- Email: [email protected]
Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature
J Infect Chemother xxx (2016) 1e3
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case Report
Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature Paul Blair a, *, Mahdi Moshgriz b, Marc Siegel c a
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA Department of Pathology, George Washington University Hospital, Washington, DC, USA c Division of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 March 2016 Received in revised form 12 June 2016 Accepted 17 August 2016 Available online xxx
Mycobacterium fortuitum is a rapidly growing mycobacterium (RGM) that is an uncommon cause of healthcare-associated infections. The most common infections caused by M. fortuitum include skin, soft tissue, and catheter-related infections. Although occasionally cultured from sputum samples, M. fortuitum is a rare cause of pulmonary disease. We report a case of M. fortuitum empyema associated with an infected pleural catheter and review M. fortuitum pulmonary infections. © 2016 Published by Elsevier Ltd on behalf of Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Keywords: Rapidly growing mycobacteria Nontuberculous mycobacterial Catheter-associated infections
1. Introduction Nontuberculous mycobacterial (NTM) infections are most commonly seen in chronic pulmonary infections in HIV-negative patients, particularly those with underlying structural lung disease [1]. Of the subset of rapidly growing NTMs, Mycobacterium abscessus is the most common cause of pulmonary infections. However, rapidly growing mycobacteria (RGM) including Mycobacterium fortuitum have rarely been reported to cause pleural space infections [2e6]. We report a case of a man with metastatic pancreatic cancer who presented with an empyema due to a M. fortuitum infection via contiguous extension from an indwelling pleural catheter.
2. Case report A 77-year-old man with a history of metastatic pancreatic cancer with recurrent hydropneumothorax requiring drainage through an indwelling pleural catheter presented to our hospital with worsening erythema and discharge at the catheter site. The patient reported tenderness at the site two days prior to admission but
* Corresponding author. 1830 E. Monument Street, 1830 Building, 4th Floor, Baltimore, MD 21287, USA E-mail address: [email protected] (P. Blair).
denied any fevers, chills, shortness of breath or malaise. The indwelling pleural catheter had been placed five months prior to admission for a recurrent right-sided hydropneumothorax as a result of a failed pleurodesis for recurrent malignant pleural effusions. The patient had required two hospitalizations in the previous two months to replace the pleural catheter after dislodgement. The patient had been treated with a course of oral clindamycin for cellulitis around the catheter site one month prior to the current presentation. On examination the patient's axillary temperature was 35.9 C, heart rate 80 beats per minute, blood pressure 105/60 mm Hg, and oxygen saturation of 100% on room air. The patient was cachectic but nontoxic appearing. There were absent breath sounds over the right hemithorax with dullness to percussion at the base. There was a 3 3 cm area of erythema, warmth, induration and tenderness to palpation at the catheter exit site with purulent exudate. Laboratory evaluation was remarkable for leukocytosis (Fig. 1) and mild anemia (hemoglobin 9.6 g/dL). Chest radiograph revealed a chest tube in place with a right-sided hydropneumothorax (Fig. 2). Patient was empirically started on intravenous vancomycin and piperacillin/tazobactam. Gram stain of the catheter exudate revealed Gram positive bacilli. The fluid from the pleural catheter was drained and revealed 13,884 leukocytes/mm3 (84% neutrophils), 128,892 erythrocytes/ mm3, glucose less than 20 mg/dL, LDH 11,839 U/L, and pH of 7.0 (Table 1). Gram stain and acid fast smears of the pleural fluid were
http://dx.doi.org/10.1016/j.jiac.2016.08.016 1341-321X/© 2016 Published by Elsevier Ltd on behalf of Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016
2
P. Blair et al. / J Infect Chemother xxx (2016) 1e3 Table 1 Pleural fluid results of current hospitalization compared to prior pleural fluid studies.
