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An Unusual Case of Mycobacterium Porcinum Related Septic Shock in a Peritoneal Dialysis Patient
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A5290 - An Unusual Case of Mycobacterium Porcinum Related Septic Shock in a Peritoneal Dialysis Patient
Author Block: F. Figueroa Rodriguez1, J. V. Silverman2, S. Dogra3, G. Nair4; 1Internal Medicine, Beaumont Health, Royal Oak, MI, United States, 2Infectious Diseases, Beaumont Health, Royal Oak, MI, United States, 3Pulmonary/Critical Care Medicine, Beaumont Health, Royal Oak, MI, United States, 4Pulmonary Division, Beaumont Health System, Royal Oak, MI, United States.
Introduction
Non Tuberculous Mycobacteria (NTM) can cause a broad range of infections that vary depending on the particular species and host’s immune status. We report a case of Mycobacterium porcinum peritonitis and shock in a patient undergoing peritoneal dialysis (PD).
Case Description
A 65 year old man with history of coronary artery disease, tuberous sclerosis and End Stage Renal Disease on PD was admitted with fever and abdominal pain of 1 week duration. A CT scan of the abdomen showed nonspecific thickening with colitis. An initial diagnostic paracentesis revealed a WBC count of 2,090/mcL. He was started on vancomycin, gentamycin and metronidazole for bacterial peritonitis. The PD catheter was removed and a non-tunneled jugular catheter was placed for dialysis access. However, the patient’s clinical status deteriorated three days into hospitalization and he was transferred to ICU. The same day, the peritoneal fluid cytology demonstrated AFB bacilli. ICU course was complicated with atrial fibrillation and shock requiring vasopressor support. Antibiotics were changed to Linezolid 600 mg every 12 hours, Amikacin 750 mg daily and Moxifloxacin 400 mg daily. On the 17th day of hospitalization Mycobacterium porcinum was isolated on dianeal fluid. Patient had slow improvement and antibiotics were de-escalated to oral Trimethoprim/Sulfamethoxazole and Moxifloxacin (to complete a 6 month regimen). He was transferred to inpatient rehabilitation and discharged home after 44 days into hospitalization.
Discussion
Mycobacterium porcinum is an extremely rare rapidly growing NTM and is mostly isolated from wound infections. It rarely causes peritonitis; accounting for less than 1% of cases. (1). Diagnosis of NTM peritonitis is challenging. Clinical worsening after starting antibiotics can alert physician to infection with an atypical pathogen. Although it belongs to NTMs rapid grower family, Mycobacterium porcinum takes more than 7 days to grow on cultures and should be distinguished from Nocardia peritonitis. Unlike most NTM, they lack response to typical anti-tuberculous drugs, but respond to quinolones, Bactrim, macrolides, aminoglycosides and cephalosporins. (2)
Our case is the second reported case of Mycobacterium porcinum and illustrates the need for high index of suspicion for NTM in patients with refractory septic shock.
References:
(1)
Wallace RJ Jr, Brown-Elliott BA, et al. Clinical and laboratory features of Mycobacterium porcinum. J Clin Microbiol 2004; 42:5689.
(2)
Ritesh Patil, MD, MPH, Trupti Patil, MD, MPH, Louis Schenfeld, MD, and Samuel Massoud, MD. Mycobacterium Porcinum Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis. J Gen Intern Med 26(3):346-8
Author Block: F. Figueroa Rodriguez1, J. V. Silverman2, S. Dogra3, G. Nair4; 1Internal Medicine, Beaumont Health, Royal Oak, MI, United States, 2Infectious Diseases, Beaumont Health, Royal Oak, MI, United States, 3Pulmonary/Critical Care Medicine, Beaumont Health, Royal Oak, MI, United States, 4Pulmonary Division, Beaumont Health System, Royal Oak, MI, United States.
Introduction
Non Tuberculous Mycobacteria (NTM) can cause a broad range of infections that vary depending on the particular species and host’s immune status. We report a case of Mycobacterium porcinum peritonitis and shock in a patient undergoing peritoneal dialysis (PD).
Case Description
A 65 year old man with history of coronary artery disease, tuberous sclerosis and End Stage Renal Disease on PD was admitted with fever and abdominal pain of 1 week duration. A CT scan of the abdomen showed nonspecific thickening with colitis. An initial diagnostic paracentesis revealed a WBC count of 2,090/mcL. He was started on vancomycin, gentamycin and metronidazole for bacterial peritonitis. The PD catheter was removed and a non-tunneled jugular catheter was placed for dialysis access. However, the patient’s clinical status deteriorated three days into hospitalization and he was transferred to ICU. The same day, the peritoneal fluid cytology demonstrated AFB bacilli. ICU course was complicated with atrial fibrillation and shock requiring vasopressor support. Antibiotics were changed to Linezolid 600 mg every 12 hours, Amikacin 750 mg daily and Moxifloxacin 400 mg daily. On the 17th day of hospitalization Mycobacterium porcinum was isolated on dianeal fluid. Patient had slow improvement and antibiotics were de-escalated to oral Trimethoprim/Sulfamethoxazole and Moxifloxacin (to complete a 6 month regimen). He was transferred to inpatient rehabilitation and discharged home after 44 days into hospitalization.
Discussion
Mycobacterium porcinum is an extremely rare rapidly growing NTM and is mostly isolated from wound infections. It rarely causes peritonitis; accounting for less than 1% of cases. (1). Diagnosis of NTM peritonitis is challenging. Clinical worsening after starting antibiotics can alert physician to infection with an atypical pathogen. Although it belongs to NTMs rapid grower family, Mycobacterium porcinum takes more than 7 days to grow on cultures and should be distinguished from Nocardia peritonitis. Unlike most NTM, they lack response to typical anti-tuberculous drugs, but respond to quinolones, Bactrim, macrolides, aminoglycosides and cephalosporins. (2)
Our case is the second reported case of Mycobacterium porcinum and illustrates the need for high index of suspicion for NTM in patients with refractory septic shock.
References:
(1)
Wallace RJ Jr, Brown-Elliott BA, et al. Clinical and laboratory features of Mycobacterium porcinum. J Clin Microbiol 2004; 42:5689.
(2)
Ritesh Patil, MD, MPH, Trupti Patil, MD, MPH, Louis Schenfeld, MD, and Samuel Massoud, MD. Mycobacterium Porcinum Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis. J Gen Intern Med 26(3):346-8
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