Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report
Abstract Background Non-Tuberculous Mycobacterial–pulmonary disease (NTM-PD) is increasing in incidence and prevalence. Mycobacterium abscessus (M.abscessus) is a rapid growing multi-resistant NTM associated with severe NTM-PD requiring prolonged antibiotic therapy. Complications of therapy are comm...
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| Format: | Article |
| Language: | English |
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BMC
2018-11-01
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| Series: | BMC Pulmonary Medicine |
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| Online Access: | http://link.springer.com/article/10.1186/s12890-018-0732-3 |
| _version_ | 1818601813295759360 |
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| author | C. Addy G. Doran A. L. Jones G. Wright S. Caskey D. G. Downey |
| author_facet | C. Addy G. Doran A. L. Jones G. Wright S. Caskey D. G. Downey |
| author_sort | C. Addy |
| collection | DOAJ |
| description | Abstract Background Non-Tuberculous Mycobacterial–pulmonary disease (NTM-PD) is increasing in incidence and prevalence. Mycobacterium abscessus (M.abscessus) is a rapid growing multi-resistant NTM associated with severe NTM-PD requiring prolonged antibiotic therapy. Complications of therapy are common but reports on direct complications of active NTM-PD are rare. Vasculitis has been described as a rare complication of NTM-PD, most often in individuals with inherited immune defects. This case is the first to describe an ANCA positive vasculitide (Microscopic Polyangiitis) secondary to M.abscessus pulmonary disease. Case presentation A 70 year old female with bronchiectasis underwent a clinical decline associated with the growth of M.abscessus and was diagnosed with NTM-PD. Before treatment could be initiated she developed small joint arthralgia and a glove and stocking axonal loss sensorimotor neuropathy. Positive Perinuclear Anti-Neutrophil Cytoplasmic Antibodies (P-ANCA) and Myeloperoxidase-ANCA (MPO-ANCA) titres led to a diagnosis of microscopic polyangiitis. Further investigation revealed reduced interferon-gamma production but no other significant immune dysfunction. Dual treatment with immunosuppressive therapy (Corticosteroids/Cyclophosphamide) for vasculitis and antimicrobial therapy for M.abscessus NTM-PD was initiated. Clinical stability was difficult to achieve with reductions in immunosuppression triggering vasculitic flares. One flare led to retinal vein occlusion with impending visual loss requiring escalation in immunosuppression to Rituximab infusions. An increase in immunosuppression led to a deterioration in NTM-PD necessitating alterations to antibiotic regimes. Adverse effects including alopecia and Achilles tendonitis have further limited antibiotic choices resulting in a strategy of pulsed intra-venous therapy to stabilise NTM-PD. Conclusions This is the first reported case of an ANCA positive vasculitis secondary to M.abscessus pulmonary disease. This rare but important complication had a significant impact on the patient adding to the complexity of an already significant disease and treatment burden. The potential role of reduced interferon-gamma production in this case highlights the importance of investigating immune function in those with mycobacterial infection and the intricate relationship between mycobacterial infection and immune dysfunction. Immune dysfunction caused by genetic defects or immunosuppressive therapy is a known risk factor for NTM-PD. Balancing immunosuppressive therapy with prolonged antimicrobial treatment is challenging and likely to become more common as the number of individuals being treated with biologics and immunosuppressive agents increases. |
| first_indexed | 2024-12-16T12:57:21Z |
| format | Article |
| id | doaj.art-56f0815084b347ff928c559747de1a29 |
| institution | Directory Open Access Journal |
| issn | 1471-2466 |
| language | English |
| last_indexed | 2024-12-16T12:57:21Z |
| publishDate | 2018-11-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Pulmonary Medicine |
