A 79-year-old male, allergic to beta-lactamics, with a personal history of corticosteroid-dependent COPD, with several annual exacerbations and under treatment with NYHA functional oxybates and full-dose bronchodilators (Situation III).
She came to the hospital for a 3-day history of cough with purulent sputum, increased respiratory distress and worsening of consciousness.
Physical examination revealed fever of 38oC, central pulmonary tapes, increased jugular venous pressure, tachycardia to 120 bpm, atrial fibrillation, and atrial fibrillation in both cases.
Painful hepatomegaly and edema in both abdomens.
Chest X-ray showed increased density in the right lower lobe, with poorly defined borders.
The hemogram showed 22,970 leukocytes/mm3 (93N, 3.4L), Hb 13 g/dl, HCT 37%, MCV 90, PLQ 235,000/mm3.
The gas pH 7.45, pO257, pCO2 36.4, HCO3 25.9, SatO2 90% results were obtained.
Blood and sputum cultures were performed in general media (blood agar and chocolate, Biomerieux®) and for the study of mycobacteria [Bactec 960 MGIT Lower Tuckin® Growth (Mycobacterial)
Gram and Ziehl stains showed no diagnostic orientation.
In sputum culture at 24 hours (intermediate quality, > 25 leukocytes 10-25 epithelial cells), only normal flora of the respiratory tract was observed.
Empirical treatment with ciprofloxacin was initiated e.v.
(500 mg/day), Vancomycin e.v.
(1 g/12 h) and Tobramycin e.v.
(200 mg/12 h).
The patient developed progressive clinical worsening (hypopnea, fever) and laboratory (the blood count then showed 40,000 leukocytes/mm3), dying on the fourth day of admission.
1.
On the same day of death, positivity was observed both in the hemocultive and in the sputum culture, both in specific medium for mycobacteria (MGIT).
Ziehl staining of both showed branched positive Ziehl bacilli stains.
From the passage of the MGIT broth to the mulatto with the aHinton (Biomerieux®) and Lowenstein, grew after 24 hours a few dry colonies, initially a whitish.
The problem strain was sent to the National Microbiology Center of Mahonda.
The 16S rDNA sequence of the microorganism was amplified by PCR and 100% homologies were identified as Notitidiscaviarum.