Total protein (mg per dL) pH Glucose (mg per dL) Appearance Erythrocytes (per mm3) Leukocytes (per mm3) Lymphocytes (%) Monocytes (%) Segmented neutrophils (%) LDH (units per liter)
Fig. 1. White blood cell count trend during patient's hospitalization.
negative. After three days there was growth of an acid fast bacillus (AFB) on blood agar from the original wound culture. No other organisms grew on the pleural fluid culture. The pleural fluid grew € wensteineJensen medium and in the BACTEC™ MGIT™ AFB on Lo Mycobacterial Detection System. Sequencing was performed at Quest Diagnostics Nichols Institute (Chantilly, VA) on both the wound exudate and the pleural fluid, which were positive for M. fortuitum complex. Antibiotics were changed to oral ciprofloxacin, oral clarithromycin, and oral linezolid as empiric coverage for a rapidly growing mycobacterial infection. The patient was discharged on twice daily oral ciprofloxacin and clarithromycin. Mycobacterial susceptibilities available after discharge showed susceptibility to amikacin, ciprofloxacin, doxycycline, linezolid, moxifloxacin, trimethoprim/sulfamethoxazole but intermediate resistance to imipenem and cefoxitin, and resistance to clarithromycin (Table 2). Ultimately, the patient decided to pursue inpatient hospice care and all antibiotics were discontinued according to the patient's wishes. 3. Discussion RGM infections are due to nontuberculous mycobacteria species that usually produce mature grow within seven days on standard mycobacterial media [1]. Although acid fast staining is often unrevealing, RGM can appear as beaded Gram-positive rods with standard Gram staining technique as was seen in our case [1,2]. The more commonly encountered RGM include M. fortuitum, Mycobacterium
Five months prior
Hospitalization
4.4 7.352 131 Clear 182 335 43 4 53 525
2.1 7.0 <<20 Cloudy 128,892 13,884 12 4 84 11,839
chelonae, M. abscessus and Mycobacterium mucogenicum. They are saprophytic organisms and are typically found in environmental water or soil samples. Tap water is often a reservoir for NTM and cases have been reported due to the use of contaminated medical instruments [1,7]. It is possible that contamination of the pleural catheter developed from exposure to the patient's home tap water. RGM pulmonary infections due to M. fortuitum are associated with esophageal motility disorders in immunocompromised patients as well as patients with underlying structural lung disease such as bronchiectasis [8,9]. Chronic vomiting and lipoid pneumonia are thought to be risk factors for RGM pulmonary infections [2,9]. RGM pulmonary disease in these patients can present with a more fulminant clinical presentation of lipoid pneumonia with high fevers, marked leukocytosis (>20,000 cells/mm3) and widespread infiltrates on radiography [8]. Although our patient was not neutropenic, his history of metastatic pancreatic cancer requiring chemotherapy, recurrent hydropneumothoraces, an indwelling pleural catheter, and multiple catheter exchanges put the patient at increased risk for infectious complications. The diagnosis of empyema based on this patient's pleural fluid studies is complicated by the fact that malignant pleural effusions can also be associated with low pH and low glucose measurements. Such low values in addition to the high neutrophil differential had not been previously been seen and were normal on this patient's pleural fluid studies during prior admissions, suggesting that he had developed an M. fortuitum empyema via contiguous spread from his pleural catheter. Of the RGM known to cause pulmonary disease, M. abscessus accounts for the majority of cases. M. fortuitum is more commonly
Fig. 2. Patient's PA (posterioranterior) and lateral chest x-ray revealing a right-sidedhydropneumothorax with a collapsed right lung and an airefluid level.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016
P. Blair et al. / J Infect Chemother xxx (2016) 1e3
3
Table 2 M. fortuitum susceptibility data [17].
