Final Diagnosis -- Mediastinal Mycobacterium Szulgai Lymphadenitis

FINAL DIAGNOSIS: INFECTION OF LYMPH NODES AND MEDIASTINAL SOFT TISSUE WITH Mycobacterium szulgai

CONTRIBUTORS' NOTE:

Mycobacterium szulgai was first reported as a species in 1972 and is named for the Polish microbiologist T. Szulga.(1) Infections with Mycobacterium szulgai are extremely rare, but cases are increasingly being noted primarily in patients with impaired cellular immunity (i.e., transplant recipients, HIV+ individuals) and in middle-aged to elderly patients with pre-existing lung disease. Although M. szulgai has been implicated in infections of many different bodily sites, ranging from a granulomatous olecranon bursitis to cutaneous infection, a case of M. szulgai osteomyelitis in an AIDS patient was recently reported.(2) Pulmonary infection clinically indistinguishable from M. tuberculosis infection is the most common manifestation.(3) Clinically, Mycobacterium szulgai infection is indistinguishable from classic infection with M. tuberculosis. Common presentations include fever, night sweats, weight loss, and a cough with or without hemoptysis.. A retrospective study of the period 1981-83 reviewing reported cases of nontuberculous mycobacterial infections in the United States included 24 (0.57% ) cases of M. szulgai infection (all sites) out of a total of 4201, corresponding to approximately 0.01 cases/100,000 population for that time period.(4)

Clinical distinction between infection with M. szulgai and tuberculosis and other nontuber-culous mycobacterial infections is not possible. Definitive diagnosis requires isolation and identification of the causative agent. On acid-fast stain of the organism, M. szulgai may exhibit some banding, such as that seen with M. kansasii. M. szulgai is a scotochromogen, producing an orange pigment both in the dark and in light.(5) A unique feature of pigment production in M. szulgai is the temperature-dependent nature of this phenomenon. When grown at body temperature (37oC), the organism is scotochromogenic, but at 25oC, the pigment is only produced in a lighted environment (e.g., the organism is photochromogenic). This places the organism in the Runyon group II classification of mycobacteria. Another characteristic of M. szulgai is relatively rapid growth in culture, with production of smooth or rough colonies on solid media within 2 weeks. Biochemical tests will help further differentiate the organism. M. szulgai will display the following reactions (5), in contrast to other scotochromogens (M. scrofulaceum, xenopi, and gordonae):

  1. Slow hydrolysis of Tween 80 ( trade name for a compound (polysorbitan mono-oleate) which identifies organisms which possess a lipase which will split the compound into oleic acid and polyoxyethylated sorbitol).
  2. Nitrates reduced to nitrites (presence of nitroreductase).
  3. Positive arylsulfatase activity (red color identifies free phenopthalein produced by enzyme action on substrate).
  4. Intolerance to 5% NaCl.

M. szulgai is commonly susceptible to standard antituberculous agents, but treatment in each case should depend upon evaluation of susceptibility for the organism. In this case, the organism was susceptible to many agents commonly used for the therapy for Mycobacterium tuberculosis infection.

References:

  1. Marks J, Jenkins PA, Tsukamura M. Mycobacterium szulgai: A new pathogen. Tubercle 1972; 53: 210-214.
  2. Pulik M, Leturdu F, Lionnet F, Petitdidier C, Genet P, Touahri T. Mycobacterium szulgai osteomyelitis in AIDS. Med Malad Infect 1996; 26(SI): 674-675.
  3. Maloney JM, Gregg CR, Stephens DS, Manian FA, Rimland D. Infections caused by Mycobacterium szulgai in humans. Rev Infect Dis 1987; 9(6): 1120-6.
  4. O'Brian RJ, Geiter LJ, Snider DE. The epidemiology of nontuberculous mycobacterial diseases in the United States: results from a national survey. Am Rev Respir Dis 1987; 135: 1007-1014.
  5. Mycobacteria. In: Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn Jr, WC (eds.) Color atlas and textbook of Diagnostic Microbiology, 4th edition, pp. 703-755. Philadelphia, JB Lippincott Co, 1992.

Contributed by Kevin D. Horn, MD and William A. Pasculle, ScD

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