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Atypical Mycobacterial Infection: Differential Diagnoses & Workup

Author: Arry Dieudonne, MD, Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital
Coauthor(s): James M Oleske, MD, MPH, François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary, Allergy, Immunology and Infectious Diseases, Department of Pediatrics, New Jersey Medical School; Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Sep 18, 2009

Differential Diagnoses

Other Problems to Be Considered

Rule out any malignant process such as lymphoma and metastatic Kaposi sarcoma and other nonmalignant etiologies, such as bacterial adenitis, mononucleosis, toxoplasmosis, tuberculous lymphadenitis, and catscratch disease in children with suppurative lymphadenitis or persistent generalized lymphadenopathies.7 HIV infection per se may cause multiorgan involvement accompanied by all the systemic symptoms observed in disseminated M avium complex (MAC) disease. Other immunodeficiencies such as severe combined immunodeficiency and IFN-gamma receptor ligand-binding deficiency should be investigated, especially in patients without AIDS with disseminated MAC disease.62

Workup

Laboratory Studies

  • Organisms from blood, biopsy material, bone marrow, and stools grow on routine bacterial media, but growth is best achieved using selective mycobacterial media, such as a Lowenstein-Jensen medium or Middlebrook 7K10 and 7K11 agar.54,63
  • Nucleic acid hybridization probes using target sequences or ribosomal RNA are available for rapid identification of clinical isolates.55
  • Species can be identified using high-performance liquid chromatography or biochemical tests.
  • Polymerase chain reaction (PCR)-restriction analysis of clinical isolates have been used for the identification of M kansasii.64
  • Disseminated M avium complex (MAC) disease is most commonly diagnosed using culture of blood and bone marrow or other normally sterile tissues or body fluids. Other ancillary studies, such as acid-fast bacilli smear or radiographic imaging of the abdomen or mediastinum for detection of lymphadenopathy, may provide supportive diagnosis information.

Imaging Studies

  • In patients without AIDS, the classic radiographic picture of the chest mimics reactivation tuberculosis. A second presentation includes the presence of patchy nodular infiltrates, without cavities in a nodular distribution.53 Those features are mostly observed in adults with chronic bronchitis and emphysema. Evidence of bronchiectasis is detectable on CT scanning.65,66
  • Multiple enlarged retroperitoneal and mesenteric lymph nodes can be observed on CT scanning of the abdomen.
  • Large bulky adenopathy may be observed on autopsy findings.
  • Some experts recommend fine-needle percutaneous aspiration to confirm the diagnosis.67

Procedures

  • Bone marrow aspirate, when biopsy is performed, may show hypocellularity and presence of foamy histiocytes.
  • Acid-fast stain and culture of bone marrow specimen may reveal the presence of MAC.

Histologic Findings

The histologic findings associated with MAC vary considerably and range from granulomas to nodular foam cell lesions to purulent and necrotizing inflammations.68 In 1994, Torriani et al studied a retrospective cohort of 44 AIDS patients with MAC bacteremia and complete autopsies over a period of 4 years.69 They found that 30% had no histologic evidence of MAC. In the remaining 70%, reticuloendothelial and gastrointestinal involvement was most common. However, the number and distribution of involved sites was variable. Derived from this study's findings, MAC bacteremia may precede widespread tissue disease, and the risk of development of detectable histologic involvement was related to the duration of bacteremia.69

More on Atypical Mycobacterial Infection

Overview: Atypical Mycobacterial Infection
Differential Diagnoses & Workup: Atypical Mycobacterial Infection
Treatment & Medication: Atypical Mycobacterial Infection
Follow-up: Atypical Mycobacterial Infection
References
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Further Reading

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Keywords

atypical mycobacteria, mycobacterial disease, mycobacterial infection, Mycobacterium tuberculosis, M tuberculous, nontuberculous mycobacteria, NTM, lymphadenitis, Mycobacterium avium complex infection, disseminated MAC disease, MAC infection, HIV-associated infections, human immunodeficiency virus, highly active antiretroviral therapy, HAART, interferon-gamma, IFN-gamma, opportunistic infections, Buruli ulcer, IFN-gamma receptor ligand-binding deficiency, Mycobacterium phlei, Mycobacterium aurum, Mycobacterium flavescens, Mycobacterium vaccae, Mycobacterium neoaurum, Mycobacterium thermoresistible, Mycobacterium smegmatis, Mycobacterium scrofulaceum, Bacillus Calmette-Guérin, AIDS, pulmonary disease, Mycobacterium ulcerans, Buruli ulcer, cystic fibrosis, CF

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Contributor Information and Disclosures

Author

Arry Dieudonne, MD, Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital
Arry Dieudonne, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Coauthor(s)

James M Oleske, MD, MPH, François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary, Allergy, Immunology and Infectious Diseases, Department of Pediatrics, New Jersey Medical School
James M Oleske, MD, MPH is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Pediatrics, American Public Health Association, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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