Amikacin Cefoxitin Ciprofloxacin Clarithromycin Doxycycline Imipenem Linezolid Moxifloxacin Trimethoprim/sulfamethoxazole
Isolated M. fortuitum MIC (mcg/mL)
Susceptible (mcg/mL)
Intermediate (mcg/mL)
Resistant (mcg/mL)
< or ¼ 1 32 < or ¼ 0.12 8 0.25 8 4 0.25 1/19
< < < < < < < < <
32 32e64 2.0 4.0 2.0e8.0 8.0 16 2 e
> > > > > > > > >
seen as a cause of skin and soft tissue infections accounting for approximately half of RGM-related skin infections. However M. fortuitum pulmonary infections are being increasing reported [2]. A review of the literature reveals that there have only been two reports of empyema due to M. fortuitum. The first report was that of a man with HIV with a CD4þ T lymphocyte count of 13 cells/mL and a massive parapneumonic M. fortuitum empyema. The second report was that of a man with a history of lobectomy for tuberculosis with chronic hypercapnic respiratory failure and a pneumothorax associated with a bronchopleural fistula [2,10]. Our patient differs from these cases in that it is the first description of a RGM empyema as a result of contiguous extension from an infected pleural catheter. All previously reported patients were responsive to therapy with appropriate antibiotics without the need for surgical intervention [10]. Treatment regimens for RGM infections are dependent upon accurate susceptibility testing as each species has its own particular resistance patterns. Furthermore, combination therapy is required, because monotherapy is associated with treatment failure [11]. Most of the first line tuberculosis agents have no activity against these mycobacteria [12,13]. M. fortuitum has a more favorable susceptibility profile than M. abscessus which exhibits more antimicrobial resistance and frequently requires surgical resection. Accordingly, the mortality rate among patients with M. fortuitum pulmonary infections is less than that among patients with M. abscessus (4% vs 15%) [8]. M. fortuitum is generally susceptible to multiple oral agents including ciprofloxacin, levofloxacin, moxifloxacin, trimethoprimsulfamethoxazole, linezolid and doxycycline [13,14]. Macrolides including clarithromycin may initially have “susceptible” MICs in 96% of isolates, but many M. fortuitum strains carry inducible erm genes and prolonged incubation will reveal MICs predicting clarithromycin resistance [13,14]. M. fortuitum isolates are also universally susceptible to parenteral agents including imipenem, tigecycline, amikacin, with almost half susceptible to cefoxitin [13,14]. Of note, the isolate in this case was resistant to imipenem despite prior reports of 100% susceptibility [13]. American Thoracic Society guidelines recommend treatment regimens for pulmonary infections with at least two agents for at least 12 months past negative repeat sputum cultures [9]. Our patient was discharged on ciprofloxacin and clarithromycin prior to the availability of susceptibilities [15]. It is also recommended that associated foreign bodies including catheters be removed as part of the therapy [16]. Although this was recommended by the medical team in our case, it was decided through multidisciplinary discussions that, given the indolent nature of the M. fortuitum infection and the patient's overall prognosis and goals of care, the indwelling catheter was to remain in place in order to drain the pleural fluid. In conclusion, M. fortuitum should be considered in the differential of organisms that can cause indwelling pleural catheter infections. Additionally, M. fortuitum is a potential etiology of
or or or or or or or or or
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
16 16 1.0 2.0 1.0 4.0 8.0 1.0 2/38
or or or or or or or or or
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
64 128 4.0 8.0 16 16 32 4.0 4/76
empyema in patients with significant underlying lung disease. This case describes direct contiguous extension from an infected pleural catheter as a cause of RGM infection in the pleural space.
Conflicts of interest The authors have no conflicts of interest to disclose.
