Scientific letter
Disseminated Mycobacterium scrofulaceum infection in a patient in treatment with golimumab
Infección diseminada por
Clara González Ojea
, Rebeca Longueira Suárez, Adrián Sousa Dominguez, Manuel Crespo Casal
Corresponding author
Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Álvaro Cunqueiro, Vigo, Spain
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"gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "The return of Koch's: Ineffective treatment or re-infection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "144" "paginaFinal" => "145" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El regreso de Koch: tratamiento ineficaz o reinfección" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1677 "Ancho" => 2507 "Tamanyo" => 413165 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray PA film showing right upper lobe cavitary lesion (green arrow). (B) Chest X-ray lateral film showing right upper lobe cavitary lesion (green arrow). (C) CT chest coronal view showing right upper lobe cavitary lesion (green arrow). (D) CT chest axial view showing right upper lobe cavitary lesion (green arrow). (E) Chest X-ray PA film showing right upper lobe scarring in area of previous cavitary lesion (red arrow). (F) Chest X-ray lateral film showing right upper lobe scarring in area of previous cavitary lesion (red arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Amos Lal, Ajay Kumar Mishra, Kamal Kant Sahu, George M. Abraham" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Amos" "apellidos" => "Lal" ] 1 => array:2 [ "nombre" => "Ajay Kumar" "apellidos" => "Mishra" ] 2 => array:2 [ "nombre" => "Kamal Kant" "apellidos" => "Sahu" ] 3 => array:2 [ "nombre" => "George M." "apellidos" => "Abraham" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X20300393?idApp=UINPBA00004N" "url" => "/2529993X/0000003800000003/v1_202003050625/S2529993X20300393/v1_202003050625/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2529993X20300381" "issn" => "2529993X" "doi" => "10.1016/j.eimce.2019.05.011" "estado" => "S300" "fechaPublicacion" => "2020-03-01" "aid" => "2040" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2020;38:140-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Severe bradycardia probably associated to Oseltamivir in a pediatric patient with acute renal injury" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "140" "paginaFinal" => "142" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bradicadia severa probablemente asociada a Oseltamivir en un paciente pediátrico con fracaso renal agudo" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1571 "Ancho" => 2091 "Tamanyo" => 267351 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiac rhythm monitoring of our patient. Panel A is the record of the HR variability during the first Holter performed the third day of treatment with Oseltamivir, showing a severe bradycardia for age. Panel B is a capture of the cardiac monitor of the patient the first day of treatment with Oseltamivir, showing a sinus bradycardia (30–50<span class="elsevierStyleHsp" style=""></span>bpm). 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He attended due to general malaise, headache, cough and a fever of 39° with no response to outpatient antibiotics. In the physical examination he presented with nuchal rigidity for which reason, in light of a normal brain computed tomography (CT), a lumbar puncture was conducted with cerebrospinal fluid compatible with lymphocytic meningitis, with 12 leukocytes/mm<span class="elsevierStyleSup">3</span> (100% mononuclear), glucose 67<span class="elsevierStyleHsp" style=""></span>mg/dl, proteins 28<span class="elsevierStyleHsp" style=""></span>mg/dl and ADA 1.7<span class="elsevierStyleHsp" style=""></span>u/l. In ordinary culture, Lowenstein and multiple PCR of the cerebrospinal fluid were negative. In light of mediastinal widening on the x-ray, a CT was performed, with pulmonary micronodules, mediastinal and mesenteric lymphadenopathies, and splenomegaly, findings suggestive of miliary tuberculosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Following a bronchoscopy with biopsy of right paratracheal adenopathy empiric antituberculosis treatment was started (isoniazid, rifampicin, pyrazinamide and ethambutol) pending microbiological results. The node biopsy revealed necrotising epithelioid granulomas with presence of acid-fast bacilli, but in the culture material <span class="elsevierStyleItalic">M. Scrofulaceum</span> was isolated sensitive to all tested antibiotics, so antibiotics were adjusted to clarithromycin, rifampicin and ethambutol. This germ was not isolated in blood or cerebrospinal fluid.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient presented with good tolerance to treatment. A CT at 6 months demonstrated practical resolution of the lymphadenopathies and pulmonary micronodules, and after completing 12 months of treatment the patient is currently asymptomatic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Atypical or nontuberculous mycobacteria are frequently found in the environment, especially in water. They are usually transmitted by inhalation or direct inoculation, they do not spread from person to person and they do not usually cause disease in immunocompetent subjects.