Scientific Letter
Pulmonary Disease Caused by Mycobacterium szulgai
Enfermedad pulmonar producida por Mycobacterium szulgai
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"correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad pulmonar producida por <span class="elsevierStyleItalic">Mycobacterium szulgai</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 686 "Ancho" => 950 "Tamanyo" => 67572 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography: fibrocavitary tracts in both upper fields, with signs of air trapping, panlobular emphysema, nodular opacities in both lungs, and bilateral pleural thickening.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mycobacterium szulgai</span> is slow-growing, rarely isolated environmental non-tuberculous mycobacterium (NTM).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> It accounted for less than 0.2% of isolated strains in a study of over 36<span class="elsevierStyleHsp" style=""></span>000 NTM samples from 14 countries, including Spain.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Like other NTM, it can be present in dust, soil, water, plants, and animals.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> Isolation from the respiratory tree does not always imply disease, so the American Thoracic Society and the Infectious Diseases Society of America have produced a series of diagnostic criteria in an attempt to establish the pathogenic role of this and other NTM when isolated from biological samples.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 49-year-old woman, employed as a cleaner, smoker of 35 pack-years, chronic alcoholic with moderate COPD, who was transferred by ambulance to the emergency department in coma (Glasgow scale 3), shock (BP 50/30<span class="elsevierStyleHsp" style=""></span>mmHg) and respiratory failure (SO<span class="elsevierStyleInf">2</span> 75% with FIO<span class="elsevierStyleInf">2</span> 0.21), where she was intubated and mechanical ventilation was applied, with administration of vasoactive amines and admission to the ICU. Two months previously she had reported general malaise, 10<span class="elsevierStyleHsp" style=""></span>kg weight loss, and in the last week, fever of up to 39<span class="elsevierStyleHsp" style=""></span>°C, cough and mucopurulent expectoration.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Examination showed that she was severely underweight (BMI 14.2), with global loss of breath sounds in both pulmonary fields. Analytical parameters on admission were 16<span class="elsevierStyleHsp" style=""></span>200 leukocytes/mm<span class="elsevierStyleSup">3</span> (81% neutrophils, 9% lymphocytes, and 10% monocytes), ESR 11<span class="elsevierStyleHsp" style=""></span>mm/1<span class="elsevierStyleHsp" style=""></span>h, blood glucose 174<span class="elsevierStyleHsp" style=""></span>mg/dl, AP 133<span class="elsevierStyleHsp" style=""></span>IU/l, gamma GT 231<span class="elsevierStyleHsp" style=""></span>IU/l, LDH 392<span class="elsevierStyleHsp" style=""></span>IU/l, and high-sensitivity C-reactive protein 9<span class="elsevierStyleHsp" style=""></span>mg/dl. Other parameters – complete blood count, hemostasis and biochemistry – were normal, including procalcitonin and immunoglobulins. Urine sample was negative for <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> antigen and positive for <span class="elsevierStyleItalic">Legionella pneumophila</span> serogroup 1 antigen, so the initial empirical treatment with ceftriaxone and azithromycin was switched to levofloxacin.