A 51-year-old female non-smoker presented with a 6-week history of a non-productive dry cough and progressive dyspnoea. The cough was associated with pleuritic chest pain and decreased energy. She denied haemoptysis or night sweats. She reported chronic gastric reflux, ongoing for 3 years following a distal oesophagectomy, total gastrectomy and jejunal-oesophageal anastomosis for gastric adenocarcinoma, vomiting and weight loss requiring a percutaneous endoscopic gastrostomy (PEG) tube for nutritional requirements. Physical examination revealed cachexia and chest was clear to auscultation. Oxygen saturations were 100% on room air and she was apyrexial. Laboratory results showed a white cell count of 8.7 x 109/L and C-reactive protein of 64mg/L. Chest radiograph demonstrated poorly defined nodular opacities in the inferior right upper lobe and a pronounced nodular consolidation in the right mid zone.
A high-resolution CT thorax showed extensive nodular changes in the right upper and lower lobes with confluent areas of consolidation with air bronchograms, see Fig. 1. Bronchoscopy was grossly normal. A bronchoalveolar alveolar lavage was carried out. There was no growth on routine, nocardia, actinomyces or fungal culture. Mycobacterial testing did not demonstrate acid-fast bacilli and Mycobacterium species were not isolated on culture. The patient was treated with piperacillin/tazobactam and a tapering dose of oral steroids with an initial clinical response. Oral azithromycin was added antimicrobial activity, pro-kinetic activity and anti-inflammatory action. Over the next 12 weeks she did not improve. Repeat bronchoscopy was again negative for bacterial and mycobacterial culture. A CT guided lung biopsy was carried out with negative culture. Steroid dose was increased to treat features of organising pneumonia. No granulomatous inflammation was observed on histology.
The patient continued to complain of cough, dyspnoea and high-volume vomitus, up to 2 L per day and weight loss to 39kg. Clinical signs deteriorated with bronchial breathing and audible crackles bilaterally. A Video Assisted Thoracic Surgery (VATS) guided right sided lung biopsy was undertaken. Histology demonstrated necrotising granulomatous inflammation, caseous necrosis and auramine-positive tubercle bacilli in association with an organising pneumonia. Mycobacterial culture demonstrated acid-fast bacilli on microscopy. GeneXpert did not detect MTB complex DNA. The patient was started on empiric treatment for non-tuberculous mycobacteria (NTM) with intravenous (IV) amikacin, IV meropenem, IV clarithromycin and oral ciprofloxacin and oral doxycycline. Culture was ultimately positive for Mycobacterium goodii (Fig. 2). The reference laboratory reported resistance to clarithromycin and ceftriaxone and susceptibility to ciprofloxacin, amikacin, cotrimoxazole, doxycycline, imipenem, linezolid and co-amoxiclav. Meropenem minimum inhibitory concentration was 1.0 mug/ml. Clarithromycin was stopped on identification of this organism. She was treated with 6 weeks IV therapy and changed to oral ciprofloxacin and doxycycline. She was subsequently changed to sulfamethoxazole/trimethoprim and ciprofloxacin.
Her course was complicated by ongoing gastric dysmotility, vomiting and aspiration pneumonia affecting tolerance of anti-mycobacterial medications. A palliative medical referral, for specific symptom control only, recommended the addition of octreotide, commenced at 1000mcgs and metoclopramide 40 mgs, subcutaneously (s/c) in 24 hours. The octreotide was increased to 2000mcgs and metoclopramide to 60 mgs s/c in 24 hours in the following week. On day 3 of this treatment she began to eat for the first time in months, volume of vomitus reduced to minimal. She was converted to somatostatin long acting depot, somatuline autogel 90 mgs deep s/c per month and domperidone 20 mgs half hour per-prandial. PEG feeding was discontinued. Over years her somatuline dose was monitored, eighteen months later her somatuline was discontinued as her symptoms were well controlled. Following discontinuation, she developed a further aspiration pneumonia. Depot somatuline 90 mgs deep s/c per month recommenced with no further aspiration pneumonia and continued weight gain.
Her dysmotility symptoms were controlled with this regimen and she tolerated her anti mycobacterial therapy. Treatment with continued with dual oral therapy for 2 years and a decision was made to continue lifelong sulfamethoxazole/trimethoprim monotherapy with regular outpatient monitoring. The cavitation and consolidation seen on radiology resolved and patient symptomatically improved.
CT thorax showing extensive nodular changes in the right upper and lower lobes with confluent areas of consolidation with air bronchograms and several foci of consolidation.