HP in addition to asthma and allergic rhinitis should be suspected in bakers with respiratory symptoms.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
References 1. Fishwick D. New occupational and environmental causes of asthma and extrinsic allergic alveolitis. Clin Chest Med. 2012; 33(4):605-616. 2. Brant A. Baker’s asthma. Curr Opin Allergy Clin Immunol. 2007;7(2):152-155. 3. Richerson HB, Bernstein IL, Fink JN, et al; Guidelines for the clinical evaluation of hypersensitivity pneumonitis: report of the Subcommittee on Hypersensitivity Pneumonitis. J Allergy Clin Immunol. 1989;84(5 pt 2):839-844. 4. Travis WD, Colby TV, Koss MN, Rosado-de-Christenson ML, Mueller NL, Kinh TE. Non-neoplastic disorders of the lower respiratory tract. In: King DW, ed. American Registry of Pathology and Armed Forces Institute of Pathology. Washington, DC: 2002. 5. Revsbech P, Andersen G. Storage mite allergy among grain elevator workers. Allergy. 1987;42(6):423-429. 6. Revsbech P, Dueholm M. Storage mite allergy among bakers. Allergy. 1990;45(3):204-208. 7. Berghofer LK, Hocking AD, Miskelly D, Jansson E. Microbiology of wheat and flour milling in Australia. Int J Food Microbiol. 2003;85(1-2):137-149. 8. Bosly HA, Kawanna MA. Fungi species and red flour beetle in stored wheat flour under Jazan region conditions [published online ahead of print August 17, 2012]. Toxicol Ind Health. doi:10.1177/0748233712457449. 9. Kaukonen K, Savolainen J, Viander M, Terho EO. Avidity of Aspergillus umbrosus IgG antibodies in farmer’s lung disease. Clin Exp Immunol. 1994;95(1):162-165. 10. Lunn JA, Hughes DT. Pulmonary hypersensitivity to the grain weevil. Br J Ind Med. 1967;24(2):158-161.
Mycobacterium Brisbanense Species Nova Isolated From a Patient With Chronic Cavitary Lung Infection Mau-Ern Poh, MBBS; Chong-Kin Liam, MBBS, FCCP; Kee-Peng Ng, PhD; and Ruixin Tan, MBBCh, BAO
We describe the first case, to our knowledge, of Mycobacterium brisbanense species nova with the type strain W6743T (5 ATCC 49938T 5 DSM 44680T) isolated from the lungs of a man with a 6-month history of productive cough and intermittent fever presenting with acute hypoglycemia. A CT scan of the thorax revealed multiple small nodules and consoli858
dation over both lungs with cavitation. Sputum culture repeatedly grew M brisbanense species nova, a novel species never before isolated in Malaysia. The case met the American Thoracic Society criteria for the diagnosis of nontuberculous mycobacterial infection. There was dramatic clinical and radiologic response to treatment with an empirical combination of rifampicin, ethambutol, and levofloxacin and subsequently clarithromycin and levofloxacin once sensitivity was known. This report is the first, to our knowledge, of the pathogen isolated in a patient with chronic cavitary lung infection since it was first identified from an antral sinus in Brisbane, Queensland, Australia, and the first time it is isolated from a human subject in Malaysia. CHEST 2014; 145(4):858–860 Abbreviations: LJ 5 Lowenstein-Jensen; MGIT 5 Mycobacteria Growth Indicator Tube
M
ycobacterium brisbanense species nova isolated from patients with lower respiratory tract infections has not been reported to date. We report a case of M brisbanense species nova isolated from a patient with extensive cavitary pneumonia with his written consent. This is the first time, to our knowledge, the organism was isolated from a patient in Malaysia after it was first identified from an antral sinus in Brisbane, Queensland, Australia.1
Case Report A 62-year-old man with type 2 diabetes mellitus and hypertension was found unconscious at home. He regained consciousness after correction of hypoglycemia at the ED. He had a 6-month history of a cough productive of clear sputum, intermittent fever, night sweats, anorexia, and significant weight loss. There was no history of contact with pulmonary TB or travel outside the country. The patient underwent a right-side nephrectomy 12 years previously for renal cell carcinoma. He was not on immunosuppressive therapy and had never smoked. The patient was febrile with a respiratory rate of 30 breaths/min and oxygen saturation of 94% on room air, but chest auscultation findings were unremarkable. There was no blood leukocytosis, and blood cultures were negative. A chest radiograph showed patchy, ill-defined airspace opacities over both lung fields (Fig 1). A CT scan of the thorax revealed multiple areas of consolidation with cavitation in both lungs (Fig 2). The Mantoux tuberculin skin test was nonreactive. Three good-quality sputum samples Manuscript received August 20, 2013; revision accepted November 4, 2013. Affiliations: From the Division of Respiratory Medicine (Drs Poh and Liam), Department of Medicine, and Department of Medical Microbiology (Drs Ng and Tan), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Correspondence to: Mau-Ern Poh, MBBS, Department of Medicine, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1952 Selected Reports
Figure 1. Chest radiograph showing patchy, ill-defined opacities over both lung fields.