| spelling | doaj.art-56f0815084b347ff928c559747de1a292022-12-21T22:30:58ZengBMCBMC Pulmonary Medicine1471-24662018-11-011811910.1186/s12890-018-0732-3Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case reportC. Addy0G. Doran1A. L. Jones2G. Wright3S. Caskey4D. G. Downey5Centre for Experimental Medicine, Queen’s University BelfastRegional Respiratory Centre, Belfast City HospitalDepartment of Respiratory Medicine, Royal Brompton HospitalsDepartment of Rheumatology, Musgrave Park HospitalRegional Respiratory Centre, Belfast City HospitalCentre for Experimental Medicine, Queen’s University BelfastAbstract Background Non-Tuberculous Mycobacterial–pulmonary disease (NTM-PD) is increasing in incidence and prevalence. Mycobacterium abscessus (M.abscessus) is a rapid growing multi-resistant NTM associated with severe NTM-PD requiring prolonged antibiotic therapy. Complications of therapy are common but reports on direct complications of active NTM-PD are rare. Vasculitis has been described as a rare complication of NTM-PD, most often in individuals with inherited immune defects. This case is the first to describe an ANCA positive vasculitide (Microscopic Polyangiitis) secondary to M.abscessus pulmonary disease. Case presentation A 70 year old female with bronchiectasis underwent a clinical decline associated with the growth of M.abscessus and was diagnosed with NTM-PD. Before treatment could be initiated she developed small joint arthralgia and a glove and stocking axonal loss sensorimotor neuropathy. Positive Perinuclear Anti-Neutrophil Cytoplasmic Antibodies (P-ANCA) and Myeloperoxidase-ANCA (MPO-ANCA) titres led to a diagnosis of microscopic polyangiitis. Further investigation revealed reduced interferon-gamma production but no other significant immune dysfunction. Dual treatment with immunosuppressive therapy (Corticosteroids/Cyclophosphamide) for vasculitis and antimicrobial therapy for M.abscessus NTM-PD was initiated. Clinical stability was difficult to achieve with reductions in immunosuppression triggering vasculitic flares. One flare led to retinal vein occlusion with impending visual loss requiring escalation in immunosuppression to Rituximab infusions. An increase in immunosuppression led to a deterioration in NTM-PD necessitating alterations to antibiotic regimes. Adverse effects including alopecia and Achilles tendonitis have further limited antibiotic choices resulting in a strategy of pulsed intra-venous therapy to stabilise NTM-PD. Conclusions This is the first reported case of an ANCA positive vasculitis secondary to M.abscessus pulmonary disease. This rare but important complication had a significant impact on the patient adding to the complexity of an already significant disease and treatment burden. The potential role of reduced interferon-gamma production in this case highlights the importance of investigating immune function in those with mycobacterial infection and the intricate relationship between mycobacterial infection and immune dysfunction. Immune dysfunction caused by genetic defects or immunosuppressive therapy is a known risk factor for NTM-PD. Balancing immunosuppressive therapy with prolonged antimicrobial treatment is challenging and likely to become more common as the number of individuals being treated with biologics and immunosuppressive agents increases.http://link.springer.com/article/10.1186/s12890-018-0732-3Non-tuberculous mycobacteriaNon-tuberculous mycobacterial pulmonary disease Mycobacterium abscessusVasculitisInterferon-gammaBronchiectasis |
| spellingShingle | C. Addy G. Doran A. L. Jones G. Wright S. Caskey D. G. Downey Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report BMC Pulmonary Medicine Non-tuberculous mycobacteria Non-tuberculous mycobacterial pulmonary disease Mycobacterium abscessus Vasculitis Interferon-gamma Bronchiectasis |
| title | Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report |
| title_full | Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report |
| title_fullStr | Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report |
| title_full_unstemmed | Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report |
| title_short | Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report |
| title_sort | microscopic polyangiitis secondary to mycobacterium abscessus in a patient with bronchiectasis a case report |
| topic | Non-tuberculous mycobacteria Non-tuberculous mycobacterial pulmonary disease Mycobacterium abscessus Vasculitis Interferon-gamma Bronchiectasis |
| url | http://link.springer.com/article/10.1186/s12890-018-0732-3 |
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