References [1] Brown-Elliott BA, Wallace Jr RJ. Infections due to nontuberculous mycobacteria other than Mycobacterium avium intracellulare. In: Mandell G, Bennett J, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 8th ed., vol. 254. Philadelphia: Churchill Livingstone; 2015. p. 2844e52. [2] Agheli A, Tehranirad M, Cofsky R. An unusual presentation of Mycobacterium fortuitum: massive isolated empyema in a patient with HIV. MedGenMed 2006;8:90. [3] Fabbian F, De Giorgi A, Pala M, Fratti D, Contini C. Pleural effusion in an immunocompetent woman caused by Mycobacterium fortuitum. J Med Microbiol 2011;60:1375e8. [4] Okazaki A, Takato H, Fujimura M, Ohkura N, Katayama N, Kasahara K. Successful treatment with chemotherapy and corticosteroids of pulmonary Mycobacterium abscessus infection accompanied by pleural effusion. J Infect Chemother 2013;19:964e8. [5] Park S, Suh GY, Chung MP, Kim H, Kwon OJ, Lee KS, et al. Clinical significance of Mycobacterium fortuitum isolated from respiratory specimens. Respir Med 2008;102:437e42. [6] Wali S. Mycobacterium chelonae empyema with bronchopleural fistula in an immunocompetent patient. Ann Thorac Med 2009;4:213e5. [7] Wallace RJ, Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annu Rev Microbiol 1998;52: 453e90. [8] Griffith DE, Girard WM, Wallace Jr RJ. Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients. Am Rev Respir Dis 1993;147:1271e8. [9] Hadjiliadis D, Adlakha A, Prakash UB. Rapidly growing mycobacterial lung infection in association with esophageal disorders. Mayo Clin Proc 1999;74: 45e51. [10] Matsumoto T, Otsuka K, Tomii K. Mycobacterium fortuitum thoracic empyema: a case report and review of the literature. J Infect Chemother 2015;21: 747e50. [11] Wallace RJ, Bedsole G, Sumter G, Sanders CV, Steele LC, Brown BA, et al. Activities of ciprofloxacin and ofloxacin against rapidly growing mycobacteria with demonstration of acquired resistance following single-drug therapy. Antimicrob Agents Chemother 1990;34:65e70. [12] Atkins BL, Gottlieb T. Skin and soft tissue infections caused by nontuberculous mycobacteria. Curr Opin Infect Dis 2014;27:137e45. [13] Brown-Elliott BA, Nash KA, Wallace RJ. Antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria. Clin Microbiol Rev 2012;25:545e82. [14] Cowman S, Burns K, Benson S, Wilson R, Loebinger MR. The antimicrobial susceptibility of non-tuberculous mycobacteria. J Infect 2016;72:324e31. [15] Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175: 367e416. [16] Kasperbauer SH, De Groote MA. The treatment of rapidly growing mycobacterial infections. Clin Chest Med 2015;36:67e78. [17] Brown-Elliott BA, Wallace Jr RJ. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria. Clin Microbiol Rev 2002;15:716e46.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case Report
Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature Paul Blair a, *, Mahdi Moshgriz b, Marc Siegel c a
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA Department of Pathology, George Washington University Hospital, Washington, DC, USA c Division of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 March 2016 Received in revised form 12 June 2016 Accepted 17 August 2016 Available online xxx
Mycobacterium fortuitum is a rapidly growing mycobacterium (RGM) that is an uncommon cause of healthcare-associated infections. The most common infections caused by M. fortuitum include skin, soft tissue, and catheter-related infections. Although occasionally cultured from sputum samples, M. fortuitum is a rare cause of pulmonary disease. We report a case of M. fortuitum empyema associated with an infected pleural catheter and review M. fortuitum pulmonary infections. © 2016 Published by Elsevier Ltd on behalf of Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Keywords: Rapidly growing mycobacteria Nontuberculous mycobacterial Catheter-associated infections
1. Introduction Nontuberculous mycobacterial (NTM) infections are most commonly seen in chronic pulmonary infections in HIV-negative patients, particularly those with underlying structural lung disease [1]. Of the subset of rapidly growing NTMs, Mycobacterium abscessus is the most common cause of pulmonary infections. However, rapidly growing mycobacteria (RGM) including Mycobacterium fortuitum have rarely been reported to cause pleural space infections [2e6]. We report a case of a man with metastatic pancreatic cancer who presented with an empyema due to a M. fortuitum infection via contiguous extension from an indwelling pleural catheter.
2. Case report A 77-year-old man with a history of metastatic pancreatic cancer with recurrent hydropneumothorax requiring drainage through an indwelling pleural catheter presented to our hospital with worsening erythema and discharge at the catheter site. The patient reported tenderness at the site two days prior to admission but
* Corresponding author. 1830 E. Monument Street, 1830 Building, 4th Floor, Baltimore, MD 21287, USA E-mail address: [email protected] (P. Blair).