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> More than 150 species have been described, and within these <span class="elsevierStyleItalic">M. scrofulaceum</span> represents just 2.2% of these infections. Their typical form of presentation is cervical lymphadenitis or scrofula in infancy, followed by slowly growing cavitary pneumonia, more common in the elderly and those with chronic lung disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Disseminated <span class="elsevierStyleItalic">M. scrofulaceum</span>infection is exceptional. Since the first report in 1971<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> we have found only 10 cases described in the literature, 6 of these in adults: one patient had an HIV infection,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 2 leukaemia,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> in another the immunological situation was unknown<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the other 2 did not have known immunodeficiency, except mild lymphopaenia in one of them.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Our patient was also immunosuppressed due to chronic treatment with golimumab. This is an anti-tumour necrosis factor (anti-TNF) monoclonal antibody, which acts by decreasing the immune response through blocking this proinflammatory cytokine. It is employed in diseases such as rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. However, due to its action on the immune system, it can increase the risk of bacterial infections, infections by mycobacteria (mainly tuberculosis but also atypical), or opportunistic/invasive fungal infections.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> As with other anti-TNFs cases of reactivation of latent tuberculosis have been described with the use of golimumab,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> so it is essential to rule out this possibility and treat it if necessary, before starting treatment with this drug. In our patient, latent tuberculosis infection was ruled out by a Mantoux test (0<span class="elsevierStyleHsp" style=""></span>mm) before starting treatment. The risk of infection by nontuberculous mycobacteria is also heightened in patients treated with anti-TNF, most often by <span class="elsevierStyleItalic">M. avium complex</span>.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However, we have not found any described cases of infection by <span class="elsevierStyleItalic">M. scrofulaceum</span> in the literature to date associated with the use of golimumab, nor with other anti-TNFs.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding treatment, just as with TB, discontinuation of the anti-TNF drug is recommended while treating the infection. Regarding antibiotic treatment, the regimen to be followed is not protocolised and neither is its duration. Given that <span class="elsevierStyleItalic">M. scrofulaceum</span> demonstrates higher rates of resistance that other mycobacteria<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> combination therapy guided by antibiogram is recommended for at least a year, individualised according to the immunocompetence level of the patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">There are no conflicts of interest and this paper has not been funded by an institution.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Ojea C, Longueira Suárez L, Sousa Dominguez A, Crespo Casal M. Infección diseminada por <span class="elsevierStyleItalic">Mycobacterium scrofulaceum</span> en paciente en tratamiento con golimumab. Enferm Infecc Microbiol Clin. 2020;38:139–140.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1286 "Ancho" => 1300 "Tamanyo" => 174151 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">TAC cross-section where multiple pulmonary micronodules can be observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disseminated Mycobacterium scrofulaceum Infection in an Immunocompetent Host" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 3 | 12 |
| 2024 October | 20 | 2 | 22 |
| 2024 September | 34 | 5 | 39 |
| 2024 August | 28 | 3 | 31 |
| 2024 July | 19 | 6 | 25 |
| 2024 June | 17 | 1 | 18 |
| 2024 May | 5 | 3 | 8 |
| 2024 April | 17 | 3 | 20 |
| 2024 March | 35 | 3 | 38 |
| 2024 February | 35 | 4 | 39 |
| 2024 January | 12 | 1 | 13 |
| 2023 December | 32 | 6 | 38 |
| 2023 November | 33 | 6 | 39 |
| 2023 October | 31 | 2 | 33 |
| 2023 September | 14 | 2 | 16 |
| 2023 August | 20 | 5 | 25 |
| 2023 July | 14 | 6 | 20 |
| 2023 June | 6 | 3 | 9 |
| 2023 May | 14 | 2 | 16 |
| 2023 April | 10 | 0 | 10 |
| 2023 March | 13 | 1 | 14 |
| 2023 February | 22 | 1 | 23 |
| 2023 January | 26 | 6 | 32 |
| 2022 December | 31 | 4 | 35 |
| 2022 November | 33 | 7 | 40 |
| 2022 October | 27 | 7 | 34 |
| 2022 September | 32 | 10 | 42 |
| 2022 August | 37 | 8 | 45 |
| 2022 July | 29 | 4 | 33 |
| 2022 June | 22 | 5 | 27 |
| 2022 May | 26 | 7 | 33 |
| 2022 April | 37 | 5 | 42 |
| 2022 March | 57 | 4 | 61 |
| 2022 February | 52 | 5 | 57 |
| 2022 January | 51 | 6 | 57 |
| 2021 December | 22 | 7 | 29 |
| 2021 November | 54 | 7 | 61 |
| 2021 October | 39 | 12 | 51 |
| 2021 September | 18 | 6 | 24 |
| 2021 August | 19 | 9 | 28 |
| 2021 July | 13 | 11 | 24 |
| 2021 June | 13 | 7 | 20 |
| 2021 May | 33 | 7 | 40 |
| 2021 April | 47 | 10 | 57 |
| 2021 March | 26 | 8 | 34 |
| 2021 February | 14 | 5 | 19 |
| 2021 January | 13 | 4 | 17 |
| 2020 December | 8 | 4 | 12 |
| 2020 November | 7 | 7 | 14 |
| 2020 October | 7 | 3 | 10 |
| 2020 September | 4 | 4 | 8 |
| 2020 August | 1 | 0 | 1 |
| 2020 March | 1 | 0 | 1 |
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