J Infect Chemother 21 (2015) 747e750
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Mycobacterium fortuitum thoracic empyema: A case report and review of the literature Takeshi Matsumoto*, Kojiro Otsuka, Keisuke Tomii Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 March 2015 Received in revised form 5 May 2015 Accepted 30 May 2015 Available online 9 June 2015
Mycobacterium fortuitum is a rapidly growing nontuberculous mycobacterium. This microorganism is an uncommon etiological agent of lung lesions; among lung lesions caused by M. fortuitum, thoracic empyema is particularly rare. A 61-year-old man who had been treated for chronic hypercapnic respiratory failure with noninvasive ventilation was admitted because of breathing difficulty and was found to have M. fortuitum thoracic empyema. He improved after the administration of amikacin, imipenem/cilastatin, and clarithromycin following sulfamethoxazole/trimethoprim and clarithromycin. This is the first report of M. fortuitum thoracic empyema in a patient without human immunodeficiency virus infection. The thoracic empyema may have developed via a pulmonary fistula in this case. This case highlights the fact that we must be aware of the possibility of M. fortuitum thoracic empyema, especially in patients with M. fortuitum lung infection and treatment with noninvasive ventilation. Multidrug therapy may be effective and important to the resolution of M. fortuitum thoracic empyema. © 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Mycobacterium fortuitum Thoracic empyema Noninvasive ventilation Pulmonary fistula
1. Introduction Nontuberculous mycobacterium infection is often encountered in daily clinical practice and may present in a variety of ways. Mycobacterium fortuitum is one of several rapidly growing mycobacteria (RGM) and is frequently seen in soil or water; it is a relatively rare etiological agent in lung lesions except in patients with gastroesophageal disorders involving chronic vomiting [1,2]. Although some uncommon pulmonary lesions associated with M. fortuitum have been reported [3e5], only one case of M. fortuitum thoracic empyema has been reported to date, and the patient had human immunodeficiency virus (HIV) infection [6]. We report the first case of M. fortuitum thoracic empyema in a patient without HIV infection and present a review of the literature. 2. Case report A 61-year-old man with breathing difficulty was admitted to our hospital with a diagnosis of acute exacerbation of chronic * Corresponding author. Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 6500047, Japan. Tel.: þ81 78 302 4321; fax: þ81 78 302 7537. E-mail address: [email protected] (T. Matsumoto).
respiratory failure with hypercapnia. He had undergone right upper lobectomy for pulmonary tuberculosis at the age of 18 years, had been diagnosed with M. fortuitum lung infection at the age of 49 years, and had been treated with isoniazid, rifampicin, ethambutol, and clarithromycin (CAM) for 2 years. He experienced chronic respiratory failure with hypercapnia and underwent home oxygen therapy (2e3 L/min) at the age of 51 years and nocturnal noninvasive ventilation (NIV) at the age of 55 years. The most recent setting was the spontaneous/timed mode (14 breaths/min, inspiratory positive airway pressure of 15 cm H2O, expiratory positive airway pressure of 2 cm H2O, and oxygen of 3 L/min). His most recent body temperature was >37 C while taking an antipyretic drug, and he underwent CAM monotherapy for 9 years. Three days before admission, he developed a worsening wet cough, and the day before admission, he developed dyspnea that did not improve. Therefore, he came to the emergency room of our hospital. Physical examination revealed fine crackles in all lung fields along with the following observations: heart rate, 95 beats/min and regular; blood pressure, 153/82 mmHg; oxygen saturation, 82% with 4 L/min oxygen; and body temperature, 37.4 C. A chest radiograph showed tracheal shift, scoliosis, old inflammatory changes in both lung apices, and infiltration in both lungs, particularly in the left middle and lower lung fields (Fig. 1a). Chest
http://dx.doi.org/10.1016/j.jiac.2015.05.012 1341-321X/© 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
748
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750
Fig. 1. (a) Chest X-ray on admission showed tracheal shift, scoliosis, and old inflammatory changes in both lung apices, and infiltration in both lungs, especially in the left middle and lower lung fields. (b, c) Unenhanced computed tomography scan of the chest on day 10 showed multiple airway lesions with thickened pleura and fluid in the left chest cavity.
