MYCOBACTERIUM AVIUM INTRACELLULARAE COMPLEX ASSOCIATED
EXTRAPULMONARY AXILLARY LYMPHADENITIS IN A HIV-SEROPOSITIVE
INFANT — A RARE CASE REPORT
*S Mahapatra, A Mahapatra, S Tripathy, G Rath, AK Dash, A Mahapatra
Opportunistic infections by Mycobacterium avium intracellulare complex in HIV infected patients, though common in
adults, are rarely seen in infants. We herewith report an interesting case of an eight month old infant presenting with
isolated axillary lymphadenitis, later on diagnosed to be tubercular lymphadenitis by Mycobacterium avium intracellulare
and finally proved to be seropositive for HIV infection born to previously undetected HIV seropositive parents.
Key words: Mycobacterium avium intracellulare, extrapulmonary, axillary lymphadenitis
*Corresponding author (email: <email@example.com>)
Department of Pathology (SM, AKD, GR), Department of
Microbiology (AM) and Department of Paediatrics (AM), MKCG
Medical College, Berhampur – 760 004, Ganjam Orissa.
The association of HIV infection with tuberculosis was
first recognised in Haitians and intravenous dr ug abusers.1,2
Tuberculosis is now recognised as one of the most common
opportunistic infections seen in HIV seropositive patients,
mostly presenting in the form of pulmonary, extrapulmonary
and disseminated opportunistic infections. The most frequent
form of extrapulmonary tuberculosis in patients with HIV
infection are lymphadenitis and milliary disease.3,4 The
diagnosis of extrapulmonary tuberculosis is usually made
presumptively by aspiration biopsy of the lymph nodes along
with demonstration of acid fast bacilli in 67-90% of these
Herewith, we report an unusual case of extrapulmonary
axillary tubercular lymphadenitis by Mycobacterium avium-
intracellulare complex (MAC) in a previously undetected HIV
An eight month old infant was brought to the paediatric
out patient department of MKCG Medical College Hospital
with clinical features of fever, weight loss and isolated left
axillary lymphadenopathy of four week duration. The infant
was earlier treated with antimalarials and antibiotics with no
Parents gave the history of vaccination against OPV, DPT
and BCG. The child was born at home out of non-
consanguineous marriage and was from a low socioeconomic
status. On examination, the child was cachectic (5 kgs),
irritable, febrile and pale. Systemic examination revealed no
significant abnormality. The only consistent finding was
isolated left axillary lymphadenopathy. The mass was two
centimeters in diameter, non-tender and mobile. All
haematological parameters were within normal limits and X-
ray chest did not reveal any abnormality. Fine needle
aspiration cytology (FNAC) of the left axillary lymphnode
showed presence of large number of foamy histiocytes
admixed with reactive lymphoid cells on a highly necrotic
background and absence of epithelioid cells and Langhan’s
giant cells (Fig. 1a) raised the suspicion of an atypical
mycobacterial infection. On Ziehl Neelsen (Z–N) staining of
the cytoaspirate large numbers of acid fast bacilli (Fig. 1b)
were found both inside and outside these histiocytes. Both the
parents and infant were advised for HIV test and all of them
were found to be seropositive for HIV I antibody by ERS
(ELISA rapid and simple method).
For further confirmation, the cytoaspirate was subjected
to culture on Lowenstein Jensen (LJ) medium. LJ medium
Indian Journal of Medical Microbiology, (2005) 23 (3):192-194
Figure 1: (a) Cytoaspirate showing scattered foamy macrophages over
a necrotic background, MGG, x 400 (inset – foamy macrophages, x1000).
(b) ZN staining of the cytoaspirate demonstrating foamy macrophages
stacked with acid fast bacilli (x1000).
revealed smooth, discrete, dull white colonies at the end of
third week of incubation (Fig. 2a). ZN staining of these
colonies revealed small deeply stained acid fast coccobacilli
(Fig. 2b). The colonies were provisionally identified as
Mycobacterium avium - intracellulare complex (MAC) based
on the morphology, slow rate of growth, inability to produce
pigment, hydrolysis of Tween-80 and the ability to produce
heat stable catalase as per stasndard procedures.7
A diagnosis of coinfection of extrapulmonary tuberculosis
(by atypical mycobacteria MAC) with HIV was made and
CD4 cell count and viral RNA load studies were requested.
Treatment was started provisionally with clarithromycin 15
mg/kg/day in divided doses and rifabutin 10mg/kg/day. The
patient responded dramatically to therapy resulting in gross
decrease in the size of the axillary node at the end of second
week and the general condition was also improved
simultaneously. The CD4
RNA load (by RNA PCR assay) was 20,000 copies/mL.
Subsequently, monotheraphy with zidovudin was added and
the patient was further kept on follow up.
cell count was 412/mL and viral
HIV infection has been a major cause of morbidity and
mortality since the first case of AIDS among children was
reported in 1982 in the United States. Perinatal transmission
of HIV accounts for 90% of paediatric AIDS cases and almost
all new HIV infection in children.8 Considerable advances,
especially in the past 5 years, in understanding the
pathogenesis, diagnosis, treatment, monitoring and prevention
of HIV infection in children has changed the epidemiology
of pediatric HIV infection all over the world. Mycobacterium
avium complex (MAC) typically occurs later in the course of
HIV disease with increasing immune suppression. Lymph
node tuberculosis accounts for 2.9% of cases in children
below one year of age.9 Lymph node affection by MAC is still
rarer in infants. MAC has a significant effect on survival
among children, with only a 50% chance of survival of seven
months after diagnosis.