denied any fevers, chills, shortness of breath or malaise. The indwelling pleural catheter had been placed five months prior to admission for a recurrent right-sided hydropneumothorax as a result of a failed pleurodesis for recurrent malignant pleural effusions. The patient had required two hospitalizations in the previous two months to replace the pleural catheter after dislodgement. The patient had been treated with a course of oral clindamycin for cellulitis around the catheter site one month prior to the current presentation. On examination the patient's axillary temperature was 35.9 C, heart rate 80 beats per minute, blood pressure 105/60 mm Hg, and oxygen saturation of 100% on room air. The patient was cachectic but nontoxic appearing. There were absent breath sounds over the right hemithorax with dullness to percussion at the base. There was a 3 3 cm area of erythema, warmth, induration and tenderness to palpation at the catheter exit site with purulent exudate. Laboratory evaluation was remarkable for leukocytosis (Fig. 1) and mild anemia (hemoglobin 9.6 g/dL). Chest radiograph revealed a chest tube in place with a right-sided hydropneumothorax (Fig. 2). Patient was empirically started on intravenous vancomycin and piperacillin/tazobactam. Gram stain of the catheter exudate revealed Gram positive bacilli. The fluid from the pleural catheter was drained and revealed 13,884 leukocytes/mm3 (84% neutrophils), 128,892 erythrocytes/ mm3, glucose less than 20 mg/dL, LDH 11,839 U/L, and pH of 7.0 (Table 1). Gram stain and acid fast smears of the pleural fluid were
http://dx.doi.org/10.1016/j.jiac.2016.08.016 1341-321X/© 2016 Published by Elsevier Ltd on behalf of Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016
2
P. Blair et al. / J Infect Chemother xxx (2016) 1e3 Table 1 Pleural fluid results of current hospitalization compared to prior pleural fluid studies.
Total protein (mg per dL) pH Glucose (mg per dL) Appearance Erythrocytes (per mm3) Leukocytes (per mm3) Lymphocytes (%) Monocytes (%) Segmented neutrophils (%) LDH (units per liter)
Fig. 1. White blood cell count trend during patient's hospitalization.
negative. After three days there was growth of an acid fast bacillus (AFB) on blood agar from the original wound culture. No other organisms grew on the pleural fluid culture. The pleural fluid grew € wensteineJensen medium and in the BACTEC™ MGIT™ AFB on Lo Mycobacterial Detection System. Sequencing was performed at Quest Diagnostics Nichols Institute (Chantilly, VA) on both the wound exudate and the pleural fluid, which were positive for M. fortuitum complex. Antibiotics were changed to oral ciprofloxacin, oral clarithromycin, and oral linezolid as empiric coverage for a rapidly growing mycobacterial infection. The patient was discharged on twice daily oral ciprofloxacin and clarithromycin. Mycobacterial susceptibilities available after discharge showed susceptibility to amikacin, ciprofloxacin, doxycycline, linezolid, moxifloxacin, trimethoprim/sulfamethoxazole but intermediate resistance to imipenem and cefoxitin, and resistance to clarithromycin (Table 2). Ultimately, the patient decided to pursue inpatient hospice care and all antibiotics were discontinued according to the patient's wishes. 3. Discussion RGM infections are due to nontuberculous mycobacteria species that usually produce mature grow within seven days on standard mycobacterial media [1]. Although acid fast staining is often unrevealing, RGM can appear as beaded Gram-positive rods with standard Gram staining technique as was seen in our case [1,2]. The more commonly encountered RGM include M. fortuitum, Mycobacterium
Five months prior
Hospitalization
4.4 7.352 131 Clear 182 335 43 4 53 525
2.1 7.0 <<20 Cloudy 128,892 13,884 12 4 84 11,839
chelonae, M. abscessus and Mycobacterium mucogenicum. They are saprophytic organisms and are typically found in environmental water or soil samples. Tap water is often a reservoir for NTM and cases have been reported due to the use of contaminated medical instruments [1,7]. It is possible that contamination of the pleural catheter developed from exposure to the patient's home tap water. RGM pulmonary infections due to M. fortuitum are associated with esophageal motility disorders in immunocompromised patients as well as patients with underlying structural lung disease such as bronchiectasis [8,9]. Chronic vomiting and lipoid pneumonia are thought to be risk factors for RGM pulmonary infections [2,9]. RGM pulmonary disease in these patients can present with a more fulminant clinical presentation of lipoid pneumonia with high fevers, marked leukocytosis (>20,000 cells/mm3) and widespread infiltrates on radiography [8]. Although our patient was not neutropenic, his history of metastatic pancreatic cancer requiring chemotherapy, recurrent hydropneumothoraces, an indwelling pleural catheter, and multiple catheter exchanges put the patient at increased risk for infectious complications. The diagnosis of empyema based on this patient's pleural fluid studies is complicated by the fact that malignant pleural effusions can also be associated with low pH and low glucose measurements. Such low values in addition to the high neutrophil differential had not been previously been seen and were normal on this patient's pleural fluid studies during prior admissions, suggesting that he had developed an M. fortuitum empyema via contiguous spread from his pleural catheter. Of the RGM known to cause pulmonary disease, M. abscessus accounts for the majority of cases. M. fortuitum is more commonly
