Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report

Abstract

BackgroundNon-Tuberculous Mycobacterial–pulmonary disease (NTM-PD) is increasing in incidence and prevalence. Mycobacterium abscessus (M.abscessus) is a rapid growing multi-resistant NTM associated with severe NTM-PD requiring prolonged antibiotic therapy. Complications of therapy are common but reports on direct complications of active NTM-PD are rare. Vasculitis has been described as a rare complication of NTM-PD, most often in individuals with inherited immune defects. This case is the first to describe an ANCA positive vasculitide (Microscopic Polyangiitis) secondary to M.abscessus pulmonary disease.Case presentationA 70 year old female with bronchiectasis underwent a clinical decline associated with the growth of M.abscessus and was diagnosed with NTM-PD. Before treatment could be initiated she developed small joint arthralgia and a glove and stocking axonal loss sensorimotor neuropathy. Positive Perinuclear Anti-Neutrophil Cytoplasmic Antibodies (P-ANCA) and Myeloperoxidase-ANCA (MPO-ANCA) titres led to a diagnosis of microscopic polyangiitis. Further investigation revealed reduced interferon-gamma production but no other significant immune dysfunction.Dual treatment with immunosuppressive therapy (Corticosteroids/Cyclophosphamide) for vasculitis and antimicrobial therapy for M.abscessus NTM-PD was initiated. Clinical stability was difficult to achieve with reductions in immunosuppression triggering vasculitic flares. One flare led to retinal vein occlusion with impending visual loss requiring escalation in immunosuppression to Rituximab infusions. An increase in immunosuppression led to a deterioration in NTM-PD necessitating alterations to antibiotic regimes. Adverse effects including alopecia and Achilles tendonitis have further limited antibiotic choices resulting in a strategy of pulsed intra-venous therapy to stabilise NTM-PD.ConclusionsThis is the first reported case of an ANCA positive vasculitis secondary to M.abscessus pulmonary disease. This rare but important complication had a significant impact on the patient adding to the complexity of an already significant disease and treatment burden. The potential role of reduced interferon-gamma production in this case highlights the importance of investigating immune function in those with mycobacterial infection and the intricate relationship between mycobacterial infection and immune dysfunction. Immune dysfunction caused by genetic defects or immunosuppressive therapy is a known risk factor for NTM-PD. Balancing immunosuppressive therapy with prolonged antimicrobial treatment is challenging and likely to become more common as the number of individuals being treated with biologics and immunosuppressive agents increases.

Nasal Septal Perforation and Widespread Skin Lesions Caused by <i>Mycobacterium chelonae</i> Infection Mimicking Granulomatosis with Polyangiitis

“…There is also a case report of a patient with NTM infection who developed ANCA-associated vasculitis secondary to myeloperoxidase-ANCA positivity (23). However, in the present case, ANCA was not detected, and the patient's condition improved after antimicrobial treatment and discontinuation of glucocorticoids, suggesting that M. chelonae infection had caused a condition mimicking GPA.…”

Development of Rheumatoid Arthritis in Cavitary Mycobacterium avium Pulmonary Disease: A Case Report of Successful Treatment with CTLA4-Ig (Abatacept)

“…Previous reports show that antineutrophil cytoplasmic antibodyassociated vasculitis and ABPA developed during progressive impairment by bronchiectasis with NTM-PD. 20,21,22 In our patient, CT imaging on referral showed bronchiectasis, several cavitary lesions, bronchiolitis, nodular lesions, and consolidation, all of which may have been formed by NTM at that time, although these features could be complications of RA (early extra-articular manifestations). However, positive sputum culture, along with cavitary lesions and infiltrative shadows, which are not typically seen in RA, 23 were seen at the time of referral.…”

Granulomatosis with polyangiitis diagnosed during the treatment of otitis media with prednisolone in a patient with anti-neutrophil cytoplasmic antibody-associated vasculitis: A case report

“…The treatment of patients with AAV and NTM-PD is controversial. Addy et al reported successful dual treatment with immunosuppressive therapy for vasculitis and antimicrobial therapy for NTM-PD [ 14 ]. Generally, achieving a balance between controlling pulmonary infection and immunosuppression is difficult.…”