Disseminated infection with MAC occurs almost
exclusively in children and adults with advanced HIV disease.
However, our case presented with only a solitary axillary
lymphadenopathy. Mycobacterium avium complex includes 3
closely related species M. avium, M. intracellulare and M.
scrofulaceum. They are intracellular organisms that proliferate
within macrophages. Defective cell mediated immunity in
children with advanced HIV disease results in uncontrolled
bacterial replication within the macrophages. Granuloma
formation is unusual and pathologic specimens are likely to
reveal macrophages filled with many bacilli as in our case. A
high tissue burden is found in lungs, liver, spleen, intestine,
bone marrow and lymph nodes. Characteristic histologic
finding of acid fast bacilli within macrophages are highly
suggestive of M. avium infection and may hasten the initiation
of therapy in children with a suspected diagnosis, but cultures
are imperative to ascertain for species identification. However,
successful cultivation of M. avium depends upon the bacillary
Our patient aged 8 months, reported to the hospital with
irregular fever, weight loss and isolated left axillary
lymphadenopathy of four months duration. The cytoaspirate
of the node demonstrated a large number of macrophages on
a highly necrotic background, which on ZN staining revealed
the characteristic pattern of histiocytes loaded with acid fast
bacilli, raising a strong suspicion of HIV infection in the child,
which was further confirmed by ELISA test. Culture of the
cytoaspirate confirmed the presence of MAC.
Isolated tubercular axillary lymphadenopathy in HIV
infected children without any other systemic involvement is
extremely rare. Hence, any child above six months of age
presenting with isolated extrapulmonary lymphadenopathy
must raise a strong suspicion of occult HIV infection even at
the early phase of the disease.
1. Sunderam G, McDonald RJ, Maniatis T,Oleska J, Kapila R,
Reichman LB. Tuberculosis as a manifestation of the acquired
immunodeficiency syndrome (AIDS), JAMA 1986;256:362-6.
2.Pitchenik AE, Fischl MA. Disseminated tuberculosis and the
acquired immunodeficiency syndrome. Ann Intern Med
3. Taliv VH, Khurana SK, Pandey J, Vermask. Current concepts
tuberculosis and HIV infection. Indian J Pathol Microbiol JPM,
4. Deodhar L. Mycobacteremia in AIDS patients- Report of 2
cases. Indian J Med Microbiol, 1999;17:196-7.
5.Modilovsky T, Sattler FR, Barnes PF. Mycobacterial disease in
Mahapatra et al - MAC Associated Extrapulmonary Tuberculosis
Figure 2: (a) LJ slope showing characteristic smooth discrete dull white
colonies of Mycobacterium avium complex after 21 days of incubation.
(b) ZN staining from the growth of LJ slope demonstrating short curved
acid fast bacilli (x1000).
Indian Journal of Medical Microbiology
patients with human immunodeficiency virus infection. Arch
Intern Med 1989;149:2201-5.
6. Kramer F, Modilevsky T, Waliany AR, Leedom JM, Barnes
PF. Delayed diagnosis of tuberculosis in patients with human
immunodeficiency virus infection. Am J Med 1990;89:451-6.
7. Koneman EW, Allen SD, Janda WM, Schreckenberger PC,
Winn JR WC (Eds.), Mycobacteria. In: Color atlas and text
book of diagnostic microbioloty. 4th edn. East Washington
Square: JB Lippincot Company; 1979. p. 705-39.
8. Centres for disease control and prevention HIV/AIDS
surveillance report. 1999;11:1-24.
9. Shahab T, Zoha MS, Malik MA, Malik A, Afzal K. Prevalence
of human immunodeficiency virus infection in children with
tuberculosis. Indian Pediatr 2004;41:595-9.
XXIX National Congress of IAMM
Welcomes delegates to IAMM MICROCON 2005 - Chennai
Venue: Sri Ramachandra Medical College and Research Institute, Porur, Chennai- 600116
“Pre Conference workshops: 19.10.2005 and 20.10.2005
(i) Sankara Nethtralaya - Application of Nucleic acid based techniques(PCR) in Diagnostic Microbiology—
Hands - on – Training”
King Institute of Preventive Medicine - Applications of tissue culture in Toxicity and Antiviral assay
of drugs— Hands-on- training.
(iii) Sri Ramachandra Medical College and RI (DU) - Conventional and MolecularDiagnostic techniques
in Mycology—Hands- on- Training
(iv) Sri Ramachandra Medical College and RI (DU) – Bioaerosols -”Recognition, evaluation and
management in health care facilities” organized by Department of Microbiology and Environmental
Health Engineering, SRMC andRI, supported in part by The Fogarty International Centre, NIH, USA
Inauguration of the congress: 20.10.2005 Evening
Conference Dates: 21.10.2005 - 23.10.2005
vol. 23, No. 3