computed tomography (CT) was not performed because the patient immediately commenced all-day NIV therapy and was thus difficult to transfer. Laboratory studies showed a white blood cell count of 11,500/mm3 with 94% neutrophils and a C-reactive protein level of 7.6 mg/dL. Arterial blood gas on 4 L/min oxygenation via a nasal cannula revealed the following: pH, 7.224; PaO2, 143 Torr; PaCO2, 111 Torr; HCO3 , 44.2 mEq/L; and base excess, 12.7 mEq/L. Cultures for bacteria, including both blood and sputum, were negative. A sputum microscopic test for acid-fast bacteria was positive, but polymerase chain reaction for tuberculosis, M. avium, and M. intracellulare was negative; therefore, it was believed to be infected by M. fortuitum. Although the causative microorganism was not identified, we continued the administration of antibiotics (piperacillin 2 g every 8 h) and NIV (14 breaths/min; inspiratory positive airway pressure, 18 cmH2O; expiratory positive airway pressure, 2 cmH2O) (NIP nasal III; ResMed, San Diego, CA, USA) based on the diagnosis of bacterial pneumonia and acute exacerbation of chronic respiratory failure with hypercapnia. Although the patient's general condition improved, his inflammatory parameters on blood examination gradually worsened. He was able to be withdrawn from all-day NIV treatment, and chest CT showed multiple airway lesions with thickened pleura and airefluid levels in the left chest cavity (Fig. 1b,c). Therefore, thoracentesis was performed to check for loculated pleural effusion. The pleural effusion was grayish white (Fig. 2), and a microscopic test for acid-fast bacteria was positive; M. fortuitum was subsequently identified by using DNAeDNA hybridization (DDH Mycobacteria; Kyokuto Pharmaceutical, Tokyo, Japan). The sputum culture for acid-fast bacteria also identified M. fortuitum. The antimicrobial susceptibility test results for the isolated M. fortuitum are shown in Table 1 [7]. No other responsible organism was found; therefore, the patient was diagnosed with M. fortuitum thoracic empyema. Continuous drainage of the pleural effusion was performed, but a continuous air leak was also observed and was thought to be due to the presence of a pulmonary fistula. The antibiotics were changed to amikacin, imipenem/cilastatin, and CAM for 3 weeks following oral administration of sulfamethoxazole/trimethoprim and CAM. After commencing these antibiotics, the patient was afebrile and the airefluid levels on the chest CT improved (Fig. 3). Finally, he was discharged on day 37 and continued antibiotic treatment on an outpatient basis. The M. fortuitum thoracic empyema did not worsen, but the patient died of acute respiratory failure 3 years later.
Fig. 2. Grayish white loculated pleural effusion was finally shown to be culture positive for Mycobacterium fortuitum.
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750 Table 1 Antimicrobial susceptibility testing for isolated Mycobacterium fortuitum. Antibiotics
Imipenem Amikacin Ciprofloxacin Trimethoprim/ sulfamethoxazole Minocycline Clarithromycin
MIC (mg/mL)
MIC (mg/mL) for category Susceptible
Intermediate
Resistant
2 16 4 2/38
4 16 1 2/38
8e16 32 2 e
32 64 4 4/76
2 2
1 2
2e4 4
8 8
MIC, minimum inhibitory concentration. The data of breakpoints are derived from Ref. [7].
