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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 446-448
 

Subdural empyma due to Mycobacterium fortuitum in a non-HIV patient


Department of Microbiology (SST), Government Medical College, Nagpur, Maharashtra, India

Date of Submission12-Jul-2013
Date of Acceptance13-Feb-2014
Date of Web Publication4-Oct-2014

Correspondence Address:
S S Tankhiwale
Department of Microbiology (SST), Government Medical College, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.142251

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 ~ Abstract 

A 14-year-old male child presented with high grade intermittent fever with altered sensorium since 5-6 days and generalised seizures. On examination neck stiffness noticed with normal haemogram and chest X-ray. CSF microscopy was normal and no growth seen in aerobic culture. CT scan showed loculated lesion. Drained pus showed acid fast organism and culture on Lowestein Jensen medium showed pale-coloured growth on 3 rd day. Organism identified as Mycobacterium fortuitum by biochemical test. Interesting aspect of this case was there is no history of trauma or injection and patient was negative for HIV antibody.


Keywords: Mycobacterium fortuitum, non-hiv patient, pus, subdural abscess


How to cite this article:
Tankhiwale S S, Katkar V J. Subdural empyma due to Mycobacterium fortuitum in a non-HIV patient . Indian J Med Microbiol 2014;32:446-8

How to cite this URL:
Tankhiwale S S, Katkar V J. Subdural empyma due to Mycobacterium fortuitum in a non-HIV patient . Indian J Med Microbiol [serial online] 2014 [cited 2019 Nov 17];32:446-8. Available from: http://www.ijmm.org/text.asp?2014/32/4/446/142251



 ~ Introduction Top


Most tuberculous infections of the central nervous system are caused by Mycobacterium tuberculosis. Less frequently other mycobacteria may be involved. Among the non-tuberculous mycobacteria (NTM) or atypical mycobacteria specifically rapid growers like Mycobacterium fortuitum and Mycobacterium chelonae are most important rapidly growing mycobacteria associated with abscess. These species are known to cause cutaneous and deeper tissue abscess following injury or trauma, ocular lesions, endocarditis following prosthetic valve replacement or open heart surgery and retroperitoneal abscess. In immunocompromised patient meningitis, pulmonary and disseminated infections are also reported. [1]

NTM are rare human pathogens which are found in the environment particularly in water. Infection by these organisms leads to delayed wound healing and requires prolonged course of expensive antibiotics. These NTM are more commonly seen in imunnocompromised patients and/or following trauma. injection and surgery. The chances of overlooking these organisms are higher unless an acid-fast staining (Zeihl-Neelsen) and culture is done on all aspirated pus specimens. The case report here emphasises these aspects.

We did not come across the documentation of subdural empyema due to this organism, in literature search without the history of trauma, surgery, catheter, prosthetic valve, immunodeficiency; hence, this report.


 ~ Case Report Top


A 14-year-old young male child belonging to middle socioeconomic status presented with high-grade intermittent fever with altered sensorium since 5-6 days and generalised seizures since last 2 days. There was no previous history of fever, weight loss, cough, tuberculosis, addiction or high risk behaviour.

On examination child was drowsy with gross neck stiffness. Pulse was 100/min. Other systems were normal. Haemogram revealed 10 gm% haemoglobin and normocytic hypochromic RBCs. X-ray chest was normal. CSF microscopy was normal. CT scan showed oval loculated subdural lesion [Figure 1].
Figure 1: M. fortuiotum growth on Mc Conkey

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Craniotomy was done and thick pus was drained. Pus was sent for microscopy, culture of aerobic as well as acid-fast bacilli.

Gram stain showed plenty of pus cells and no organisms. Zeihl -Neelsen stain showed small (2-3 μ) acid-fast bacilli. Aerobic culture was negative. On Lowenstein-Jensen media, pale-coloured moist colonies seen on third day which was presumptively identified as a rapidly growing NTM [Figure 2]. Organism was identified as M. fortuitum by identification tests like pink growth on modified MacConkey (Crystal violet deficient) agar on third day [Figure 3], positive urease test, 5% NaCl tolerance, sensitive to ciprofloxacin and positive iron uptake test. [1],[2]
Figure 2: CT Scan showing subdural empyma

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Figure 3: Growth on L. J. medium

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The patient was treated with anti-tubercular drugs Isonex 20 mg/kg/day and Rifampicilin 10 mg/kg/day without any improvement in patient's condition till they receive the report of M. fortuitum. Then they stop the antitubercular drug and started the clarithromycin and ciprofloxacin. Patient responded to treatment with complete recovery after 6 weeks of therapy.


