimentation rate, C reactive protein, and calcemia, elevated alkaline phosphatase (170 UI/1), and a CD4 + count of 8 x 106/1. Bone roentgenograms revealed cortical osteolysis of the right tibia. This was further confirmed by bone CT scan. A bone scan demonstrated that the lesion was unique. Bone biopsy and aspirates were performed. Ziehl-Neelsen-stained smears revealed numerous acid-fast bacilli. Cultures from the bone grew a scotochromogenic mycobacterium, identified as M. szulgai. Biopsy specimen from bone lesion revealed granuloma with epithelioid and giant cells containing numerous acidfast bacilli. Chest roentgenograms revealed mediastinal * 15° R6unionIrlterdiscipfinafle de Chimioth6rapie Anti-Infectieuse. Paris, 7 et 8 d6cembre 1995. ** Departments of Haematologyand Bacteriology, Victor Dupouy Hospital, 69 rue du Lieutenant Colonel Prudhon - F-95107 Argenteuil.
lymphadenopathy and a nodule in the left upper lobe, and a sputum smear was positive for acid-fast bacilli. Results of repeated urine and stool cultures for mycobacteria were negative. Cultures of sputum and blood yielded M. szulgai. Therapy with isoniazid, rifampin, ethambutol, and ofloxacin was initiated. After one month of treatment the pain resolved. The organism was susceptible to rifampin, rifabutin, kanamycin, ethambutol, clarithromycin, and amikacin but showed resistance to isoniazid, pirazinamide, and streptomycin. Isoniazid and ofloxacin were discontinued and clarithromycin was added to the therapeutic regimen. She developed Pneumocystis carinii pneumonia 4 months after the diagnosis of M. szulgai infection.
M. szulgai is a rare human pathogen that has been described in less than 40 cases in the literature (1, 2). The organism usually causes pulmonal2¢ disease similar to that caused by Mycobacterium tuberculosis (1, 2, 3). In non HIV-infected patients, bone diseases due to M. szulgai have been reported twice: one patient developed cutaneous lesions and osteomyelitis while taking steroids (3); an other developed M. szulgai osteomyelitis at multiple sites following Salmonella paratyphi bacteremia (4). In AIDS patients, only 3 cases of M. szulgai infection have been reported (5, 6, 7). Pulmonary disease was the prominent feature in two (5, 7), renal and possibly non documented bone infection was reported in the other (6).
674
RESUME
O S T E O M Y E L I T E A MYCOBACTERIUM SZULGA1 A U C O U R S D U S I D A
Nous rapportons le premier cas d'ostdomyOlite document6e h Mycobacterium szulgai au cours du SIDA. Une patiente de 35 ans, infect6e par te VIH depuis 1986 et profond6ment immunoddprimde (CD4 : 8/~tl), pr6sente un tableau d'ost6omydlite du tibia. Une ponction biopsie met en 6vidence de tr6s nombreux bacilles acido-alcoolor6sistants identifi6s comme M. szulgai en culture. Un traitement associant 6thambutol, isoniazide, rifampicine, ofloxacine est d6but6. L'antibiogramme montre une sensibilit6 h la rifampicine, la rifabutine, l'6thambutol et la clarithromycine, mais une rdsistance ~ l'isoniazide et au pyrazinamide. L'isoniazide est remplac6 par la clarithromycine. L'6volution est favorable. M. szulgai est exceptiormellement responsable d'infection chez l'homme. L'atteinte pulmonaire est la plus habituelle. Au cours du SIDA, seules 3 observations d'infections ~ M. szulgai ont 6t6 rapport6es. M o t s - c l ~ s : S I D A - Mycobactdrie - Ost6omy61ite.
REFERENCES 1.
2.
3. 4.
M A L O N E Y J.M., G R E G G C.R., STEPHENS D.S., M A N I A N F.A., R I M L A N D D. - Infections caused b y Mycobacterium szulgai in humans. Rev Infect Dis. 1987 ; 9 : 1120-6. D Y L E W S K I J.S., Z A C K O N H.M., L A T O U R A.H., B E R R Y G.R. Mycobacterium szulgai : an unusual pathogen. Rev Infect Dis. 1987 ; 9 : 578-80. C R O S S G.M., M A R S H A L L A.G., A T O N J.K. - C u t a n e o u s Mycobacterium szulgai infection. Arch Dermatol. 1985 ; 121 : 247-9. GUR H., P O R A T S., H A A S H., N A P A R S T E K Y., E L I A K I M M. Disseminated mycobacterial disease caused by Mycobacterium szulgai.
675
5.
6.
7.
Arch Intern Med. 1984 ; 144 : 1861-3. N E W S H A N G., T O R R E S R.A. - P u l m o n a r y infection due to multidrug-resistant Mycobacterium szulgai in a patient with AIDS. Clin Infect Dis. 1994 ; 18 : 1022-3. ROIG P., NIETO A., N A V A R R O V., B E R N A C E R B., BORRAS R. Mycobacteriosis from Mycobacterium szulgai in a patient with human immunodeficiency virus infection. An Med Interna. 1993 ; 10 : 182-4. Z A M B O N I M., t G R E J A R.P., B O N E C K E R C., T O R R E S F I L H O H.M. - Mycobacterium szulgai infection in a patient with hemophilia and AIDS. Rev Assoc Med Bras. 1992 ; 38 : 150-2.