3. Discussion To the best of our knowledge, this is the first reported case of M. fortuitum thoracic empyema in a man without HIV infection. Mycobacterium fortuitum is an RGM that can infect the skin, soft tissue, or bone. Pulmonary infection is uncommon, but may occur in patients with a background of pulmonary disease or immunological disorders; most pulmonary infections are opportunistic [8e10]. Many cases are developed after the cure of pulmonary tuberculosis [2]. A few cases of uncommon pulmonary infection by M. fortuitum have been reported to date, including lung abscesses [3,5] and pleuritis [4]; however, M. fortuitum thoracic empyema was reported
749
in only one case involving a patient with HIV infection [6] (Table 2). In this case, although the patient had chronic respiratory failure, he was immunocompetent. Two theories regarding the pathogenesis of thoracic empyema in patients with pulmonary lesions have been proposed: direct infiltration to the pleura or spread via a pathway such as a pulmonary fistula. Approximately 1.5% of patients with pulmonary tuberculosis develop pneumothorax [11], but pneumothorax in patients with nontuberculous mycobacterium is rare; additionally, reports of pneumothorax caused by M. fortuitum are scarce [12]. The pneumothorax in the present case appeared to be related to a pulmonary fistula of unknown cause, and NIV was performed in the destroyed lung to treat the chronic hypercapnic respiratory failure. The incidence of pneumothorax during NIV was reported less than 5% [13], and the data regarding thoracic empyema during NIV is insufficient and is only provided as a case report [14]. However, we could not exclude the possibility that NIV might have contributed to the development of the pulmonary fistula, and we must be aware of the possibility of the development of pulmonary fistulas in association with nocturnal NIV. Thoracic empyema with a pulmonary fistula may be difficult to treat, and bronchoscopic or surgical treatment is generally chosen [15]. However, among RGM, M. fortuitum is recognized as relatively easy to treat [16], and the thoracic empyema in the present case was successfully controlled without surgery. All previously reported patients with uncommon M. fortuitum infections also fully recovered after treatment. Although there is no consensus
Fig. 3. Comparison of unenhanced chest computed tomography scans (a) before and (b) after treatment of Mycobacterium fortuitum, showing decreased loculated pleural effusion.
Table 2 Previous reports of uncommon pulmonary Mycobacterium fortuitum infection. Authors
Age (y), sex
Presentation
Antibiotics
Treatment other than antibiotics
Comorbidity
Outcome
Vadakekalam and Ward [3] Fabbian et al. [4] Glatstein et al. [5] Agheli et al. [6] Present case
53, male
Lung abscess
Ciprofloxacin
None
Emphysema
Full recovery
74, female 0, female 56, male 61, male
Pleuritis Lung abscess Thoracic empyema Thoracic empyema
Ceftriaxone and ciprofloxacin Clarithromycin Azithromycin and doxycycline Amikacin, imipenem/cilastatin, and clarithromycin
None Thoracotomy Drainage Drainage
None None Human immunodeficiency virus Chronic respiratory failure and old tuberculosis
Full Full Full Full
recovery recovery recovery recovery
750
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750
regarding the most appropriate treatment, it is recommended to use at least two antibiotics with in vitro susceptibility until negative sputum cultures have been obtained for at least 12 months [1]. In patients with mycobacterial infection, the susceptibility test results tend to be poorly correlated with the clinical treatment effect; for M. fortuitum, however, a good treatment outcome can generally be achieved based on the susceptibility test results [17,18]. The present patient had been treated with CAM for a long period of time, but susceptibility to CAM was maintained. We referred to the susceptibility test results and administered multidrug therapy including CAM, which led to successful control of the infection. In conclusion, we must be aware of the possibility of thoracic empyema formation, especially in patients with M. fortuitum lung infection and treatment with NIV. Multidrug therapy may be effective and important for control of the thoracic empyema. Conflict of interest The authors have no conflict of interest. References [1] 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. [2] 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. [3] Vadakekalam J, Ward MJ. Mycobacterium fortuitum lung abscess treated with ciprofloxacin. Thorax 1991;46:737e8. [4] 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.
