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• W1867960413 abstract "Mycobacterium avium–intracellulare (MAI) most often causes disseminated infection involving numerous organs in patients with advanced HIV infection. The disease is characterized by a systemic illness with fever, fatigue, weight loss and gastrointestinal symptoms. Highly active antiretroviral therapy (HAART) results in some reconstitution of immune functions even in patients with advanced immunodeficiency. At present, it is uncertain to what degree this partial improvement of immune functions can alter the clinical presentation of opportunistic infections in patients with advanced immunodeficiency treated with HAART. We report the first case of vertebral osteomyelitis as the only manifestation of MAI infection in an AIDS patient. This 36-year-old patient had a history of intravenous use of heroin and cocaine since the age of 12 and was prescribed methadone maintenance treatment for 10 years. At the age of 18 she had suffered from acute hepatitis, and 10 years later chronic hepatitis C was diagnosed and confirmed by biopsy. HIV infection was first determined at the age of 28 and was treated with zidovudine, followed by didanosine and zalcitabine. In January 1994 the CD4 lymphocyte count was 44/µL. Two years later, she presented with recurrent oral thrush, and severe HIV-associated encephalopathy with seizures was noted. HAART, including stavudine, lamivudine and indinavir, was started, and the viral load dropped from 500 000 RNA copies/mL to less than 400 copies/mL with an increase in CD4 counts to 423 cells/μL after 9 months. A few weeks later, the patient was hospitalized because of a confused state. On admission, there was no history of fever, diarrhea or weight loss. The patient had signs of severe liver failure with altered consciousness, jaundice and ascites. After stopping the use of psychoactive drugs and after treatment with lactulose and non-absorbable antibiotics, she improved. She now complained of severe pain in the interscapular area. Conventional X-ray of the thoracic spine was performed and was suggestive of vertebral osteomyelitis T8–9 and T9–10. A CT scan confirmed extensive bone destruction, and soft tissue swelling with fluid collection was observed (Figure 1). Blood cultures for bacteria, fungi and mycobacteria showed no growth. Two CT-guided fine-needle biopsies were performed but produced only a small amount of material which was negative by direct microscopic examination and by culture. A surgical approach by thoracoscopy was performed, and showed extensive destruction of disks and vertebrae. Histopathologic examination of the bone sample showed a non-specific inflammatory reaction without the presence of granuloma. Auramine staining revealed numerous acid-fast bacilli, and culture of bone tissue and soft tissue specimens grew Mycobacterium avium–intracellulare. Treatment with clarithromycin (500 mg twice-daily), rifabutin (300 mg once a day) and ethambutol (15 mg/kg once a day) was started. A CT scan performed after 6 months of treatment showed bone sclerosis and resolution of soft tissue swelling and fluid collection. The patient died 8 months later, with the clinical picture of a hepatorenal syndrome after a long period of overuse of psychoactive drugs. During that hospitalization, there was no clinical, radiologic or microbiological evidence for active MAI infection. To our knowledge, this is the first case of vertebral osteomyelitis caused by MAI in an AIDS patient. A few cases have been described in other immunocompromised patients [1Zventina JR Demos TC Rubenstein H Mycobacterium intracellulare infection of the shoulder and spine in a patient with steroid-treated systemic lupus erythematosus.Skeletal Radiol. 1982; 8: 11-13Google Scholar, 2Pirofsky JG Huang CT Waites KB Spinal osteomyelitis due to Mycobacterium avium–intracellulare in an elderly man with steroid-induced osteoporosis.Spine. 1993; 18: 1926-1929Crossref PubMed Scopus (29) Google Scholar] or in immunocompetent hosts [3Weiner BK Love TV Fraser RD Mycobacterium avium intracellulare: vertebral osteomyelitis.J Spinal Disord. 1998; 11: 89-91Crossref PubMed Google Scholar, 4Igram CM Petrie SG Harris MB Atypical mycobacterial vertebral osteomyelitis in an immunocompetent patient.Orthopedics. 1997; 20: 163-166PubMed Google Scholar]. Recently, septic arthritis and osteomyelitis of the knee without evidence of disseminated infection was described in an AIDS patient [5Sheppard DC Sullam PM Primary septic arthritis and osteomyelitis due to Mycobacterium avium complex in a patient with AIDS.Clin Infect Dis. 1997; 25: 925-926Crossref PubMed Scopus (20) Google Scholar]. We speculate that, in our case, MAI was acquired when the CD4 cell counts were low, leading to bacteremia and asymptomatic bone involvement. Partial immune reconstitution following HAART therapy prevented the clinical picture of typical disseminated infection. Furthermore, it is conceivable that improved immune functions contributed significantly to the appearance of symptomatic focal disease such as vertebral osteomyelitis. A similar phenomenon was recently described by Race et al [6Race EM Adelson-Mitty J Kriegel GR et al.Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease.Lancet. 1998; 351: 252-255Abstract Full Text Full Text PDF PubMed Scopus (328) Google Scholar], with focal mycobacterial lymphadenitis including intense inflammatory reaction after initiation of HAART, a reaction secondary to the re-emergence of functionally immune competent cells. It is likely that, with wider use of HAART, more inflammatory syndromes as a consequence of immune recovery will be observed." @default.
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• W1867960413 title "Vertebral osteomyelitis caused by Mycobacterium avium–intracellulare in a patient with AIDS" @default.
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