Mycobacterium abscessus pneumonia in severe alcoholism

In the USA, Mycobacterial tuberculosis the infection is not common and the infection rate has decreased significantly (incidence of 2.4 cases per 100,000 people in 2021 compared to 12.2 in 1980 according to the CDC website). The incidence of nontuberculous mycobacterial infections (NTMs) is increasing rapidly. A relatively recent study suggested an increase in incidence from 2.5 cases per 100,000 people in the 1980s to 15.2 cases per 100,000 people by 2013 in the United States. [1]. Nontuberculous mycobacterial lung disease is typically described in patients with underlying parenchymal lung disease such as cystic fibrosis, bronchiectasis, or a history of tuberculosis, as well as in immunocompromised patients, such as those with Advanced HIV or other forms of long-term immunosuppression. [2]. This report describes the unique case of a 52-year-old man who was diagnosed with Mycobacterium abscessus lung disease with chronic alcohol dependence disorder as the only significant risk factor in his medical history. The medical literature has suggested that alcoholism is a risk factor for NTM lung infections and with this case report we highlight the importance of understanding this association. [3].

A 52-year-old man with a medical history of alcohol dependence disorder and anxiety presented to the emergency department with nonspecific pain in his left upper back for three to four months. The pain was in the left side of the upper back and above the shoulder blade, gradually getting worse and radiating to the left armpit and upper left chest. He described the pain as acute, intermittent and without aggravating factors. The patient also approved of involuntary weight loss, approximately 11 pounds over the past two to three months. Besides weight loss, he had no B-cell symptoms such as fever, night sweats, changes in appetite or fatigue.

The patient had no history of incarceration or homelessness. The only travel story for him was a cruise to the Caribbean islands for a short time. He had mostly lived in Florida and Tennessee when he was young and was now domiciled in New York. He has a history of alcohol dependence disorder (eight to 10 cans of beer a day) but no history of recreational drug use or smoking. He denies any history of recurrent infections, any sick contact or contact with patients infected with tuberculosis. He had no history of vaccination against bacille Calmette-Guérin (BCG) nor any history of opportunistic infections in the past. When he arrived in the ER he was tachycardic and tachypneic but otherwise hemodynamically stable (temp 98.1 Fahrenheit, blood pressure 110/55 mmHg, heart rate 140, respiratory rate 32 with SpO2 74% on room air). The examination was relevant for a decrease in breath sound on the left lung fields and tachycardia. He was then placed on oxygen supplementation by high-flow nasal cannula with an improvement in his SpO2 to 94%.

He underwent an emergency chest computed tomography with intravenous contrast which revealed a 6.8 x 5.1 x 6.7 cm irregular cavitary lesion in the left hilum and left upper lobe with a 1.5 cm nodular component along the along the posterior side; severe narrowing of the left main pulmonary artery with attenuation of the branch of the left upper lobe segment; additional smaller thick-walled cavities noted in the lingula measuring up to 2.7 x 1.6 x 1.3 cm; and multiple centrilobular and arborescent nodules in the right middle lobe, lingula, and left lower lobe (Figure 13). He was admitted for a complementary infectious assessment.

In the assessment carried out, he had a purified protein derivative (PPD) done which was negative, QuantiFERON was indeterminate and the HIV screening was negative. He eventually underwent bronchoscopy and bronchial alveolar lavage was sent for cultures which tested positive for Mycobacterium abscessus (Table 1). The patient was eventually initiated on an intravenous antibiotic regimen with amikacin, tigecycline, and cefoxitin via a peripherally inserted central catheter (PICC) line based on the results of susceptibility testing, which is planned to be continue for at least six to 12 months. He will be followed closely in the outpatient department to determine clinical improvement and resolution of the cavitary lesion with serial clinical imaging.

ANTIBIOTIC SENSITIVITIES
Amikacin 16 μg/ml (susceptible)
Cefoxitin 64 μg/ml (intermediate)
Ciprofloxacin >4 μg/ml (resistant)
Clarithromycin >16 μg/ml (resistant)
Doxycycline >16 μg/ml (resistant)
Imipenem >32 μg/ml (resistant)
Linezolid >32 μg/ml (resistant)
Moxifloxacin >8 μg/ml (resistant)
tigecycline 0.25 μg/ml (No interpretation available)
Tobramycin 16 μg/ml (resistant)
Trimethoprim-sulfamethoxazole 8 μg/ml (resistant)

Nontuberculous mycobacteria (NTM) have been recognized for many years as pathogenic organisms. Although they are regularly present in the environment of body surfaces or secretions as colonizers, the rate of clinical infection in humans is considered to be low. Since reporting is not mandatory in several countries around the world, the exact frequency of illness due to different NTM species is not determined. An estimated prevalence of disease in the United States was approximately 15.2 cases/100,000 in 2013. It should also be noted that isolation of NTM does not necessarily indicate infection. [1,4].

NTM infections are usually seen in immunocompromised patients, such as those with a history of tuberculosis infection, advanced HIV disease, cystic fibrosis, and a history of taking immunosuppressive drugs. Diseases caused by NCDs are classified into major clinical syndromes: lymph node disease (lymphadenitis), skin disease, musculoskeletal disease, lung disease and disseminated disease according to organ system involvement. There are over 170 identified species, however, the Mycobacterium avium complex, Mycobacterium kansasii, Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium fortuitum are the most reported in infections [5,6].

Previously thought to be rare, NTM infections are now increasingly recognized, especially with the advancement of detection techniques such as the polymerase chain reaction. Lung involvement is considered the most common manifestation of the infection. Predisposing factors are basic parenchymal lung diseases such as bronchiectasis, chronic obstructive pulmonary disease, interstitial lung disease or immunosuppression in uncontrolled HIV infection, after transplantation and use anti-tumor necrosis factor-α biologics. [7]

Some studies have shown that lung NTM infections are noted in postmenopausal female populations without immune dysfunction but with a slender physique, scoliosis, and mitral valve prolapse. Other less common risk factors described in the literature include gastroesophageal reflux disease, vitamin D deficiency, low body mass index, and rheumatoid arthritis. [8]

We describe an interesting case of lung disease Mycobacterium abscessus in a patient with severe alcohol dependence disorder but an otherwise immunocompetent individual. It was not noted that he had a significant history of predisposition to lung parenchymal disease at baseline, and no history of systemic immunosuppression was noted. Theoretically, we suggest that a history of alcohol dependence disorder, although not properly understood, may have played some role in predisposing to NTM infection. Alcohol consumption has been suggested to have an altering effect on innate and adaptive immune responses and dysregulation of the inflammatory cascade predisposing to viral and bacterial infections and sterile inflammation [9]. Additionally, alcohol dependence is also associated with gastroesophageal reflux. [10]. We hypothesize that alcohol-induced reflux disease may have played some role in our patient’s predisposition to have NTM lung infection. The association of gastroesophageal reflux disease with NTMs has not been studied in detail, but limited data suggest a high prevalence of such infections even in the absence of classic reflux disease symptoms. [11].

infections by Mycobacterium abscessus are conventionally considered difficult to manage without standard treatment. Treatment options are limited with current antimicrobial agents and are therefore often considered an incurable chronic infection in the right clinical setting. [12]

Nontuberculous mycobacterium is an important environmental pathogen that can cause a wide range of diseases in humans. It is important to elucidate important risk factors, including dysregulation of the immune system that may predispose to significant infections by these organisms. Alcoholism is considered an important risk factor for predisposing patients to NTM infections and with this case report we urge more robust studies to assess this association.

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