[5] Glatstein M, Scolnik D, Bensira L, Domany KA, Shah M, Vala S. Lung abscess due to non-tuberculous, non-mycobacterium fortuitum in a neonate. Pediatr Pulmonol 2012;47:1034e7. [6] Agheli A, Tehranirad M, Cofsky R. An unusual presentation of mycobacterium fortuitum: massive isolated empyema in a patient with HIV. MedGenMed 2006;8:90. [7] Clinical and Laboratory Standards Institute. Susceptibility testing of mycobacteria, nocardiae, and other aerobic actinomycetes; approved standardsecond edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2011. M24eA2. [8] Hand WL, Sanford JP. Mycobacterium fortuitumea human pathogen. Ann Intern Med 1970;73:971e7. [9] Jeong YJ, Lee KS, Koh WJ, Han J, Kim TS, Kwon OJ. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section ct and histopathologic findings. Radiology 2004;231:880e6. [10] Smith MB, Schnadig VJ, Boyars MC, Woods GL. Clinical and pathologic features of mycobacterium fortuitum infections. An emerging pathogen in patients with aids. Am J Clin Pathol 2001;116:225e32. [11] Aktogu S, Yorgancioglu A, Cirak K, Kose T, Dereli SM. Clinical spectrum of pulmonary and pleural tuberculosis: a report of 5,480 cases. Eur Respir J 1996;9:2031e5. [12] Hagiwara E, Sekine A, Sato T, Baba T, Shinohara T, Endo T, et al. [Case of pneumothorax associated with pulmonary mycobacterium fortuitum infection]. Kansenshogaku Zasshi 2008;82:73e6. [13] Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001;163:540e77. [14] Caiano Gil J, Calisto R, Amado J, Barreto V. Eikenella corrodens and porphyromonas asaccharolytica pleural empyema in a diabetic patient with obstructive sleep apnea syndrome on noninvasive ventilation. Rev Port Pneumol 2013;19:76e9. [15] Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005;128:3955e65. [16] Han XY, De I, Jacobson KL. Rapidly growing mycobacteria: clinical and microbiologic studies of 115 cases. Am J Clin Pathol 2007;128:612e21. [17] Wallace Jr RJ, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to mycobacterium fortuitum and mycobacterium chelonei on the basis of in vitro susceptibilities. J Infect Dis 1985;152:500e14. [18] Sungkanuparph S, Sathapatayavongs B, Pracharktam R. Infections with rapidly growing mycobacteria: report of 20 cases. Int J Infect Dis 2003;7: 198e205.
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Mycobacterium fortuitum thoracic empyema: A case report and review of the literature Takeshi Matsumoto*, Kojiro Otsuka, Keisuke Tomii Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 March 2015 Received in revised form 5 May 2015 Accepted 30 May 2015 Available online 9 June 2015
Mycobacterium fortuitum is a rapidly growing nontuberculous mycobacterium. This microorganism is an uncommon etiological agent of lung lesions; among lung lesions caused by M. fortuitum, thoracic empyema is particularly rare. A 61-year-old man who had been treated for chronic hypercapnic respiratory failure with noninvasive ventilation was admitted because of breathing difficulty and was found to have M. fortuitum thoracic empyema. He improved after the administration of amikacin, imipenem/cilastatin, and clarithromycin following sulfamethoxazole/trimethoprim and clarithromycin. This is the first report of M. fortuitum thoracic empyema in a patient without human immunodeficiency virus infection. The thoracic empyema may have developed via a pulmonary fistula in this case. This case highlights the fact that we must be aware of the possibility of M. fortuitum thoracic empyema, especially in patients with M. fortuitum lung infection and treatment with noninvasive ventilation. Multidrug therapy may be effective and important to the resolution of M. fortuitum thoracic empyema. © 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Mycobacterium fortuitum Thoracic empyema Noninvasive ventilation Pulmonary fistula
1. Introduction Nontuberculous mycobacterium infection is often encountered in daily clinical practice and may present in a variety of ways. Mycobacterium fortuitum is one of several rapidly growing mycobacteria (RGM) and is frequently seen in soil or water; it is a relatively rare etiological agent in lung lesions except in patients with gastroesophageal disorders involving chronic vomiting [1,2]. Although some uncommon pulmonary lesions associated with M. fortuitum have been reported [3e5], only one case of M. fortuitum thoracic empyema has been reported to date, and the patient had human immunodeficiency virus (HIV) infection [6]. We report the first case of M. fortuitum thoracic empyema in a patient without HIV infection and present a review of the literature. 2. Case report A 61-year-old man with breathing difficulty was admitted to our hospital with a diagnosis of acute exacerbation of chronic * Corresponding author. Department of Respiratory Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 6500047, Japan. Tel.: þ81 78 302 4321; fax: þ81 78 302 7537. E-mail address: [email protected] (T. Matsumoto).