 ~ Discussion Top


Tuberculous involvement of the central nervous system (CNS) is an important and serious type of extrapulmonary involvement. Focal lesions, intracranial tuberculosis and tuberculous abscess are usually located in cerebral or cerebellar hemispheres, uncommonly in brain stem and very rarely in spinal cord. [3]

Infections due to NTM are uncommon. Among the rapid grower NTM, M. fortuitum and M. chelonae cause skin and wound infections and abscesses. In a bacteriological study of 50 cases of brain abscess in 1993, two cases of Mycobacterium were found. One of these two was due to M. fortuitum. [4] M. fortuitum has also been reported from cases of post-injection abscess. [5]

M. fortuitum wound infection following laparoscopic tubectomy in seven patients was reported in a town health centre near Chandigarh. They all presented as chronic discharging sinuses at the site of incision. M. fortuitum was found to be the causative agent of nosocomial infection in surgical wounds. [6]

One such case of iatrogenic Mycobacterium infection after an epidural injection was reported by O' Brien. A 39-year-old man received an epidural injection for low back pain and 3 months after the injection he developed infective mass causing spinal pain. Mass was excised and sent for microbiological study which revealed M. fortuitum. [7]

Dalovisio et al., in 1981 have listed eight cases of CNS infections. Of which one case was that of subdural empyema. No other case of subdural empyema was found. [8]

In the present case no organism was grown in aerobic culture. Zeihl-Neelsen stain showed acid fast organism which were grown on Lowenstein-Jensen media. Treatment with anti-tubercular drugs alone was not effective in this case. Patient responded to treatment when clarithromycin and ciprofloxacin were given along with surgical drainage of pus. Recovery was complete in 6 weeks.

The unique feature in this case was that the patient was an immuno-competent one without history of trauma, injection or surgery. The cause of M. fortuitum infection cannot be elicited by history in this case but child may have received injury which was not serious one to be narrated by family but enough to give chance to organism to enter inside the body.

He was a victim of atypical mycobacterial infection which was reported to cause infection in immunocompromised host, following trauma like injection, surgery or injury. Is it a signal of atypical mycobacteria being more virulent to cause infection in immuno-competent person without history of injury or trauma?

 
 ~ References Top

1.Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC. Colour Atlas and Textbook of Diagnostic Microbiology: 5thed (Lippincot-Raven Publishers New York) 1997:893-943  Back to cited text no. 1
    
2.Silcox VA, good RC, Floyd M. Identification of clinically significant mycobacterium fortuitum complex isolates: J Clin Microbial 1981;14(6):686-91  Back to cited text no. 2
    
3.Ravindrakumargarg. Tuberculosis of central nervous system, review article JAMA. India 1999;2(6):34-43  Back to cited text no. 3
    
4.Lakshmi V rao RR Dinkar I. Bacteriology of Brain abscess: Observation on 50 cases: J Med Microbiol 1993;38:187-90  Back to cited text no. 4
    
5.Devi dRG, idumati VA, Indra S, BabuPRS, Sridharan D, Belwadi MRS. Injection site abscess due to Mycobacterium fortuitum: Indian. J Med Microbiol 2003;21(2):133-4  Back to cited text no. 5
    
6.Sethi S, Sharma M, Ray P, Singh M, GuptaA.Microbacterial wound infection following leproscopy. Indian J Med Res 2001;113:83-4  Back to cited text no. 6
    
7.O` Brien RJ, Geiter L J, snider DE. Epidemiology of nontubercuious mycobacterial diseases in the United States. Am review of Respir Dis. 1987;135:1007-14  Back to cited text no. 7
    
8.DalovisioJR Panky GA, Wallace RJ, Jones DB. Clinical usefulness of Amikacin and Doxycycline in the treatment of infection due to M fortuitum and M. chelonae, Review of Inf Disease. 1981;3:1068-74  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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