CASE REPORT

Cavitary pneumonia secondary to Tsukamurella inan AIDS patient. First case and a review of theliterature

Maria Luisa Alcaidea, Luis Espinozab,*, Lilian Abbob

aInternal Medicine, Jackson Memorial Hospital, University of Miami, Miami, FL, USAbClinical Immunology, Division of Infectious Diseases, Department of Medicine, University of Miami Schoolof Medicine, 1400 NW 10th Avenue, Suite 813A, Miami, FL 33136, USA

Accepted 27 July 2003

Available online 18 September 2003

KEYWORDSTsukamurella; AIDS;Cavitations; Pneumonia

Summary Tsukamurella is a Gram-positive, variable rod-shaped, weakly acid-alcohol-fast,nonmotile,aerobicbacteriumthatbelongs to thegenusRhodococcus.Tsukamurellahas been reported as a cause of infections in humans with immunosuppression andindwelling foreign bodies. It has also been isolated in one patient with AIDS (AcquiredImmunodeficiency Syndrome) as a saprophytic organism. Optimal management ofinfections secondary to this micro-organism is still uncertain due to the paucity of cases.The combination of a beta-lactam and an aminoglycoside, along with removal ofmedicaldevices, appear to be the treatment of choice.We report the case of an AIDS patientwhopresented withmultiple lung cavitary lesions secondary to Tsukamurella. This is the firstcase reportedofTsukamurellaasapathogenicagent in anAIDSpatient.Wealsoproposeasuccessful oral antibiotic regimen with fluoroquinolone and rifampin to treat infectionssecondary to this uncommon micro-organism.Q 2003 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Case report

A 55-year-old Latin man presented to the ClinicalImmunology clinic at Jackson Memorial Hospital(Miami) complaining of two-week history of weak-ness, fever, and cough with minimal whitishsputum. His past medical history includedcutaneous T-cell lymphoma and Acquired Immuno-deficiency Syndrome (AIDS). The patient had historyof chronic use of tobacco (1–2 pack of cigarettes/day for 40 years). Travel history included manyCentral and South American countries, last time

more than 10 years ago. He lived in an apartmentwith two dogs, one cat and two birds. The riskfactor for human immunodeficiency virus (HIV)infection was homosexual and heterosexual unpro-tected intercourse. Atovaquone was included in theregimen as prophylaxis for Pneumocistis cariniipneumonia (PCP) since the patient was receiving UVlight therapy for his cutaneous T-cell lymphoma.The physical exam was unremarkable except formultiple hyperpigmented macular skin lesions. TheCD4 cell count was 115 cells/mm3 and the viral load1361 copies/ml after one month on stavudine,lamivudine, and lopinavir/ritonavir. A chest radi-ography and Computed Tomography (CT) scan ofthe thorax revealed multiple cavities with patchy

0163-4453/$30.00 Q 2003 The British Infection Society. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S0163-4453(03)00139-7

Journal of Infection (2004) 49, 17–19

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*Corresponding author. Tel.: þ1-305-243-4598; fax: þ1-305-243-4037.

E-mail address: lespinoza@med.miami.edu

areas of consolidation and chronic emphysematouschanges. Microbiology of sputum samples andbronchoscopy with bronchio-alveolar lavageinitially yielded negative results on direct examin-ation. Culture results inoculated for two weekswere initially reported as Mycobacterium but finalidentification of the micro-organism revealed Tsu-kamurella sp. in the basis of biochemical tests.Follow-up chest radiography demonstrated newcavitary lesions, and several repeated sputumcultures confirmed the growth of Tsukamurella.During this time, the patient remained clinicallystable, although complaining of malaise, cough,and occasional fevers. The patient refused to havean intravenous line insertion for either vancomycinor amikacin therapy. Outpatient treatment withciprofloxacin 750 mg PO BID and rifabutin 150 mgPO QD was started. Two weeks after the treatmentwas initiated the patient reported clinical improve-ment with resolution of his cough and remission ofthe fever, however, two weeks later the dose ofciprofloxacin was decreased to 250 mg PO BIDbecause of recurrent gastrointestinal symptoms

(nausea and vomiting). New image studies twomonths after initiation of the therapy revealedimprovement of the cavitary lesions and scarring ofthe patchy infiltrates (Fig. 1), and the therapy wasdiscontinued after completion of a total of 12weeks. Further sputum cultures have remainednegatives, chest radiographies demonstrated scar-ring tissue only, and the patient is doing clinicallywell one year later.

