Letter to the Editor
Pulmonary cavity due to Mycobacterium malmoense: Diagnosis with bronchoalveolar lavage following percutaneous instillation of normal saline
Cavitación pulmonar por Mycobacterium malmoense: diagnóstico por lavado broncoalveolar tras instilación percutánea de suero salino
Luis Gorospe Sarasúaa,
, Pilar Martín-Dávilab, Pilar Navío-Martínc, Margarita Martín-Martínd
Corresponding author
a Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain
d Servicio de Oncología Radioterápica, Hospital Universitario Ramón y Cajal, Madrid, Spain
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"<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Pilar" "apellidos" => "Navío-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Margarita" "apellidos" => "Martín-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Oncología Radioterápica, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cavitación pulmonar por <span class="elsevierStyleItalic">Mycobacterium malmoense:</span> diagnóstico por lavado broncoalveolar tras instilación percutánea de suero salino" ] ] "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" => 622 "Ancho" => 1500 "Tamanyo" => 87107 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Coronal CT image <span class="elsevierStyleItalic">minimal intensity projection</span> (MinIP), showing communication of the cavitary lesion (asterisk) of the right lung apex, with sub-segmental apical bronchi (arrow) of RUL. (B) Axial image of chest CT (lung parenchyma) with the patient in ventral decubitus, in which the end of the needle (arrow) is detected within the cavitary lesion (asterisk), immediately before proceeding to saline instillation inside.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) does not recognize a positive percutaneous aspirate culture as microbiological diagnostic criteria, valid for the diagnosis of pulmonary nontuberculous mycobacterial disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> A case of focal pulmonary disease, cavitated by <span class="elsevierStyleItalic">Mycobacterium malmoense</span>, microbiologically confirmed after intracavitary instillation of saline and CT-guided aspiration. A subsequent bronchoalveolar lavage (BAL) culture also isolated <span class="elsevierStyleItalic">Mycobacterium malmoense</span>. A BAL made a few weeks earlier had been negative. We believe that, if a positive culture of the aspirate from the pulmonary focal lesions was to be included in the criteria for the diagnosis of pulmonary nontuberculous mycobacterial diseases, the diagnosis of these infections would be easier.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 43-year-old Colombian woman, who consulted for cough of several weeks of evolution. 5 years earlier she had been diagnosed of cervical carcinoma. It was treated with radiotherapy and chemotherapy, with no evidence of tumour relapse. A thin-walled cavitary lesion in the right upper lobe (RUL) was detected in a chest computed tomography (CT), accompanied by several small sub-millimetric range satellite nodules, which were infectious in appearance. This cavitary lesion appeared to communicate in multiplanar reconstructions of CT with the airway (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Two sputum cultures were negative. A RUL apical segment selective BAL was negative for malignant cells and infectious organisms. A percutaneous fine needle aspiration of the cavitary lesion was decided, given the slow but steady growth of the cavitary lesion in a new chest CT. Such procedure was CT-guided, performing a 20<span class="elsevierStyleHsp" style=""></span>ml saline instillation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), and an aspirate through the same needle, 3<span class="elsevierStyleHsp" style=""></span>min after 10<span class="elsevierStyleHsp" style=""></span>ml of cloudy liquid. The procedure was uneventful, sending part of the sample obtained to pathology, and another to microbiology, for their appropriate processing. Multiple acid-fast bacilli were detected in the aspirate liquid in the immediate microbiological analysis; no tumour cells were identified in the sample submitted to pathology. The next day, the patient was scheduled for a new guided BAL of the RUL, procedure which was performed in the same way as the previous BAL; the RUL apical segment was washed with 100<span class="elsevierStyleHsp" style=""></span>ml of saline. Both cultures, the percutaneous CT-guided aspiration as well as the second BAL, were positive for <span class="elsevierStyleItalic">Mycobacterium malmoense after 46 days of incubation.</span> Treatment was initiated with 4 different drugs (rifampicin, isoniazid, clarithromycin and ethambutol), with good clinical and radiological response.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The percutaneous aspirate positive culture is not currently recognized by IDSA/ATS as a microbiological diagnostic criterion for the diagnosis of pulmonary nontuberculous mycobacterial disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However, it does consider a combination of pulmonary, transbronchial or obtained-by-other-means biopsy as a valid diagnostic criterion if there are histopathological findings of granulomatous inflammation together with a positive culture of lung biopsy, BAL or sputum. This criterion can be a little strict, as it excludes (non-histological) liquid aspirates in cases like ours, in which a tissue sample that can be processed histologically is not obtained, and, therefore, histopathological findings of granulomatous inflammation cannot be demonstrated. CT-guided percutaneous aspiration of infectious foci (cavitated or not) is a safe and cost-effective diagnostic technique in the detection and culture of multiple infectious agents.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> To the best of our knowledge, and in line with other authors, if the criteria for the diagnosis of pulmonary nontuberculous mycobacterial diseases were to include positive cultures from pulmonary focal lesion aspirates, the diagnosis of these infections would be easier.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Unfortunately, some of these pulmonary nodular lesions need to be surgically removed in order to reach a definitive microbiological diagnosis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Percutaneous CT-guided aspiration of isolated cavitated infectious pulmonary lesions allows to easily differentiate fungal infections or bacterial abscesses from mycobacterial infections.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> We believe that the sequential completion of percutaneous CT-guided lavage/aspiration of a cavitated lesion followed by a BAL, as performed in the case of our patient, may increase in some cases the diagnostic yield of BAL, if this has previously proved negative for microorganisms. At the same time, it meets one of the IDSA/ATS microbiological diagnostics criteria, that is, a positive BAL. We have not found in the scientific literature a sequential diagnostic approach, percutaneous lavage/aspiration followed by BAL of an infectious cavitary lung lesion. We have not found any cases of lung disease due to <span class="elsevierStyleItalic">Mycobacterium malmoense</span> percutaneously diagnosed after a cavitary lesion aspirate.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gorospe Sarasúa L, Martín-Dávila P, Navío-Martín P, Martín-Martín M. Cavitación pulmonar por <span class="elsevierStyleItalic">Mycobacterium malmoense:</span> diagnóstico por lavado broncoalveolar tras instilación percutánea de suero salino. Med Clin (Barc). 2017;148:191–192.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 1500 "Tamanyo" => 87107 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Coronal CT image <span class="elsevierStyleItalic">minimal intensity projection</span> (MinIP), showing communication of the cavitary lesion (asterisk) of the right lung apex, with sub-segmental apical bronchi (arrow) of RUL. (B) Axial image of chest CT (lung parenchyma) with the patient in ventral decubitus, in which the end of the needle (arrow) is detected within the cavitary lesion (asterisk), immediately before proceeding to saline instillation inside.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.E. Griffith" 1 => "T. Aksamit" 2 => "B.A. Brown-Elliott" 3 => "A. Catanzaro" 4 => "C. Daley" 5 => "F. 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| 2023 March | 2 | 2 | 4 |