Fig. 2. Patient's PA (posterioranterior) and lateral chest x-ray revealing a right-sidedhydropneumothorax with a collapsed right lung and an airefluid level.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016
P. Blair et al. / J Infect Chemother xxx (2016) 1e3
3
Table 2 M. fortuitum susceptibility data [17].
Amikacin Cefoxitin Ciprofloxacin Clarithromycin Doxycycline Imipenem Linezolid Moxifloxacin Trimethoprim/sulfamethoxazole
Isolated M. fortuitum MIC (mcg/mL)
Susceptible (mcg/mL)
Intermediate (mcg/mL)
Resistant (mcg/mL)
< or ¼ 1 32 < or ¼ 0.12 8 0.25 8 4 0.25 1/19
< < < < < < < < <
32 32e64 2.0 4.0 2.0e8.0 8.0 16 2 e
> > > > > > > > >
seen as a cause of skin and soft tissue infections accounting for approximately half of RGM-related skin infections. However M. fortuitum pulmonary infections are being increasing reported [2]. A review of the literature reveals that there have only been two reports of empyema due to M. fortuitum. The first report was that of a man with HIV with a CD4þ T lymphocyte count of 13 cells/mL and a massive parapneumonic M. fortuitum empyema. The second report was that of a man with a history of lobectomy for tuberculosis with chronic hypercapnic respiratory failure and a pneumothorax associated with a bronchopleural fistula [2,10]. Our patient differs from these cases in that it is the first description of a RGM empyema as a result of contiguous extension from an infected pleural catheter. All previously reported patients were responsive to therapy with appropriate antibiotics without the need for surgical intervention [10]. Treatment regimens for RGM infections are dependent upon accurate susceptibility testing as each species has its own particular resistance patterns. Furthermore, combination therapy is required, because monotherapy is associated with treatment failure [11]. Most of the first line tuberculosis agents have no activity against these mycobacteria [12,13]. M. fortuitum has a more favorable susceptibility profile than M. abscessus which exhibits more antimicrobial resistance and frequently requires surgical resection. Accordingly, the mortality rate among patients with M. fortuitum pulmonary infections is less than that among patients with M. abscessus (4% vs 15%) [8]. M. fortuitum is generally susceptible to multiple oral agents including ciprofloxacin, levofloxacin, moxifloxacin, trimethoprimsulfamethoxazole, linezolid and doxycycline [13,14]. Macrolides including clarithromycin may initially have “susceptible” MICs in 96% of isolates, but many M. fortuitum strains carry inducible erm genes and prolonged incubation will reveal MICs predicting clarithromycin resistance [13,14]. M. fortuitum isolates are also universally susceptible to parenteral agents including imipenem, tigecycline, amikacin, with almost half susceptible to cefoxitin [13,14]. Of note, the isolate in this case was resistant to imipenem despite prior reports of 100% susceptibility [13]. American Thoracic Society guidelines recommend treatment regimens for pulmonary infections with at least two agents for at least 12 months past negative repeat sputum cultures [9]. Our patient was discharged on ciprofloxacin and clarithromycin prior to the availability of susceptibilities [15]. It is also recommended that associated foreign bodies including catheters be removed as part of the therapy [16]. Although this was recommended by the medical team in our case, it was decided through multidisciplinary discussions that, given the indolent nature of the M. fortuitum infection and the patient's overall prognosis and goals of care, the indwelling catheter was to remain in place in order to drain the pleural fluid. In conclusion, M. fortuitum should be considered in the differential of organisms that can cause indwelling pleural catheter infections. Additionally, M. fortuitum is a potential etiology of
or or or or or or or or or
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
16 16 1.0 2.0 1.0 4.0 8.0 1.0 2/38
or or or or or or or or or
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
64 128 4.0 8.0 16 16 32 4.0 4/76
empyema in patients with significant underlying lung disease. This case describes direct contiguous extension from an infected pleural catheter as a cause of RGM infection in the pleural space.