were received for laboratory investigations. Following decontamination according to standard protocol,2 the first two of three good-quality sputum samples were inoculated onto both Mycobacteria Growth Indicator Tube (MGIT) (Becton Dickinson and Co) and Lowenstein-Jensen (LJ) medium while the third sample was inoculated directly onto LJ medium only. WBC counts and epithelial cell counts were not routinely performed in our mycobacterial laboratory. All three samples were direct smear negative for acid-fast bacilli. After seven days of incubation, growths were detected on MGIT and LJ medium for only the first and second sputum samples. GenoType Mycobacterium CM (common mycobacteria) and AS (additional species) tests (Hain Lifescience GmbH) using DNA·STRIP technology (Hain Lifescience GmbH), which permitted the identification of 30 mycobacterial species, were used to identify the growths on the MGIT and LJ medium. The isolates, however, were not identifiable by these two tests
Figure 2. CT scan of the thorax showing multiple areas of consolidation with cavitation in both lungs. journal.publications.chestnet.org
and, therefore, were not among the nontuberculous mycobacteria listed in the two panels. Because the mycobacteria was deemed a rapid grower, empirical treatment with a combination of rifampicin, ethambutol, and levofloxacin was given, and the patient’s symptoms improved after 1 week. To identify the isolates, we used polymerase chain reaction-restriction fragment length polymorphism analysis targeting hsp65 gene regions, which has been reported as a good molecular test to identify mycobacterial species.3,4 The 221M13 forward primer Tb11 (59-GTAAAACGACGGCCAGTACCAACGATGGTGTGTCCAT-39) and M13 reverse primer Tb12 (59-CAGGAAACAGCTATGACCCTTGTCGAACCGCATACCCT-39) were used to amplify a 441-base pair portion of the hsp65 gene. All the isolates were subsequently identified as M brisbanense species nova. Each isolate was subcultured onto a common lot of sheep blood agar plates and incubated in ambient air at 30°C for 72 h. Etest strips (ciprofloxacin, clarithromycin, amikacin, imipenem, linezolide) were applied with the minimum concentration of each gradient toward the center, according to the manufacturer’s instructions (bioMérieux, Inc). For quality control, Staphylococcus aureus 29213 and Enterococcus faecalis 29212 were tested at each site each time the Etest was performed.5 Interpretation of the minimum inhibitory concentration for these antibiotics were based on the Clinical and Laboratory Standards Institute guidelines 2011.6 The isolated strain was found to be sensitive to all the antibiotics tested. On finding out the sensitivity, the patient was subsequently treated with a combination of clarithromycin and levofloxacin. On follow-up 2 and 5 months into therapy, he was asymptomatic with negative sputum cultures and reduced lung infiltrates on chest radiograph (Fig 3).
