A Case of Intestinal Mycobacterium tilburgii in the Setting of Pancytopenia and Idiopathic CD4 Lymphopenia

Document Type

Article

Abstract

Introduction: Mycobacterium tilburgii is a nontuberculous atypical mycobacterium that is implicated as an opportunistic pathogen and is rarely reported in literature. This organism is historically nonculturable, which has hindered the collection of sensitivity data to direct treatment. This is a unique case of a patient with no history of HIV who presented with vague, systemic symptoms and was eventually found to have acid-fast bacilli (AFB) in intestinal organs discovered via upper endoscopy.

Case Description/Methods: A 67-year-old man with a history of H. pylori, eczema, reflux esophagitis, gastric ulcers, and hemorrhoids presented to a gastroenterology clinic for esophagogastroduodenoscopy and colonoscopy after 3 recent hospitalizations for fatigue, pancytopenia, and unintended weight loss. Initial hospital labs were significant for elevated alkaline phosphatase and hypoalbuminemia. A computed tomography abdomen pelvis showed marked inflammation of the small bowel and a bone marrow biopsy showed a clonal T cell population. During endoscopies, multiple AFB were identified from biopsies obtained from the duodenum, terminal ileum, and colon, raising concern for gastrointestinal tuberculosis. Subsequent BM biopsy also revealed AFB, prompting initiation of anti-tuberculosis therapy that was later modified after a polymerase chain rection analysis confirmed M. tilburgii. Throughout hospitalizations, serial HIV testing was negative despite a CD4 count of 10. There was no clear explanation for his immunosuppressed state apart from upadacitinib use, which was discontinued about 1 year prior. Furthermore, the patient underwent a liver biopsy, which showed AFB organisms present in the portal and sinusoidal macrophages without evidence of fibrosis. One may postulate that AFB invasion of the portal vasculature could have resulted in portal hypertension, previously evidenced by a single medium type 1 isolated gastric varix. The patient was started on daily rifampin, ethambutol, azithromycin, and pyridoxine, and amikacin 3 days weekly. He has shown gradual weight gain and improved energy on medication and is now being closely monitored with outpatient care.

Discussion: Our case uniquely demonstrates that disseminated M. tilburgii can occur in an immunocompetent appearing person. This patient was found to have an extensive gastrointestinal manifestation of this rare infection. Ultimately, this case exemplifies the necessity of thorough workups and highlights the utility of a multidisciplinary approach for patients with vague clinical presentations.

First Page

S3127

DOI

10.14309/01.ajg.0001049228.85047.a1

Publication Date

10-1-2024

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