ObjectiveThe objective of this study is to describe the clinical significance of Mycobacterium simiae at a major tertiary care center in Lebanon.MethodsThis is a retrospective study of patients with positive cultures for M. simiae isolated between 2004 and 2016 at the American University of Beirut Medical Center.ResultsThis study included 103 M. simiae isolates recovered from 51 patients. Their mean age was 62.7 years. The majority were males and smokers. Specimens were mostly from respiratory sources (97%). Common comorbidities included chronic lung disease (such as chronic obstructive pulmonary disease), solid tumor, systemic disease, and diabetes mellitus. Productive cough and dyspnea were the most common symptoms. Frequent radiographic findings were infiltrates and nodules on chest X-ray and nodules, infiltrates, and bronchiectasis on chest computed tomography scan. Among 18 tested isolates, 5.8% were resistant to clarithromycin, 11.7% to amikacin, and 70–100% to other antimicrobials. Out of 13 patients receiving early treatment, 5 noted improvement, one had recurrence of symptoms, two received alternative diagnosis, and five died. Two of those deaths were related to M. simiae. Common treatment regimens included clarithromycin in different combinations with trimethoprim-sulfamethoxazole, moxifloxacin, and amikacin. Moreover, clofazimine was used in only two patients whose isolates were resistant to all but one agent. Duration of treatment ranged from 6–24 months.ConclusionIn Lebanon, M. simiae is increasingly encountered with true infection rates of at least 47%. Furthermore, the prevalence of multidrug resistance among the Lebanese M. simiae isolates is very high limiting the treatment options.

A young man with aortic prosthetic valve replacement, presented with prolonged fever and diagnosed with brucella endocarditis based on positive transthoracic echo findings with high titer positive brucellacapt serology. He was started on medical treatment with doxycycline and rifampin to which gentamicin and ceftriaxone were added and he was planned for surgical intervention. Unfortunately, the patient developed cardiogenic with septic shock before performing surgery and died within 24 h soon after admission.

What is the history of Mycobacterium simiae and what are some of its genomic components?

M ycobacterium simiae is an emerging pathogen described mainly in Asia and to a lesser extent in the United States. We read with great interest the study by Coolen-Allou et al. (1) entitled "Mycobacterium simiae: clinical, radiological and microbiological characteristics in 97 patients," which is one of the first studies to describe M. simiae infection in Africa. This study included 97 patients with M. simiae infection and described several aspects related to this mycobacterium, including clinical presentation, treatment, and outcomes. The study had a design similar to that of our study entitled "Emergence of Mycobacterium simiae: a retrospective study from a tertiary care center in Lebanon" (2); however, their results were different in several aspects. First, the infectivity of M. simiae was lower in their review than in ours, with 21.6% of their isolates and 47% of our isolates meeting the American Thoracic Society (ATS) criteria for a nontuberculous mycobacterial infection. This lower infectivity is in accordance with that described by Van Ingen et al. from the Netherlands (3) and Hashemi-Shahraki et al. (4) from Iran. Moreover, non-cystic fibrosis bronchiectasis was the most common underlying lung comorbidity in the work of Coolen-Allou et al. (1), whereas recurrent pneumonias and asthma were most common in our study. Chronic obstructive pulmonary disease was commonly seen in both studies, a finding which is similar to the results of the series by Shitrit et al. (5). Among nonpulmonary comorbidities, a high number of patients (11%) had chronic kidney disease in their study, unlike our study and the study by Baghaei et al. (6), where diabetes was mostly found. More patients received steroids, whether systemic or inhaled, in the Reunion Island study than in ours. Regarding symptomatology, the patients in the former study developed more weight loss, less cough and sputum production, and much less hemoptysis than our patients. When comparing radiological findings, the two studies described similar findings, except for more ground glass predominance in our study. Finally, clarithromycin was the backbone of therapy in both studies and was used in combination with 3 or more drugs to which the organism was found to be susceptible, as is the case in other M. simiae studies. Isolates from both countries also had high susceptibility to amikacin. However, the isolates from Reunion Island were more likely than the isolates in our study to be susceptible to moxifloxacin (92% versus 30%) and were not as resistant to antituberculous medications as the isolates in our study. Our results were more in accordance with the susceptibility profile of the isolates found by Van Ingen et al. (7). Finally unlike our study, Coolen-Allou et al. focused solely on the outcomes of patients meeting ATS criteria who received treatment (1). The differences in epidemiology, clinical manifestations, radiographic findings, and drug susceptibility patterns of M. simiae between the 2 studies highlight the importance of conducting research on this e...

BK virus (BKV) pneumonia is a rare entity especially seen in immunosuppressed patients, for which cidofovir is the used treatment option. We describe a case of a young female patient who presented for altered kidney function six months following kidney transplantation for focal segmental glomerulosclerosis and was found to have BKV nephritis. Her in-hospital stay was complicated by BKV pneumonia requiring mechanical ventilation, in addition to CMV colitis. She was treated with leflunomide/ciprofloxacin and ganciclovir for her pneumonia and colitis, respectively. The patient improved clinically except that her kidney function deteriorated. Leflunomide/ciprofloxacin combination may constitute an effective and safe alternative to cidofovir for the treatment of BKV pneumonia, in particular when cidofovir is not available.