Figure 3. Chest radiograph showing significant reduction in lung infiltrates 5 mo into treatment. CHEST / 145 / 4 / APRIL 2014
859
Discussion To our knowledge, this report is the first of M brisbanense species nova isolated from multiple sputum specimens from a single human subject with extensive pneumonia aside from the original specimen isolated from an antral sinus in Brisbane, Australia.1 Before this case, this organism has not been reported as a pathogen causing pneumonia. M brisbanense species nova was first recognized as a human pathogen in 2004 when it was isolated as a single strain from an antral sinus in Brisbane, Australia, and distinguished from other members of the Mycobacterium fortuitum sorbitol-negative third biovariant complex using molecular techniques.1 The radiographic findings of multiple small pulmonary nodules with cavitation can often be seen in lung infections by nontuberculous mycobacteria, such as Mycobacterium avium complex and Mycobacterium abscessus.7 The present patient met the American Thoracic Society definition of nontuberculous mycobacterial lung disease.7 The absence of an alternative pathogen supports the clinical relevance of this novel species in this patient. The antimicrobial susceptibility of the isolate in this patient is consistent with previous reports of M brisbanense species nova being susceptible to amikacin, amoxycillin/clavulanate, ciprofloxacin, imipenem, and trimethoprim/sulfamethoxazole.1
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
860
References 1. Schinsky MF, Morey RE, Steigerwalt AG, et al. Taxonomic variation in the Mycobacterium fortuitum third biovariant complex: description of Mycobacterium boenickei sp. nov., Mycobacterium houstonense sp. nov., Mycobacterium neworleansense sp. nov. and Mycobacterium brisbanense sp. nov. and recognition of Mycobacterium porcinum from human clinical isolates. Int J Syst Evol Microbiol. 2004;54(pt 5): 1653-1667. 2. Kent PT, Kubica GP. Public Health Mycobacteriology: A Guide for the Level III Laboratory. Washington, DC: US Department. of Health and Human Services, Public Health Service, Centers for Disease Control; 1985. 3. Ong CS, Ngeow YF, Yap SF, Tay ST. Evaluation of PCR-RFLP analysis targeting hsp65 and rpoB genes for the typing of mycobacterial isolates in Malaysia. J Med Microbiol. 2010; 59(pt 11):1311-1316. 4. Ringuet H, Akoua-Koffi C, Honore S, et al. hsp65 sequencing for identification of rapidly growing mycobacteria. J Clin Microbiol. 1999;37(3):852-857. 5. Woods GL, Bergmann JS, Witebsky FG, et al. Multisite reproducibility of Etest for susceptibility testing of Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium fortuitum. J Clin Microbiol. 2000;38(2):656-661. 6. Clinical and Laboratory Standards Institute. Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes; Approved Standard—Second Edition. CLSI document M24-A2. Wayne, PA: Clinical and Laboratory Standards Institute; 2011. 7. Griffith DE, Aksamit T, Brown-Elliott BA, et al; ATS Mycobacterial Diseases Subcommittee; American Thoracic Society; Infectious Disease Society of America. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases [published correction appears in Am J Respir Crit Care Med. 2007;175(7):744-745]. Am J Respir Crit Care Med. 2007;175(4):367-416.
Selected Reports
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
References 1. Fishwick D. New occupational and environmental causes of asthma and extrinsic allergic alveolitis. Clin Chest Med. 2012; 33(4):605-616. 2. Brant A. Baker’s asthma. Curr Opin Allergy Clin Immunol. 2007;7(2):152-155. 3. Richerson HB, Bernstein IL, Fink JN, et al; Guidelines for the clinical evaluation of hypersensitivity pneumonitis: report of the Subcommittee on Hypersensitivity Pneumonitis. J Allergy Clin Immunol. 1989;84(5 pt 2):839-844. 4. Travis WD, Colby TV, Koss MN, Rosado-de-Christenson ML, Mueller NL, Kinh TE. Non-neoplastic disorders of the lower respiratory tract. In: King DW, ed. American Registry of Pathology and Armed Forces Institute of Pathology. Washington, DC: 2002. 5. Revsbech P, Andersen G. Storage mite allergy among grain elevator workers. Allergy. 1987;42(6):423-429. 6. Revsbech P, Dueholm M. Storage mite allergy among bakers. Allergy. 1990;45(3):204-208. 7. Berghofer LK, Hocking AD, Miskelly D, Jansson E. Microbiology of wheat and flour milling in Australia. Int J Food Microbiol. 2003;85(1-2):137-149. 8. Bosly HA, Kawanna MA. Fungi species and red flour beetle in stored wheat flour under Jazan region conditions [published online ahead of print August 17, 2012]. Toxicol Ind Health. doi:10.1177/0748233712457449. 9. Kaukonen K, Savolainen J, Viander M, Terho EO. Avidity of Aspergillus umbrosus IgG antibodies in farmer’s lung disease. Clin Exp Immunol. 1994;95(1):162-165. 10. Lunn JA, Hughes DT. Pulmonary hypersensitivity to the grain weevil. Br J Ind Med. 1967;24(2):158-161.
