Case Presentation:
A 56‐year old female with a history only significant for hernia repair and colonoscopy six months prior to admission presented with a fever for a week, generalized abdominal pain and vomiting. Physical examination revealed an ill‐appearing woman with bilateral costo‐vertebral tenderness. Diagnostic data revealed a serum white cell count (WBC) of 22.9 k/ul. Urine analysis revealed WBC of 25‐50/hpf and moderate bacteria. Blood cultures grew E.coli. Antibiotic coverage with levofloxacin was initiated. However due to persistent fevers, computed tomography (CT) of the abdomen was ordered, revealing pyleonephrites with out abcess. Repeat CT a few days later due to the continued fevers revealed a resolution of pylenonephrites. Fever persisted for 3 weeks despite the change in the antibiotic class and expansion of the antimicrobial coverage. Repeat blood cultures and urine cultures were negative. Evaluation of fever of unknown origin included trans‐esophageal echocardiogram, MRI of lumbar spine and cerebrospinal fluid analysis all of which were normal. During her hospital stay the patient gradually became pancytopenic requiring filgrastim therapy and blood transfusion. Evaluation for hemolytic process was negative. EGD and Colonoscopy was normal. Autoimmune serologies were negative. Bone marrow biopsy revealed acid‐fact bacilli with DNA polymerase chain reaction (PCR), and revealed M.chelonae. Patient was started on Clarithromycin and Gatifloxacin during which the fever resolved. The source of infection was likely related to colonoscopy or the hernia repair.
Discussion:
M.cheloneae is a rapidly growing atypical mycobacterium, ubiquitous in the environment. M.chelonae infection is most commonly seen in patients with immunosupression and tumors. Cutaneous infections are the most common presentation and are associated with cosmetic procedures like facelifts, breast augmentation and liposuction. Infection by Mycobacterium chelonae has been reported following some surgical and medical procedures, including small outbreaks related to endoscopies and bronchoscopy has been reported. Dual therapy with clarithromycin and a fluroquinolone for 6 months should be initiated. This is the first reported case of disseminated M.chelonae in a immunocompetent host without other cutaneous or organ manifestation.
Conclusion:
M chelonae typically cause infection in immune competent hosts following minor procedures. Rarely, disseminated infections have been reported in immunosupressed hosts. We report a t a surreptitious case of disseminated M.chelonae infection with no cutaneous lesions or internal solid organ involvement in an immunocompetent patient as the cause of fever of unknowm origin. Hospitalists should carefully review patient history of surgeries and procedures‐ even minor ones ‐and will still need a low threshold of suspicion to detect this unusual infection.
Author Disclosure Block:
V. Bala, None; D. Dressler, None.