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Chest radiograph revealed fibrocavitary tracts in both upper fields with signs of air trapping, confirmed on CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No particular findings were revealed in the head or the abdomen. Fiberoptic bronchoscopy was performed, showing signs of inflammation of the bronchial mucosa, and bronchial aspirates were obtained for standard and mycobacterial culture. Standard culture techniques showed growth of saprophytic flora, with no <span class="elsevierStyleItalic">Legionella</span> spp. or fungal strains. No alcohol-acid resistant bacilli (AARB) were observed on Ziehl-Neelsen staining. A serology study for HIV and IgM antibodies against <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>, <span class="elsevierStyleItalic">Coxiella burnetii, Chlamydophila pneumoniae</span>, <span class="elsevierStyleItalic">Legionella pneumoniae</span> and anti-<span class="elsevierStyleItalic">Chlamydophila psittaci</span> indirect immunofluorescence were negative. Blood cultures and Mantoux were also negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">One week after admission to the ICU, bronchoscopy was repeated, with similar findings and negative PCR for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> (GeneXpert<span class="elsevierStyleSup">®</span>, Cepheid). After extubation, a Stage IVA epidermoid carcinoma at the base of the tongue was diagnosed. Three weeks later, AARB growth was observed in 2 bronchial aspirates obtained on bronchoscopy. Solid phase hybridization was performed using GenoType<span class="elsevierStyleSup">®</span> Mycobacterium CM/AS (Hain Lifescience, Germany), but the strain could not be identified, so it was sent to the Mycobacteria Genetic Group of the Universidad de Zaragoza, where it was identified as <span class="elsevierStyleItalic">Mycobacterium szulgai</span> (<span class="elsevierStyleItalic">M. szulgai</span>). Treatment began with rifampicin 600<span class="elsevierStyleHsp" style=""></span>mg, ethambutol 600<span class="elsevierStyleHsp" style=""></span>mg, and azithromycin 250<span class="elsevierStyleHsp" style=""></span>mg/day, and continued for 10 months until she died due to tumor progression. Initially, despite treatment for her cancer with chemotherapy and radiation therapy, the patient's clinical and radiation therapy progress was good, and no <span class="elsevierStyleItalic">M. szulgai</span> growth was encountered in follow-up sputums.</p><p id="par0030" class="elsevierStylePara elsevierViewall">According to the ATS/IDSA criteria, isolation of <span class="elsevierStyleItalic">M. szulgai</span> is associated with real lung disease to a greater extent than other NTM.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,6</span></a> Although it has been described in immunosuppressive states and with the administration of drugs, cancer, and HIV infection, this association is considerably rarer than with other NTM.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7–13</span></a> It is highly unusual for a diagnosis of <span class="elsevierStyleItalic">M. szulgai</span> to be the first manifestation of an underlying tumor, but the patient presented other risk factors for developing the disease, such as chronic alcoholism, smoking, and COPD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is more common in men (>85% of patients reported), and can appear at any age, although most individuals are, on average, around 50–60 years old. In over 2 thirds of patients, disease is limited to the respiratory system, and the radiological and clinical picture is indistinguishable from that of <span class="elsevierStyleItalic">M. tuberculosis</span> and other NTM. Extrapulmonary disease and disseminated disease have also been described in immunocompromised patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In line with the ATS/IDSA guidelines, Philley and Griffith recommend a combination of at least 3 oral drugs: ethambutol 15<span class="elsevierStyleHsp" style=""></span>mg/kg/day, rifampicin 600<span class="elsevierStyleHsp" style=""></span>mg/day or rifabutin 150–300<span class="elsevierStyleHsp" style=""></span>mg/day, and azithromycin 250<span class="elsevierStyleHsp" style=""></span>mg/day or clarithromycin 500<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h, or moxifloxacin 400<span class="elsevierStyleHsp" style=""></span>mg/day, for at least 12 months after a negative culture: most patients respond well.