respiratory failure with hypercapnia. He had undergone right upper lobectomy for pulmonary tuberculosis at the age of 18 years, had been diagnosed with M. fortuitum lung infection at the age of 49 years, and had been treated with isoniazid, rifampicin, ethambutol, and clarithromycin (CAM) for 2 years. He experienced chronic respiratory failure with hypercapnia and underwent home oxygen therapy (2e3 L/min) at the age of 51 years and nocturnal noninvasive ventilation (NIV) at the age of 55 years. The most recent setting was the spontaneous/timed mode (14 breaths/min, inspiratory positive airway pressure of 15 cm H2O, expiratory positive airway pressure of 2 cm H2O, and oxygen of 3 L/min). His most recent body temperature was >37 C while taking an antipyretic drug, and he underwent CAM monotherapy for 9 years. Three days before admission, he developed a worsening wet cough, and the day before admission, he developed dyspnea that did not improve. Therefore, he came to the emergency room of our hospital. Physical examination revealed fine crackles in all lung fields along with the following observations: heart rate, 95 beats/min and regular; blood pressure, 153/82 mmHg; oxygen saturation, 82% with 4 L/min oxygen; and body temperature, 37.4 C. A chest radiograph showed tracheal shift, scoliosis, old inflammatory changes in both lung apices, and infiltration in both lungs, particularly in the left middle and lower lung fields (Fig. 1a). Chest
http://dx.doi.org/10.1016/j.jiac.2015.05.012 1341-321X/© 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
748
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750
Fig. 1. (a) Chest X-ray on admission showed tracheal shift, scoliosis, and old inflammatory changes in both lung apices, and infiltration in both lungs, especially in the left middle and lower lung fields. (b, c) Unenhanced computed tomography scan of the chest on day 10 showed multiple airway lesions with thickened pleura and fluid in the left chest cavity.
computed tomography (CT) was not performed because the patient immediately commenced all-day NIV therapy and was thus difficult to transfer. Laboratory studies showed a white blood cell count of 11,500/mm3 with 94% neutrophils and a C-reactive protein level of 7.6 mg/dL. Arterial blood gas on 4 L/min oxygenation via a nasal cannula revealed the following: pH, 7.224; PaO2, 143 Torr; PaCO2, 111 Torr; HCO3 , 44.2 mEq/L; and base excess, 12.7 mEq/L. Cultures for bacteria, including both blood and sputum, were negative. A sputum microscopic test for acid-fast bacteria was positive, but polymerase chain reaction for tuberculosis, M. avium, and M. intracellulare was negative; therefore, it was believed to be infected by M. fortuitum. Although the causative microorganism was not identified, we continued the administration of antibiotics (piperacillin 2 g every 8 h) and NIV (14 breaths/min; inspiratory positive airway pressure, 18 cmH2O; expiratory positive airway pressure, 2 cmH2O) (NIP nasal III; ResMed, San Diego, CA, USA) based on the diagnosis of bacterial pneumonia and acute exacerbation of chronic respiratory failure with hypercapnia. Although the patient's general condition improved, his inflammatory parameters on blood examination gradually worsened. He was able to be withdrawn from all-day NIV treatment, and chest CT showed multiple airway lesions with thickened pleura and airefluid levels in the left chest cavity (Fig. 1b,c). Therefore, thoracentesis was performed to check for loculated pleural effusion. The pleural effusion was grayish white (Fig. 2), and a microscopic test for acid-fast bacteria was positive; M. fortuitum was subsequently identified by using DNAeDNA hybridization (DDH Mycobacteria; Kyokuto Pharmaceutical, Tokyo, Japan). The sputum culture for acid-fast bacteria also identified M. fortuitum. The antimicrobial susceptibility test results for the isolated M. fortuitum are shown in Table 1 [7]. No other responsible organism was found; therefore, the patient was diagnosed with M. fortuitum thoracic empyema. Continuous drainage of the pleural effusion was performed, but a continuous air leak was also observed and was thought to be due to the presence of a pulmonary fistula. The antibiotics were changed to amikacin, imipenem/cilastatin, and CAM for 3 weeks following oral administration of sulfamethoxazole/trimethoprim and CAM. After commencing these antibiotics, the patient was afebrile and the airefluid levels on the chest CT improved (Fig. 3). Finally, he was discharged on day 37 and continued antibiotic treatment on an outpatient basis. The M. fortuitum thoracic empyema did not worsen, but the patient died of acute respiratory failure 3 years later.
