26 Oct 2021

7/19/2021 – Disseminated MAC

Dr. Krithika Chennapan (PGY3) presented the case of a 68yo Taiwanese Male with PMH of HTN, BPH s/p failed TURP c/b foley dependence, anterior uveitis, and IgG4-related disease, who was admitted from hematology clinic for hypercalcemia identified on routine labs.

On admission, the patient reports generalized fatigue and decreased appetite over the last 6 months. He also endorses 6 months of progressively worsening R knee pain exacerbated by ambulation, requiring the use of a walker for the last 1 month.

PMH: HTN, HLD, BPH requiring indwelling foley, IgG4-related disease**, anterior uveitis, insomnia, h/o CMV viremia
PSH: TURP, Cataract extraction
Meds: Omelsartan 20mg qDay, oxybutynin 5mg BID, azathioprine 50mg BID, dorzolamide 2% ophthalmic solution qDay to OD, temazepam 7.5mg QHS, valacyclovir 500mg qDay, multivitamin qDay, norco 5 PRN pain
Allergies: Finasteride (Stevens-Johnson), Flomax (Stevens-Johnson)
FH: HTN and colon cancer in mother, Alzheimer’s in father
SH: Born in Taiwan. Lives with wife and son. Never tobacco, alcohol or drug use.

**Regarding IgG4-Related Disease: The patient was initially diagnosed with suspected IgG4-related disease with severe systemic inflammation 1 year prior to admission, after presenting with diffuse lymphadenopathy and undergoing LN biopsy. Shortly after diagnosis, he was treated with various agents including steroids, rituximab, cyclophosphamide, and azathioprine. His last infusion of cyclophosphamide + rituximab was 2 months PTA. At the time of admission, he continues on oral azathioprine.

Pertinent Positive ROS: +Constipation, +blurry vision in R eye (unchanged)
Vitals: :  T 36.6     HR 73     RR 16     BP 112/65     O2 sat 95% RA     Weight: 80 kg     BMI 25
Pertinent Positive Exam Findings: R knee swollen, tender with passive and active ROM 

PTH: 5 (15-64) / Vit D 25 OH: 24 (30-100) / Vit D 1,25 Dihydroxy: 110 (18-64)

R Knee Synovial Fluid Analysis:
Clarity               Cloudy
Color                 Yellow
WBC                  10,590 (63% PMNs, 37% MONONUCLEAR)
RBC                    3,000
Crystals             Negative
Culture No anaerobes isolated; No fungus isolated
AFB Stain: POSITIVE
MTB PCR: NOT DETECTED
CULTURE: MYCOBACTERIUM AVIUM INTRACELLULARE COMPLEX

Blood, Sputum, Synovial Fluid, Bone Marrow, Bone Lesion AFB Stain: POSITIVE
Blood, Sputum, Synovial Fluid, Bone Marrow, Bone Lesion CULTURE: MAC

Teaching Points:
•Take a thorough history of MAC and TB, and obtain a QuantiFERON Gold test prior to starting TNF inhibitors or other biologics
•If a patient has a history of MAC, prescribe prophylaxis prior to starting the above agents
•In immunocompetent adults with MAC, consider the possibility that they could have a genetic predisposition to acquiring the infection

Click here to read more about nontuberculous mycobacterial infections in immunocompromised hosts.

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