A 41-year-old Korean woman complained of a slight cough without dyspnea or a fever. She was referred to our department by her primary care physician. She was affected by tuberculosis when she was 34 years of age in Korea and treated with unspecified chemotherapy; no signs of relapses occurred until 41 years of age. The precise data regarding her past clinical history in Korea were unavailable. Her hearing ability was lost completely due to unknown reasons. She had no history of diabetes mellitus or other immunosuppressive diseases. Physical examinations at the initial visit showed a height of 162.0 cm, body weight of 58.0 kg, arterial blood pressure of 102/58 mmHg, pulse rate of 74/min, and body temperature of 36.5  C. The breath sounds were decreased in the left lung. No lymphadenopathy was found. Her laboratory examinations are shown in Table 1. The white blood cell count was within the normal range and C-reactive protein (CRP) level was increased to 2.91 mg/dL. The carcinoembryonic antigen (CEA) value was normal, however, the soluble interleukin-2 receptor (sIL-2R) value was increased to 1094 U/mL. The blood glucose level was normal and HIV antibody was negative. The serum immunoglobulin levels were normal. Both CD4+ and CD8+ lymphocyte counts were in the normal ranges. An interferon-gamma release assay (Cellestis Company, QuantiFERON  TB Gold) was negative. The antigens for urine Streptococcus pneumoniae and Legionella pneumophila were negative. The bacterial culture, acid-fast bacilli smear and culture, and polymerase chain reaction (PCR) tests for Mycobacterium tuberculosis, M. avium, and Mycobacterium intracellulare of the sputum were all negative. A chest X-ray and CT scan showed a broad consolidation with an angiogram sign throughout the upper-lobe of left lung, however, other imaging findings such as cavity lesions, small nodules, and bronchiectasis were not observed (Fig. 1A-C). Lymph nodes around the arch of the aorta and under the carina of the trachea were slightly enlarged. PET/CT showed a high SUVmax of 26.9 on the consolidation shadow (Fig. 1D). Transbronchial aspiration cytology (TBAC) could not obtain adequate specimens from the consolidation due to stenosis of the left upper lobe bronchus. The cytodiagnosis, common bacterium culture, acid-fast bacilli smear and the PCR tests for M. tuberculosis, M. avium, and M. intracellulare of the lavage fluid were all negative. Furthermore, the acid-fast bacilli culture of the lavage fluid was negative. Thus, a CT-guided percutaneous needle lung biopsy was performed and the biopsy specimens showed caseous granulomas without atypical cells by hematoxylin and eosin (H&E) staining (Fig. 2), but no bacteria by Kinyoun staining. The bacterial culture, acid-fast bacilli smear, acid-fast bacilli culture and PCR tests for M. tuberculosis, M. avium, and M. intracellulare of the biopsy specimens were negative. The consolidation of the left lung enlarged and left pleural effusion developed one week following the lung biopsy (Fig. 1E). Thus, we performed a diagnostic puncture in the left thorax. The pleural effusion was lymphocyte predominant and serological tests showed a total protein (TP) concentration of 5.0 g/dL, albumin of 2.5 g/dL, lactate dehydrogenase (LD) of 223 IU/L, glucose of 95 mg/dL, immunoglobulin G (IgG) of 1216 mg/dL, and adenosine deaminase (ADA) of 84.3 U/L. Effusion specimens were negative for antinuclear antibody (ANA) and rheumatoid factor (RF). The acid-fast bacilli smear and PCR tests for M. tuberculosis, M. avium, and M. intracellulare of the effusion were all negative Finally, M. avium was cultured from the left pleural effusion and we diagnosed the patient with M. avium infection.
Because ethambutol (EB) was thought to be unsuitable due to her complete hearing loss, combination chemotherapy with rifampicin (RFP) 450 mg, clarithromycin (CAM) 800 mg, and levofloxacin (LVFX) 500 mg were administered. The chest image significantly improved after two years of this chemotherapy (Fig. 1F).
CT. scan at the initial visit revealed broad consolidation with a positive angiogram sign (arrow) throughout the upper-lobe of the left lung.