Fig. 2. Grayish white loculated pleural effusion was finally shown to be culture positive for Mycobacterium fortuitum.
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750 Table 1 Antimicrobial susceptibility testing for isolated Mycobacterium fortuitum. Antibiotics
Imipenem Amikacin Ciprofloxacin Trimethoprim/ sulfamethoxazole Minocycline Clarithromycin
MIC (mg/mL)
MIC (mg/mL) for category Susceptible
Intermediate
Resistant
2 16 4 2/38
4 16 1 2/38
8e16 32 2 e
32 64 4 4/76
2 2
1 2
2e4 4
8 8
MIC, minimum inhibitory concentration. The data of breakpoints are derived from Ref. [7].
3. Discussion To the best of our knowledge, this is the first reported case of M. fortuitum thoracic empyema in a man without HIV infection. Mycobacterium fortuitum is an RGM that can infect the skin, soft tissue, or bone. Pulmonary infection is uncommon, but may occur in patients with a background of pulmonary disease or immunological disorders; most pulmonary infections are opportunistic [8e10]. Many cases are developed after the cure of pulmonary tuberculosis [2]. A few cases of uncommon pulmonary infection by M. fortuitum have been reported to date, including lung abscesses [3,5] and pleuritis [4]; however, M. fortuitum thoracic empyema was reported
749
in only one case involving a patient with HIV infection [6] (Table 2). In this case, although the patient had chronic respiratory failure, he was immunocompetent. Two theories regarding the pathogenesis of thoracic empyema in patients with pulmonary lesions have been proposed: direct infiltration to the pleura or spread via a pathway such as a pulmonary fistula. Approximately 1.5% of patients with pulmonary tuberculosis develop pneumothorax [11], but pneumothorax in patients with nontuberculous mycobacterium is rare; additionally, reports of pneumothorax caused by M. fortuitum are scarce [12]. The pneumothorax in the present case appeared to be related to a pulmonary fistula of unknown cause, and NIV was performed in the destroyed lung to treat the chronic hypercapnic respiratory failure. The incidence of pneumothorax during NIV was reported less than 5% [13], and the data regarding thoracic empyema during NIV is insufficient and is only provided as a case report [14]. However, we could not exclude the possibility that NIV might have contributed to the development of the pulmonary fistula, and we must be aware of the possibility of the development of pulmonary fistulas in association with nocturnal NIV. Thoracic empyema with a pulmonary fistula may be difficult to treat, and bronchoscopic or surgical treatment is generally chosen [15]. However, among RGM, M. fortuitum is recognized as relatively easy to treat [16], and the thoracic empyema in the present case was successfully controlled without surgery. All previously reported patients with uncommon M. fortuitum infections also fully recovered after treatment. Although there is no consensus
Fig. 3. Comparison of unenhanced chest computed tomography scans (a) before and (b) after treatment of Mycobacterium fortuitum, showing decreased loculated pleural effusion.
