Page 88 - SAHCS HIVMed Journal Vol 20 No 1 2019

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 6 Case Report

An unusual case of abdominal mycobacterial infection:

Case report and literature review

Authors: This article presents a case of an HIV-infected paediatric patient with an unusual Mycobacterium
Pieter Ekermans genavense infection with predominantly abdominal organ involvement.
1
Rene de Gama 2
Celeste Kock 3 Keywords: Mycobacterium genavense; Non-tuberculous mycobacterium; 16S rRNA sequence
Ebrahim Hoosien 1
Tomas Slavik 4 analysis; Line-probe assay; Fastidious; Retractile mesenteritis.
Terry Marshall 5
Craig Corcoran 5
Jakko van Ingen 6 The patient is a chronically ill 8-year-old boy from Limpopo province in South Africa, living with
his adoptive parents. He was born prematurely at 7 months’ gestation, weighing 1.9 kg. There
Affiliations: was a history of recent travel to the Kruger National Park, and to India 6 months prior to admission.
1 Department of Microbiology, All his vaccinations were up to date on history, but this was never confirmed. He was markedly
National Reference
Laboratory, AMPATH underweight for his age (with weight-for-age and height-for-age z scores of −2 and −1, respectively,
Laboratories, Centurion, and body mass index of 13) with a 2-year history of abdominal distension, diarrhoea, failure to
South Africa thrive and drenching night sweats. There was no history of chronic cough. His treatment up to the
time of admission included nutritional and iron supplements and repeated courses of antibiotics.
2 Department of Paediatrics,
Netcare Unitas Hospital, No clinical improvement was achieved with this management.
Centurion, South Africa
The patient was referred to a paediatric gastroenterologist in October 2016. He was acutely ill,
3 Department of Paediatrics, severely wasted (17 kg) and pyrexial (39 °C). He was clinically pale with a tachycardia and mild
Mediclinic Midstream oedema of his lower limbs. Hepatosplenomegaly was detected, although there was no peripheral
Hospital, Midstream,
South Africa lymphadenopathy. His abdomen was severely distended, and he had recurrent diarrhoea and
vomiting with marked intolerance of all foods.
4 Department of Histology,
AMPATH Laboratories, Abdominal computed tomography (CT) scan and ultrasound revealed massively enlarged intra-
Pretoria, South Africa abdominal lymph nodes (see Figure 1) with a moth-eaten appearance of the spleen. Prominent
collateral circulation was seen, which was suggestive of portal hypertension.
5 Department of Molecular
Medicine, National Reference
Laboratory, AMPATH Laboratory investigations confirmed that the patient was HIV-infected with a CD4 count of 59
Laboratories, Centurion, cells/μL (7%) and HIV viral load of 453 780 copies/mL (log 5.66). Further testing revealed mildly
10
South Africa elevated liver enzymes. Moderate proteinuria was present and the faecal α-1 antitrypsin result
was in keeping with a protein-losing enteropathy. His blood count showed microcytic hypochromic
6 Department of Medical
Microbiology, Radboud anaemia, with the iron function studies reflecting a pattern of reticuloendothelial iron blockade
University Medical Center, (see Table 1).
Nijmegen, the Netherlands
The differential diagnosis included tuberculosis or lymphoma. Over a period of 7 months,
Corresponding author:
Pieter Ekermans, endoscopically and surgically obtained biopsy material was submitted for histology (see Table 2).
[email protected] Histological images of the duodenum and a lymph node are shown in Figure 2. The findings were
consistent with non-tuberculous mycobacterial infection.
Dates:
Received: 12 June 2019
Accepted: 13 July 2019 Further testing of the biopsy specimens included mycobacterial cultures, all of which showed no
Published: 28 Aug. 2019 growth. Acid-fast bacilli (AFB) were noted during the processing of the tissue samples obtained
from the intra-abdominal lymph nodes on 12 October 2016, and again in biopsy material obtained
on 08 March 2017. Microscopy performed on a stool sample on 26 March 2017 also showed acid-
fast organisms with a coccoid appearance. The polymerase chain reaction (PCR) assay for
Mycobacterium avium complex was negative (artus® Mycobac. diff. LC PCR from Qiagen,
Germany). Numerous PCR assays for Mycobacterium tuberculosis complex were negative, which
include Nanogen (Nanogen Inc., San Diego, CA, USA), BD MAX (BD Diagnostics, Sparks, MD)
Read online: and the Xpert® MTB/RIF assay (Cepheid Inc., CA, USA). The urinary lipoarabinomannan test
Read online:
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mobile device How to cite this article: Ekermans P, De Gama R, Kock C, et al. An unusual case of abdominal mycobacterial infection: Case report and
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to read online. literature review. S Afr J HIV Med. 2019;20(1), a993. https://doi.org/10.4102/sajhivmed.v20i1.993
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Copyright: © 2019. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.
http://www.sajhivmed.org.za 81 Open Access