Mycobacterium Brisbanense Species Nova Isolated From a Patient With Chronic Cavitary Lung Infection Mau-Ern Poh, MBBS; Chong-Kin Liam, MBBS, FCCP; Kee-Peng Ng, PhD; and Ruixin Tan, MBBCh, BAO
We describe the first case, to our knowledge, of Mycobacterium brisbanense species nova with the type strain W6743T (5 ATCC 49938T 5 DSM 44680T) isolated from the lungs of a man with a 6-month history of productive cough and intermittent fever presenting with acute hypoglycemia. A CT scan of the thorax revealed multiple small nodules and consoli858
dation over both lungs with cavitation. Sputum culture repeatedly grew M brisbanense species nova, a novel species never before isolated in Malaysia. The case met the American Thoracic Society criteria for the diagnosis of nontuberculous mycobacterial infection. There was dramatic clinical and radiologic response to treatment with an empirical combination of rifampicin, ethambutol, and levofloxacin and subsequently clarithromycin and levofloxacin once sensitivity was known. This report is the first, to our knowledge, of the pathogen isolated in a patient with chronic cavitary lung infection since it was first identified from an antral sinus in Brisbane, Queensland, Australia, and the first time it is isolated from a human subject in Malaysia. CHEST 2014; 145(4):858–860 Abbreviations: LJ 5 Lowenstein-Jensen; MGIT 5 Mycobacteria Growth Indicator Tube
M
ycobacterium brisbanense species nova isolated from patients with lower respiratory tract infections has not been reported to date. We report a case of M brisbanense species nova isolated from a patient with extensive cavitary pneumonia with his written consent. This is the first time, to our knowledge, the organism was isolated from a patient in Malaysia after it was first identified from an antral sinus in Brisbane, Queensland, Australia.1
Case Report A 62-year-old man with type 2 diabetes mellitus and hypertension was found unconscious at home. He regained consciousness after correction of hypoglycemia at the ED. He had a 6-month history of a cough productive of clear sputum, intermittent fever, night sweats, anorexia, and significant weight loss. There was no history of contact with pulmonary TB or travel outside the country. The patient underwent a right-side nephrectomy 12 years previously for renal cell carcinoma. He was not on immunosuppressive therapy and had never smoked. The patient was febrile with a respiratory rate of 30 breaths/min and oxygen saturation of 94% on room air, but chest auscultation findings were unremarkable. There was no blood leukocytosis, and blood cultures were negative. A chest radiograph showed patchy, ill-defined airspace opacities over both lung fields (Fig 1). A CT scan of the thorax revealed multiple areas of consolidation with cavitation in both lungs (Fig 2). The Mantoux tuberculin skin test was nonreactive. Three good-quality sputum samples Manuscript received August 20, 2013; revision accepted November 4, 2013. Affiliations: From the Division of Respiratory Medicine (Drs Poh and Liam), Department of Medicine, and Department of Medical Microbiology (Drs Ng and Tan), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Correspondence to: Mau-Ern Poh, MBBS, Department of Medicine, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1952 Selected Reports
Figure 1. Chest radiograph showing patchy, ill-defined opacities over both lung fields.
were received for laboratory investigations. Following decontamination according to standard protocol,2 the first two of three good-quality sputum samples were inoculated onto both Mycobacteria Growth Indicator Tube (MGIT) (Becton Dickinson and Co) and Lowenstein-Jensen (LJ) medium while the third sample was inoculated directly onto LJ medium only. WBC counts and epithelial cell counts were not routinely performed in our mycobacterial laboratory. All three samples were direct smear negative for acid-fast bacilli. After seven days of incubation, growths were detected on MGIT and LJ medium for only the first and second sputum samples. GenoType Mycobacterium CM (common mycobacteria) and AS (additional species) tests (Hain Lifescience GmbH) using DNA·STRIP technology (Hain Lifescience GmbH), which permitted the identification of 30 mycobacterial species, were used to identify the growths on the MGIT and LJ medium. The isolates, however, were not identifiable by these two tests
Figure 2. CT scan of the thorax showing multiple areas of consolidation with cavitation in both lungs. journal.publications.chestnet.org
and, therefore, were not among the nontuberculous mycobacteria listed in the two panels. Because the mycobacteria was deemed a rapid grower, empirical treatment with a combination of rifampicin, ethambutol, and levofloxacin was given, and the patient’s symptoms improved after 1 week. To identify the isolates, we used polymerase chain reaction-restriction fragment length polymorphism analysis targeting hsp65 gene regions, which has been reported as a good molecular test to identify mycobacterial species.3,4 The 221M13 forward primer Tb11 (59-GTAAAACGACGGCCAGTACCAACGATGGTGTGTCCAT-39) and M13 reverse primer Tb12 (59-CAGGAAACAGCTATGACCCTTGTCGAACCGCATACCCT-39) were used to amplify a 441-base pair portion of the hsp65 gene. All the isolates were subsequently identified as M brisbanense species nova. Each isolate was subcultured onto a common lot of sheep blood agar plates and incubated in ambient air at 30°C for 72 h. Etest strips (ciprofloxacin, clarithromycin, amikacin, imipenem, linezolide) were applied with the minimum concentration of each gradient toward the center, according to the manufacturer’s instructions (bioMérieux, Inc). For quality control, Staphylococcus aureus 29213 and Enterococcus faecalis 29212 were tested at each site each time the Etest was performed.5 Interpretation of the minimum inhibitory concentration for these antibiotics were based on the Clinical and Laboratory Standards Institute guidelines 2011.6 The isolated strain was found to be sensitive to all the antibiotics tested. On finding out the sensitivity, the patient was subsequently treated with a combination of clarithromycin and levofloxacin. On follow-up 2 and 5 months into therapy, he was asymptomatic with negative sputum cultures and reduced lung infiltrates on chest radiograph (Fig 3).
