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Abstract

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Article in Japanese

Case Report

A case of disseminated nontuberculous mycobacteriosis in immunodeficiency due to treatment of severe hard metal lung

Kazuaki Sugahara  Shinichiro Okamoto  Susumu Hirosako  Hidenori Ichiyasu  Kazuhiko Fujii  Hirotsugu Kohrogi 

Department of Respiratory Medicine, Kumamoto University Hospital

ABSTRACT

A 44-year-old man with a 24-year history of hard metal lung developed multiple subcutaneous nodules. He was initially treated with prednisolone for 4 years. Then at the age of 35 he was administered prednisolone 40 mg/day for relapse of the disease, followed by immunosuppressant tacrolimus and insulin for steroid-induced diabetes. At the age of 43, he was administered long-term oxygen therapy and prednisolone was increased to 50 mg/day. A biopsy of the subcutaneous nodule revealed infiltration of neutrophils and histiocytes and numerous acid-fast bacilli that were identified as Mycobacterium intracellulare by PCR, but neither Langhans giant cells nor epithelioid granulomas were found. A positive culture of M. intracellulare from sputa, blood, and urine confirmed the diagnosis of disseminated nontuberculous mycobacteriosis. His peripheral CD4 lymphocyte count was 12/µl. Shortly after administration of rifampicin, ethambutol, and clarithromycin, corticosteroid withdrawal syndrome and a decrease in tacrolimus concentration were observed. We increased the dose of prednisolone and tacrolimus to 2-fold and 3.5-fold, respectively. These pharmacological events probably resulted from CYP3A4 induction by rifampicin, in spite of the inhibition CYP3A4 by clarithromycin. Furthermore, rifampicin may decrease the blood concentration of clarithromycin. Finally, the disappearance of subcutaneous nodules and the clearance of M. intracellulare from sputa, blood, and urine cultures were obtained within 3 months.

KEYWORDS

Disseminated  Nontuberculous mycobacteriosis  Immunodeficiency  Tacrolimus  Pharmacodynamics 

Received 24 Dec 2015 / Accepted 11 Apr 2016

AJRS, 5(5): 235-239, 2016

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