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient met ATS/IDSA criteria for pulmonary disease due to <span class="elsevierStyleItalic">M. szulgai</span>, since she had consistent radiological lesions on Rx and CT, <span class="elsevierStyleItalic">M. szulgai</span> was isolated in 2 samples of bronchial aspirate obtained 1 week apart, and the presence of other mycobacteria, other pathogens, and lung cancer were ruled out. Clinical and radiological progress of the infection with rifampicin, ethambutol, and azithromycin treatment was good, even though the patient later died due to progression of the tumor at the base of the tongue.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Milagro Beamonte A, Briz Muñoz E, Torres Sopena L, Borderías Clau L. Enfermedad pulmonar producida por <span class="elsevierStyleItalic">Mycobacterium szulgai</span>. Arch Bronconeumol. 2017;53:353–354.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 686 "Ancho" => 950 "Tamanyo" => 67572 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography: fibrocavitary tracts in both upper fields, with signs of air trapping, panlobular emphysema, nodular opacities in both lungs, and bilateral pleural thickening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Mycobacterium szulgai</span>, a new pathogen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 2 | 10 |
| 2024 October | 71 | 38 | 109 |
| 2024 September | 68 | 20 | 88 |
| 2024 August | 92 | 41 | 133 |
| 2024 July | 92 | 23 | 115 |
| 2024 June | 98 | 30 | 128 |
| 2024 May | 92 | 35 | 127 |
| 2024 April | 43 | 25 | 68 |
| 2024 March | 57 | 16 | 73 |
| 2024 February | 34 | 26 | 60 |
| 2023 March | 9 | 5 | 14 |
| 2023 February | 38 | 27 | 65 |
| 2023 January | 42 | 34 | 76 |
| 2022 December | 64 | 35 | 99 |
| 2022 November | 51 | 22 | 73 |
| 2022 October | 47 | 37 | 84 |
| 2022 September | 39 | 20 | 59 |
| 2022 August | 43 | 51 | 94 |
| 2022 July | 41 | 41 | 82 |
| 2022 June | 45 | 33 | 78 |
| 2022 May | 57 | 28 | 85 |
| 2022 April | 80 | 37 | 117 |
| 2022 March | 84 | 42 | 126 |
| 2022 February | 83 | 26 | 109 |
| 2022 January | 84 | 31 | 115 |
| 2021 December | 39 | 46 | 85 |
| 2021 November | 61 | 45 | 106 |
| 2021 October | 68 | 44 | 112 |
| 2021 September | 48 | 40 | 88 |
| 2021 August | 46 | 40 | 86 |
| 2021 July | 37 | 30 | 67 |
| 2021 June | 46 | 35 | 81 |
| 2021 May | 69 | 42 | 111 |
| 2021 April | 111 | 94 | 205 |
| 2021 March | 97 | 34 | 131 |
| 2021 February | 81 | 34 | 115 |
| 2021 January | 59 | 21 | 80 |
| 2020 December | 70 | 29 | 99 |
| 2020 November | 49 | 24 | 73 |
| 2020 October | 56 | 30 | 86 |
| 2020 September | 65 | 16 | 81 |
| 2020 August | 87 | 19 | 106 |
| 2020 July | 67 | 23 | 90 |
| 2020 June | 41 | 11 | 52 |
| 2020 May | 38 | 15 | 53 |
| 2020 April | 32 | 17 | 49 |
| 2020 March | 53 | 20 | 73 |
| 2020 February | 65 | 31 | 96 |
| 2020 January | 49 | 25 | 74 |
| 2019 December | 79 | 16 | 95 |
| 2019 November | 53 | 26 | 79 |
| 2019 October | 64 | 22 | 86 |
| 2019 September | 40 | 12 | 52 |
| 2019 August | 52 | 24 | 76 |
| 2019 July | 46 | 12 | 58 |
| 2019 June | 40 | 12 | 52 |
| 2019 May | 55 | 8 | 63 |
| 2019 April | 67 | 19 | 86 |
| 2019 March | 40 | 11 | 51 |
| 2019 February | 37 | 14 | 51 |
| 2019 January | 25 | 8 | 33 |
| 2018 December | 27 | 20 | 47 |
| 2018 November | 68 | 25 | 93 |
| 2018 October | 73 | 19 | 92 |
| 2018 September | 28 | 12 | 40 |
| 2018 May | 13 | 0 | 13 |
| 2018 April | 33 | 7 | 40 |
| 2018 March | 28 | 8 | 36 |
| 2018 February | 46 | 8 | 54 |
| 2018 January | 13 | 8 | 21 |
| 2017 December | 35 | 8 | 43 |
| 2017 November | 23 | 7 | 30 |
| 2017 October | 25 | 10 | 35 |
| 2017 September | 29 | 15 | 44 |
| 2017 July | 0 | 1 | 1 |
| 2017 May | 0 | 1 | 1 |
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