Mycobacterium szulgai is a rarely reported human pathogen that causes a variety of clinical syndromes. We report a case of an M. szulgai septic arthritis and osteomyelitis in a patient with human immunodeficiency virus infection manifesting as an immune reconstitution syndrome. (Infect Dis Clin Pract 2006;14:392-393) M ycobacterium szulgai is a nontuberculous mycobacte rium that is a relatively rare human pathogen and causes a variety of clinical syndromes. It is often associated with advanced human immunodeficiency virus (HIV) disease.1 Here, we report a case of M. szulgai causing septic arthritis and osteomyelitis of the knee in a patient with hepatitis C virus infection (HCV) and acquired immunodeficiency syndrome (AIDS) with subsequent immune reconstitution syndrome after the start of antiretroviral therapy (ART). CASE REPORTA 48-year-old man with chronic HCV and HIV infections presented to the infectious disease clinic for evaluation of pain, swelling, and stiffness in his right knee, which he reported as having persisted for more than 6 months. He was evaluated for his knee pain 4 months earlier, and a magnetic resonance imaging (MRI) at that time suggested a Brodie abscess or an osseous neoplasm. A biopsy was planned, but the patient refused, and several months later, he presented to the infectious disease clinic for management of his HIV and HCV. At that visit, the patient was afebrile but complaining of increased knee pain and difficulty in ambulating. He had not yet initiated ART, and his CD4 cell count was 28 cells/mL with an HIV viral load of 250,000 copies/mL (Amplicor; Roche Diagnostics, Basel, Switzerland) and an HCV viral load of more than 700,000 copies/mL (Amplicor HCV monitor 2.0; Roche Diagnostics). Physical examination revealed no erythema, warmth, or effusion of the knee, but there was a limitation in his range of motion. He continued to refuse patella biopsy. ART was initiated with lopinavir/ ritonavir, tenofovir, and emtricitabine, and the patient had a good response. Six weeks later, his viral load was 89 copies/mL, and his CD4 count had climbed to 136 cells/mL. Two months later, the patient presented with right knee effusion, erythema, tenderness to palpation, and an overlying eschar that was draining yellow purulent material. His CD4 count was 134 cells/mL, and viral load was not obtained. An MRI done at that time revealed tibial edema and a large 2.2 Â 1.1-cm destructive abscess within the patella extending anteriorly and posteriorly (Fig. 1). The patient underwent operative debridement and was treated with vancomycin and aztreonam. Operative specimens revealed acute and chronic inflammation on pathology, and acid-fast bacilli on culture. A sample was sent for tuberculosis polymerase chain reaction testing (Amplified Mycobacterium tuberculosis Direct Test; Gen-Probe, San Diego, Calif); the results of which were negative. The patient was empirically treated with clarithromycin, rifampicin, isoniazid, pyrazinamide, and ethambutol while pending pathogen confirmation, and his...
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