Conflicts of interest The authors have no conflicts of interest to disclose.
References [1] Brown-Elliott BA, Wallace Jr RJ. Infections due to nontuberculous mycobacteria other than Mycobacterium avium intracellulare. In: Mandell G, Bennett J, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 8th ed., vol. 254. Philadelphia: Churchill Livingstone; 2015. p. 2844e52. [2] Agheli A, Tehranirad M, Cofsky R. An unusual presentation of Mycobacterium fortuitum: massive isolated empyema in a patient with HIV. MedGenMed 2006;8:90. [3] Fabbian F, De Giorgi A, Pala M, Fratti D, Contini C. Pleural effusion in an immunocompetent woman caused by Mycobacterium fortuitum. J Med Microbiol 2011;60:1375e8. [4] Okazaki A, Takato H, Fujimura M, Ohkura N, Katayama N, Kasahara K. Successful treatment with chemotherapy and corticosteroids of pulmonary Mycobacterium abscessus infection accompanied by pleural effusion. J Infect Chemother 2013;19:964e8. [5] Park S, Suh GY, Chung MP, Kim H, Kwon OJ, Lee KS, et al. Clinical significance of Mycobacterium fortuitum isolated from respiratory specimens. Respir Med 2008;102:437e42. [6] Wali S. Mycobacterium chelonae empyema with bronchopleural fistula in an immunocompetent patient. Ann Thorac Med 2009;4:213e5. [7] Wallace RJ, Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annu Rev Microbiol 1998;52: 453e90. [8] Griffith DE, Girard WM, Wallace Jr RJ. Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients. Am Rev Respir Dis 1993;147:1271e8. [9] Hadjiliadis D, Adlakha A, Prakash UB. Rapidly growing mycobacterial lung infection in association with esophageal disorders. Mayo Clin Proc 1999;74: 45e51. [10] Matsumoto T, Otsuka K, Tomii K. Mycobacterium fortuitum thoracic empyema: a case report and review of the literature. J Infect Chemother 2015;21: 747e50. [11] Wallace RJ, Bedsole G, Sumter G, Sanders CV, Steele LC, Brown BA, et al. Activities of ciprofloxacin and ofloxacin against rapidly growing mycobacteria with demonstration of acquired resistance following single-drug therapy. Antimicrob Agents Chemother 1990;34:65e70. [12] Atkins BL, Gottlieb T. Skin and soft tissue infections caused by nontuberculous mycobacteria. Curr Opin Infect Dis 2014;27:137e45. [13] Brown-Elliott BA, Nash KA, Wallace RJ. Antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria. Clin Microbiol Rev 2012;25:545e82. [14] Cowman S, Burns K, Benson S, Wilson R, Loebinger MR. The antimicrobial susceptibility of non-tuberculous mycobacteria. J Infect 2016;72:324e31. [15] Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175: 367e416. [16] Kasperbauer SH, De Groote MA. The treatment of rapidly growing mycobacterial infections. Clin Chest Med 2015;36:67e78. [17] Brown-Elliott BA, Wallace Jr RJ. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria. Clin Microbiol Rev 2002;15:716e46.
Please cite this article in press as: Blair P, et al., Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature, J Infect Chemother (2016), http://dx.doi.org/10.1016/j.jiac.2016.08.016