Figure 3. Chest radiograph showing significant reduction in lung infiltrates 5 mo into treatment. CHEST / 145 / 4 / APRIL 2014
859
Discussion To our knowledge, this report is the first of M brisbanense species nova isolated from multiple sputum specimens from a single human subject with extensive pneumonia aside from the original specimen isolated from an antral sinus in Brisbane, Australia.1 Before this case, this organism has not been reported as a pathogen causing pneumonia. M brisbanense species nova was first recognized as a human pathogen in 2004 when it was isolated as a single strain from an antral sinus in Brisbane, Australia, and distinguished from other members of the Mycobacterium fortuitum sorbitol-negative third biovariant complex using molecular techniques.1 The radiographic findings of multiple small pulmonary nodules with cavitation can often be seen in lung infections by nontuberculous mycobacteria, such as Mycobacterium avium complex and Mycobacterium abscessus.7 The present patient met the American Thoracic Society definition of nontuberculous mycobacterial lung disease.7 The absence of an alternative pathogen supports the clinical relevance of this novel species in this patient. The antimicrobial susceptibility of the isolate in this patient is consistent with previous reports of M brisbanense species nova being susceptible to amikacin, amoxycillin/clavulanate, ciprofloxacin, imipenem, and trimethoprim/sulfamethoxazole.1
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
860
References 1. Schinsky MF, Morey RE, Steigerwalt AG, et al. Taxonomic variation in the Mycobacterium fortuitum third biovariant complex: description of Mycobacterium boenickei sp. nov., Mycobacterium houstonense sp. nov., Mycobacterium neworleansense sp. nov. and Mycobacterium brisbanense sp. nov. and recognition of Mycobacterium porcinum from human clinical isolates. Int J Syst Evol Microbiol. 2004;54(pt 5): 1653-1667. 2. Kent PT, Kubica GP. Public Health Mycobacteriology: A Guide for the Level III Laboratory. Washington, DC: US Department. of Health and Human Services, Public Health Service, Centers for Disease Control; 1985. 3. Ong CS, Ngeow YF, Yap SF, Tay ST. Evaluation of PCR-RFLP analysis targeting hsp65 and rpoB genes for the typing of mycobacterial isolates in Malaysia. J Med Microbiol. 2010; 59(pt 11):1311-1316. 4. Ringuet H, Akoua-Koffi C, Honore S, et al. hsp65 sequencing for identification of rapidly growing mycobacteria. J Clin Microbiol. 1999;37(3):852-857. 5. Woods GL, Bergmann JS, Witebsky FG, et al. Multisite reproducibility of Etest for susceptibility testing of Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium fortuitum. J Clin Microbiol. 2000;38(2):656-661. 6. Clinical and Laboratory Standards Institute. Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic Actinomycetes; Approved Standard—Second Edition. CLSI document M24-A2. Wayne, PA: Clinical and Laboratory Standards Institute; 2011. 7. Griffith DE, Aksamit T, Brown-Elliott BA, et al; ATS Mycobacterial Diseases Subcommittee; American Thoracic Society; Infectious Disease Society of America. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases [published correction appears in Am J Respir Crit Care Med. 2007;175(7):744-745]. Am J Respir Crit Care Med. 2007;175(4):367-416.
Selected Reports