We have performed an extensive review of theliterature for Tsukamurella infections. Eighteencases of Tsukamurella infection have beenreported. The clinical manifestations include bac-teraemia (11 cases)1 –6,10 cutaneous infection (twocases)7,8 meningitis (one case),9 peritonitis (onecase),11 lung infection (one case)12 and kneeprosthesis infection (one case).13 Most of thereported cases were related to intra-vascularprosthetic devices and all but two of the casesoccurred in immunocompromised hosts (malignan-cies or chronic renal failure). The associationbetween Tsukamurella and AIDS has been proposedin one patient in whom Tsukamurella appeared to

Figure 1 CT scan of the chest: initial presentation (top pictures) and after two months of treatment (bottom pictures)with ciprofloxacin and rifabutin.

M.L. Alcaide et al.18

be only a commensal.14 Tsukamurella belong to thegenus Rhodococcus, a well-known life threateningopportunistic pathogen associated with AIDS. Toour knowledge, no cases have been reported ofTsukamurella as a cause of infection in a HIVinfected patient.

The difficulties we encountered in the diagnosisof this case have been previously reported. Themicrobiologic characteristics of this bacteria (mor-phology, slow growth and weakly acid-alcohol-fast)may lead to the diagnosis of Corynebacterium,coagulase-negative Staphylococcus, Rhodococcus,Nocardia, Gordonia or, as initially in our case,Mycobacterium. One recent review proposes theuse of high-performance liquid chromatography toidentify these micro-organisms.1

In this patient, who presented with consti-tutional symptoms, fever and lung cavitary lesions,tuberculosis was one of our first considerations.Tuberculin test and plain chest films had beennegative in the recent past. Sputum analysis andbronchial washing did not determine the diagnosis;and inoculation of the samples for two weeks gavethe preliminary diagnosis of Mycobacterium infec-tion. The identification of the Mycobacterium asTsukamurella sp. was initially considered a con-taminant or a saprophytic carriage. Due to thepersistence of the symptoms and the worsening ofthe chest films new samples from sputum werecollected and bronchio-alveolar lavage was done.The growth of Tsukamurella in these new samplesconfirmed the aetiology of the lung infection andtreatment was initiated.

Many combinations have been proposed for thetreatment of Tsukamurella. The combination of abeta-lactam and an aminoglycoside, along withremoval of medical devices appears to be thetreatment of choice in most of the reports butoptimal management is uncertain and should bebased on susceptibility test.1–3,11 In our patient, weselected a combination of ciprofloxacin 750 mg POBID and rifabutin 150 mg PO QD. Our choice wasbased on previous reports of sensitivity, avail-ability, PO administration instead of intravenous,concurrent use of protease inhibitor, and actualguidelines for the treatment of Rhodococcusinfection.15

The length of treatment has not been deter-mined and should be individualized according toclinical response. As in Rhodococcus infections,frequent relapses can be expected and prolongedoral suppressive treatment is recommended. In our

patient, since the risk factor for the infection isimmunosuppression secondary to HIV, it seemsappropriate to maintain the treatment until sup-pression of viral load and increase in CD4 cell countover 200 cell/mm3 if remission of symptoms persistand improvement of chest image studies continues.

References

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2. Rey D, Fraise P, Riegel P, Piemont Y, Lang JM. Tsukamurellainfections. Review of the literature apropos of a case. PatholBiol (Paris) 1997;45(1):60—65.

3. Chong Y, Lee K, Cho CY, Kim MJ, Kwon OH, Lee HJ.Tsukamurella inchonensis bacteremia in a patient whoingested hydrochloric acid. Clin Infect Dis 1997;24(6):1267—1268.

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7. Gromel F, Lozniewski A, Barband A. et al. Cutaneousinfection caused by Tsukamurella paurometabolum. ClinInfect Dis 1996;23(4):839—840.

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10. Sheridan E, Warwick S, Chan A, et al. Tsukamurellatyrosinosolvens intravascular catheter infection identifiedusing 16S ribosomal DNA sequencing. CID 2003;36:e69—e70.

11. Casella P, Tommasi A, Tortorano AM. Peritonie da Gordonaaurantica (Rhodococcus auranticus) in dialisi peritonealeambulatoria continua. Microbiol Med 1987;2:47—48.

12. Tsukamera M, Kawakami K. Lung infection caused byGordona aurantica (Rhodococcus auranticus). J Clin Micro-biol 1982;16:604—607.

13. Larking JA, Lit L, Wills T, Szentivanyi A. Infection of a kneeprosthesis with Tsukamurella species A. South Med J 1999;(8):831—832.

14. Rey D, De Briel D, Heller R, Fraise P, Partisani M, Leiva-MenaM, Lang JM. Tsukamurella and HIV infection. AIDS 1995;9(12):1379.

15. Von Graevenitz A. Antimicrobial therapy of infections withaerobic Gram-positive rods. Clin Microbiol Infect 2001;4(Suppl.):43—46.

Tsukamurella pneumonia in AIDS. First case and review 19