Disseminated Mycobacterium simiae infection in a patient with adult-onset immunodeficiency due to anti-interferon-gamma antibodies - a case report

Abstract

Background: Mycobacterial species other than Mycobacterium tuberculosis and Mycobacterium leprae are generally free-living organisms and Mycobacterium simiae is one of the slowest growing Non-tuberculous mycobacteria. This is the first case report of Mycobacterium simiae infection in Sri Lanka and only very few cases with extrapulmonary manifestation reported in the literature.

Case presentation: A 24-year-old, previously healthy Sri Lankan male presented with generalized lymphadenopathy with discharging sinuses, evening pyrexia, weight loss, poor appetite and splenomegaly. Lymph node biopsies showed sheets of macrophages packed with organisms in the absence of granulomata. Ziehl Neelsen, Wade Fite and Giemsa stains revealed numerous red coloured acid-fast bacilli within foamy histiocytes. Slit skin smear for leprosy was negative and tuberculosis, fungal and bacterial cultures of the lymph node and bone marrow did not reveal any growth. Later he developed watery diarrhea and colonoscopy revealed multiple small polyps and ulcers throughout the colon extending up to the ileum, Which was confirmed to be due to cytomegalovirus confirmed by PCR and successfully treated with ganciclovir. Positron emission tomography scan guided biopsies of the gut and lymph nodes confirmed presence of mycobacterial spindle cell pseudo-tumours and PCR assays revealed positive HSP65. The culture grew Mycobacterium Simiae. Flow cytometry analysis on patient's blood showed extremely low T and B cell counts and immunofixation revealed low immunoglobulin levels. His condition was later diagnosed as adult onset immunodeficiency due to anti- interferon - gamma autoantibodies. He was initially commenced on empirical anti-TB treatment with atypical mycobacterial coverage. He is currently on a combination of daily clarithromycin, ciprofloxacin, linezolid with monthly 2 g/kg/intravenous immunoglobulin to which, he had a remarkable clinical response with complete resolution of lymphadenopathy and healing of sinuses.

Conclusions: This infection is considered to be restricted to certain geographic areas such as mainly Iran, Cuba, Israel and Arizona and this is the first case report from Sri lanka. Even though the infection is mostly seen in the elderly patients, our patient was only 24 years old. In the literature pulmonary involvement was common presentation, but in this case the patient had generalized lymphadenopathy and colonic involvement without pulmonary involvement.

Keywords: Adult-onset immunodeficiency due to anti-interferon-gamma antibodies; Case report; Disseminated Mycobacterium simiae infection; Sri lanka.

Fig. 1

Cervical and axillary lymph nodes later developed in to discharging sinuses

Fig. 2

Repeated lymph node biopsies showing sheets of macrophages packed with organisms in the absence of granulomata

Fig. 3

Ziehl Neelsen revealing numerous red coloured acid-fast bacilli within foamy histiocytes

Fig. 4

Wade Fite revealed numerous red coloured acid-fast bacilli within foamy histiocytes

Fig. 5

Giemsa stains revealed numerous red coloured acid-fast bacilli within foamy histiocytes

Fig. 6

Grocott stain showing weak positivity

Fig. 7

Colonoscopy revealed multiple small polyps and ulcers throughout the colon extending up to the ileum

Fig. 8

Complete resolution of lymphadenopathy and healing of sinuses

Fig. 9

Time line of the case report