Fatal Pulmonary Mycobacterium Celatum Infection in an Immunocompetent Patient.
An Eight-Year Follow-Up of the First Case, a Review of the Literature and a Report 255
of Beta-2 Microglobulin as a Potential Indicator of Disease Severity
plemental oxygen.
In august 2010 the patient returned to us, now again
with a respiratory insufficiency and a fast atrial fibrilla-
tion. She was reinstituted on tinzaparin and also received
loracarbef and furosemide. Sputum samples grew proteus
mirabilis and treatment was changed to ciprofloxacin.
Her ESR was only 32 and her CRP 36. Her x-ray showed
progressive infiltrates in her right lower lobe. Neverthe-
less she regained her respiratory sufficiency and was
discharged on September 13th with an alleviated cough in
order to wait for the results of the mycobacterial samples.
She was found dead in her sleep at her home on Sep-
tember 14th, 2010. Her sister refused an autopsy.
During the whole eight-year period we followed her
beta-2 microglobulin serum levels. She had a reasonable
kidney function for her age, with a creatinine clearance
of 40 - 45 and no other known reasons for an elevated
level of beta-2 microglobulin. Her levels before institu-
tion of treatment were 4.1 mg/l (ref 0.6 - 2.4). Treatment
resulted in a rapid drop to 2.7 mg/l. In april 2007, con-
comitant with her exacerbation, levels rose to 3.8 mg/l.
They then went dow n with treatment and hovered around
2.7 mg/l until autumn 2008, when she had another exac-
erbation and a concomitant rise to 5.4 mg/l. On treatment
levels declined to 2.9 mg/l and have on discontinuation
of all therapy risen again to 3.9 mg/l in summer, 2009.
Unfortunately, no beta-2-microglobulin samples were
measured on her last admission to our ward.
3. Discussion
Atypical mycobacteria may be found as commensals in
the bronchial tree, but a surprising number of them are
pathogens in a true sense. Treatment may be prolonged
and very difficult.
A decision to treat non-tuberculous mycobacteria rests
on repeated cultures of the same Specimen, or culture
positive cases with progressive disease and no other
known cause.
We know that M celatum may be misclassified as M
tuberculosis with the Amplified M tuberculosis direct test
[11]. We have been able to grow M. celatum on three
occasions and the patient has responded to treatment,
relapsed twice after amikacin was withdrawn, improved
on its reinstitution, and, finally, succumbing to the dis-
ease when treatment was withheld. We cannot rule out
that this patient first suffered from a mycobacterium
avium-intracellulare infection but we deem it highly un-
likely that this p athogen would be so easily treated th at it
would disappear after just six months of chemotherapy,
never to return, especially when this patient immediately
afterwards g ot col o ni zed by M. celatum.
4. Conclusions
We deem that it is the first Swedish case of a Mycobacte-
rium celatum infection, the first fatal case in a previously
healthy individual, and th e third case in the world of pul-
monary infection in an immunocompetent patient with no
previous lung disease, confirming that M. celatum is a
true pathogen in man. The PPD test was strong ly positive.
Cultures, direct smears and PCR assays have been nega-
tive for M. tuberculosis. We therefore suggest that the
PPD may cross-react with M. celatum. A negative Quan-
tiferon Go ld test has b een performed in 2009. W e postu-
late that central retinal vein thrombosis might be a rare
side effect of etha mbutol.
Unfortunately, the ototoxic effect of aminoglycosides
is well known and may occur more frequently in the eld-
erly, when treatment is prolonged and when other oto-
toxic drugs are added. We therefore advise the utmost
caution when adding potentially ototoxic and/or nephro-
genic drugs to an aminoglycoside-containing regimen,
even if the aminoglycoside is given in a low total weekly
dose. We would also like to point out the dangers of
withholding treatment altogether in these infection s .
Finally, we would like to draw attention to beta-2 mi-
croglobulin, which is said to be synthetised in granulo-
mata. There is an excellent paper published on beta-2 mi-
croglobulin levels in tuberculosis p atients [12]. We tenta-
tively postulate that this test could be of potential value
in monitoring the course of non-tuberculous mycobacte-
rial diseases.
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