Table 2 Previous reports of uncommon pulmonary Mycobacterium fortuitum infection. Authors
Age (y), sex
Presentation
Antibiotics
Treatment other than antibiotics
Comorbidity
Outcome
Vadakekalam and Ward [3] Fabbian et al. [4] Glatstein et al. [5] Agheli et al. [6] Present case
53, male
Lung abscess
Ciprofloxacin
None
Emphysema
Full recovery
74, female 0, female 56, male 61, male
Pleuritis Lung abscess Thoracic empyema Thoracic empyema
Ceftriaxone and ciprofloxacin Clarithromycin Azithromycin and doxycycline Amikacin, imipenem/cilastatin, and clarithromycin
None Thoracotomy Drainage Drainage
None None Human immunodeficiency virus Chronic respiratory failure and old tuberculosis
Full Full Full Full
recovery recovery recovery recovery
750
T. Matsumoto et al. / J Infect Chemother 21 (2015) 747e750
regarding the most appropriate treatment, it is recommended to use at least two antibiotics with in vitro susceptibility until negative sputum cultures have been obtained for at least 12 months [1]. In patients with mycobacterial infection, the susceptibility test results tend to be poorly correlated with the clinical treatment effect; for M. fortuitum, however, a good treatment outcome can generally be achieved based on the susceptibility test results [17,18]. The present patient had been treated with CAM for a long period of time, but susceptibility to CAM was maintained. We referred to the susceptibility test results and administered multidrug therapy including CAM, which led to successful control of the infection. In conclusion, we must be aware of the possibility of thoracic empyema formation, especially in patients with M. fortuitum lung infection and treatment with NIV. Multidrug therapy may be effective and important for control of the thoracic empyema. Conflict of interest The authors have no conflict of interest. References [1] 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. [2] 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. [3] Vadakekalam J, Ward MJ. Mycobacterium fortuitum lung abscess treated with ciprofloxacin. Thorax 1991;46:737e8. [4] 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.
[5] Glatstein M, Scolnik D, Bensira L, Domany KA, Shah M, Vala S. Lung abscess due to non-tuberculous, non-mycobacterium fortuitum in a neonate. Pediatr Pulmonol 2012;47:1034e7. [6] Agheli A, Tehranirad M, Cofsky R. An unusual presentation of mycobacterium fortuitum: massive isolated empyema in a patient with HIV. MedGenMed 2006;8:90. [7] Clinical and Laboratory Standards Institute. Susceptibility testing of mycobacteria, nocardiae, and other aerobic actinomycetes; approved standardsecond edition. Wayne, PA: Clinical and Laboratory Standards Institute; 2011. M24eA2. [8] Hand WL, Sanford JP. Mycobacterium fortuitumea human pathogen. Ann Intern Med 1970;73:971e7. [9] Jeong YJ, Lee KS, Koh WJ, Han J, Kim TS, Kwon OJ. Nontuberculous mycobacterial pulmonary infection in immunocompetent patients: comparison of thin-section ct and histopathologic findings. Radiology 2004;231:880e6. [10] Smith MB, Schnadig VJ, Boyars MC, Woods GL. Clinical and pathologic features of mycobacterium fortuitum infections. An emerging pathogen in patients with aids. Am J Clin Pathol 2001;116:225e32. [11] Aktogu S, Yorgancioglu A, Cirak K, Kose T, Dereli SM. Clinical spectrum of pulmonary and pleural tuberculosis: a report of 5,480 cases. Eur Respir J 1996;9:2031e5. [12] Hagiwara E, Sekine A, Sato T, Baba T, Shinohara T, Endo T, et al. [Case of pneumothorax associated with pulmonary mycobacterium fortuitum infection]. Kansenshogaku Zasshi 2008;82:73e6. [13] Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001;163:540e77. [14] Caiano Gil J, Calisto R, Amado J, Barreto V. Eikenella corrodens and porphyromonas asaccharolytica pleural empyema in a diabetic patient with obstructive sleep apnea syndrome on noninvasive ventilation. Rev Port Pneumol 2013;19:76e9. [15] Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005;128:3955e65. [16] Han XY, De I, Jacobson KL. Rapidly growing mycobacteria: clinical and microbiologic studies of 115 cases. Am J Clin Pathol 2007;128:612e21. [17] Wallace Jr RJ, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to mycobacterium fortuitum and mycobacterium chelonei on the basis of in vitro susceptibilities. J Infect Dis 1985;152:500e14. [18] Sungkanuparph S, Sathapatayavongs B, Pracharktam R. Infections with rapidly growing mycobacteria: report of 20 cases. Int J Infect Dis 2003;7: 198e205.
