Bolton-Maggs, Colman, Dixon, Myskow, Williams, Donnelly, Hind
steroids and the addition ofchlorambucil per-
treated with chlorambucil for a year and was
symptom free on no treatment at the time of
reporting.3 A review of 15 cases ofpulmonary
phoma" showed monoclonality in 13 (includ-
with diffuse or patchy lung shadowing on
radiography had been treated with a mixture
steroids, two receiving steroids and chloram-
bucil alone. One of these was lost to follow
up and the other had a clinical response with
no change in the radiographic appearance.4
Insufficient detail is given in this and other
reports8 to evaluate the regimens used. Two
of a reported series of 13 patients with lym-
phocytic interstitial pneumonitis were treated
with chlorambucil and steroids with improve-
ment in one.'0 There is no consensus estab-
lished for the treatment of these conditions.
histologically these patients have low
grade lymphoma, we chose to treat our two
agents well tried and effective for other types
of low grade B cell lymphoma and chronic
lymphatic leukaemia and used successfully in
some patients with "pseudolymphoma". To
all three pseudolymphomas).
date this approach has produced a good
response in these two patients.
1 Saltzstein SL. Pulmonary malignant lymphomas and
pseudolymphomas: classification, therapy and progno-
sis. Cancer 1963;16:928-55.
2 Gibbs AR, Seal ME. Primary lymphoproliferative condi-
tions ofthe lung. Thorax 1978;33:140-52.
3 Herbert A, Wright DH, Isaacson PG, Smith JL. Primary
malignant lymphoma of the lung. Hum Pathol 1984;15:
4 Addis BJ, Hyjek E, Isaacson PG. Primary pulmonary lym-
phoma: a reappraisal of its histogenesis and its relation-
to pseudolymphoma and lymphoid
pneumonia. Hisroparhology 1988;13:1-17.
5 Li G, Hansmann M-L, Zwingers T, Lennert K. Primary
lymphomas of the lung: morphological, immunohisto-
chemical and clinical features. Histopathology 1990;16:
6 Robbins R, Peale AR, Al-Saleem T. Pseudolymphomas.
7 Isaacson PG, Wright DH. Extranodal malignant lym-
phoma arising from mucosa-associated lymphoid tissue.
8 Kennedy JL, Nathwani NB, Burke JS, Hill RL, Rappaport
H. Pulmonary lymphomas and other pulmonary lym-
phoid lesions. Cancer 1985;56:539-52.
9 Herbert A, Walters MT, Cawley MID, Godrey RC.
Lymphocytic interstitial pneumonia identified as lym-
phoma of mucosa associated lymphoid tissue. Y Pathol
10 Strimlan CV, Rosenow EC, Weiland LH, Brown LR.
cases. Ann Inten Med 1978;88:616-21.
11 Goldman JM. The lymphomas. In: Hoffbrand AV, Lewis
SM, eds. Postgraduate haematology. 3rd edn. Oxford:
12 Krikorian JG, Portlock CS, Cooney DP, Rosenberg SA.
Spontaneous regression of non-Hodgkin's lymphoma: a
report ofnine cases. Cancer 1980;46:2093-9.
interstitial pneumonitis. Review of 13
in the blood of an HIV
D Veale, D Fishwick, J E S White,
A D Gascoigne, K Gould, P A Corris
syndrome (AIDS),' and the M avium com-
plex is the most frequently isolated subtype.2
There are few reports of isolation of non-
tuberculous mycobacteria from blood cul-
tures in non-HIV patients.3 We report a
young man with a familial myelodysplasia and
persistent Epstein-Barr virus infection who
developed widespread M kansasii infection
with isolation ofthe organism from blood cul-
J E S White
A D Gascoigne
P A Corris
Newcastle upon Tyne
Dr D Veale
Reprints will not be
Received 6 April 1992
Returned to authors
23 June 1992
Revised version received
27 July 1992
Accepted 30 July 1992
A 23 year old man with a congenital
myelodysplastic disorder and fibrosing
lung disease received
prednisolone. After nine months his con-
dition deteriorated and Mycobacterium
kansasii was isolated from blood cultures
and lymph node biopsy specimens. He
responded to antituberculous treatment.
M kansasii has not previously been iso-
lated from the blood stream ofHIV nega-
Mycobacterial bacteraemia with organisms
other than M tuberculosis (mycobacteria other
than tuberculosis, MOT) is not unusual in
A 23 year old man developed fever and
rigours five weeks after returning from a holi-
day in Spain. He then developed a cough
with clear sputum and nausea.
history he had suffered severe varicella and
recurrent herpes simplex infections and a per-
sistent Epstein-Barr virus infection from the
age of 20 years. An older brother had died of
refractory anaemia with excess lymphoblasts.
Genetic studies had determined familial dys-
chromosome 1.4 Immunological studies had
shown leucopenia with a profound lympho-
penia but no other abnormality. On examina-
tion he had
generalised lung crackles. White blood cell
count (WBC) was o09 x 109/1 and he was
HIV antibody negative. Chest radiography
showed diffuse patchy parenchymal shadow-
In his past
Culture ofMycobactenium kansasii in the blood ofan HIV negative patient Download full-text
ing. He was treated with broad spectrum
antibiotics but showed no clinical response
and was referred to the regional respiratory
centre. Open lung biopsy samples showed
Hamman-Rich syndrome. Specimens were
cultured and examined on a weekly basis, but
there was no evidence of fungi, mycobacteria,
weeks. He was treated with high dose steroids
and showed an immediate clinical and func-
Twelve months later, while taking 20 mg
acyclovir 200 mg
times a day, he became unwell and had a
recurrence of fever. No lymph nodes were
palpable but he had persistence oflung crack-
les. His haemoglobin was 92 g/dl and his
1-4 x 109/1. One week later repeat
chest radiography showed the new develop-
ment of mediastinal adenopathy and a diag-
nosis of Epstein-Barr driven lymphoma was
suspected. Large fleshly lymph nodes were
found at mediastinoscopy, and histological
bacilli which proved to be M kansasii on cul-
ture. He also developed a large pericardial
effusion which required drainage. He was
initially treated with standard antituberculous
chemotherapy comprising rifampicin, ison-
iazid, and pyrazinamide. He deteriorated,
however, on this regimen and treatment was
ethambutol, and ciprofloxacin with gradual
and sustained improvement. M kansasii was
isolated from blood cultures, sputum, peri-
cardial fluid, and mediastinal tissue. All speci-
Jensen slopes andtissue
Kirchner's broth. Blood cultures were inocu-
lated directly into the broth, then saponised.
The organism was
rifampicin, ethionamide, ciprofloxacin, capreo-
mycin, ethambutol, and cycloserine but resis-
pyrazinamide. No synergy tests were per-
formed. He did not suffer any relapse of
symptoms following completion of 12 months
treatment. The dosage of
prednisolone was gradually reduced and he
has returned to active sports.
M kansasii has been isolated from many envi-
ronmental sources including tap water5 and
grows best at 37°C. It is usually sensitive to
rifampicin and ethambutol.6 In immunocom-
petent patients treatment for between three
and 24 months resulted in cure in all cases
with no relapses after a mean follow up of five
years. M kansasii has been recorded in peri-
cardial effusion in one previous report.7
Disseminated infection with MOAr
first reported by Koch and Rabinowitsch in
1907.8 There have been numerous reports of
disseminated M avium complex infection in
patients with AIDS,29 but a study of 134
patients who were immunosuppressed from
causes other than HIV showed no isolation of
kansasii has been reported in patients with
AIDS.10 Pierce et al isolated MOTT from
blood in eight patients with non-HIV related
immunodeficiency, all of whom were on long
term steroids for a variety of conditions
including preleukaemia,3 but in none of these
was the organismM kansasii.
Bacteraemia with mycobacteria other than
M avium complex is a rare event and occurs
patients.' Isolation of M kansasii from blood
unknown in non-HIV patients. It may be that
the organism is seldom present in blood, but
it is most probably because blood culture
Technical inadequacies may also play their
part, but the development of radiometric
detection methods may improve the yield of
positive results." 12
As MOTT in immunosuppressed patients
may well be more responsive to treatment in
non-HIV patients"3 than in those with HIV, it
is important to culture specimens including
frequently obtained blood samples for a pro-
longed period with appropriate media in rele-
vant clinical situatlons.
infection with M
We wish to thank the Respiratory Pathogens section of the
Public Health Laboratory, Newcastle upon Tyne, for their
help with the isolation and identification ofthe mycobacteria.
1 Peters M, Schurmann D, Mayr AC, Hetzer R, Pohle HD,
Ruf B. Immunosuppression and mycobacteria other
than Mycobacterium tuberculosis; results from patients
with and without HIV infection. Epidemiol Infect 1989;
2 Green JB, Sidhu GS, Lewin S, Levine JF, Masur H,
intracellulare: a cause of disseminated life-threatening
infection in homosexuals and drug abusers. Ann Intern
3 Pierce PF, DeYoung DR, Roberts GD. Mycobacteremia
and the new blood culture systems. Ann Intern Med
4 Paul B, Reid MM, Davison EV, Abela M, Hamilton PJ.
Familial myelodysplasia: progressive disease associated
with emergence of monosomy 7. Br J Haematol 1987;
5 Joyson DM. Water; the natural habitat of M kansasii.
6 Banks J, Hunter AM, Campbell IA, Jenkins PA, Smith
PA. Pulmonary infection with M kansasii in Wales,
1970-9; review oftreatment and response. Thorax 1983;
7 Palmer JA, Watanakunakom C. Mycobacterium kansasii
pericarditis. Thorax 1984;39:876-7.
8 Koch M, Rabinowitsch L. Die tuberkulose der vogel und
ihre beziehungen zur sangertiertuberkulose.
Arch PatholAnat 1907;190:246.
9 Zakowski P, Fligiel S, Berlin OGW, Johnson BL Jr.
Disseminated Mycobacterium avium-intracellulare infec-
tion in homosexual men dying of acquired immuno-
deficiency. JAMA 1982;248:2980.
10 Sherer R, Sable R, Sonnenberg M, Cooper S, Spencer P,
deficiency syndrome. Ann Intern Med 1986;105:710-2.
11 Salfmnger M, Stool ED, Piot D, Heifets L. Comparison of
three methods for recovery of Mycobacterium avium
complex from blood specimens. Y Clin Microbiol 1988;
12 Kiebn T, Cammarata
Mycobacterium avium-M intracellulare from isolator lysis-
centrifugation and BACTEC 13A blood culture sys-
tems. J7 Clin Microbiol 1988;26:760-1.
13 Horsburg CR, Mason UG, Farhi DC, Iseman MD.
Disseminated infection with Mycobacterium avium-intra-
cellulare: a report of 13 cases and a review of the litera-
ture. Medicine 1985;64:36-48.