It is not always about lady windermere: Cavitating lung disease due to mycobacterium avium complex.
Avasarala SK, Hejab A, and Lazar M. It is not always about lady windermere: Cavitating lung disease due to mycobacterium avium complex. Am J Respir Crit Care Med 2017; 195.
Am J Respir Crit Care Med
Pulmonary Mycobacterium avium complex (MAC) infections are becoming more prevalent in the general population; they usually occur in older, white patients with underlying pulmonary disease. We present a case of smoldering MAC infection in an immunocompetent black woman with no known pulmonary disease. Case: A 58-year-old black woman presented with a 1-day history of hemoptysis. Prior to this, she reported being in her usual state of health and had an extensive negative review of systems: fever, shortness of breath, cough, chest pain, fatigue, or weight loss. Social history was negative for smoking, alcohol, and illicit substance use; there was no concern for occupational exposure to particulate matter. There were no known risk factors for tuberculosis; her tuberculin skin test the prior year was nonreactive. Physical examination was only remarkable for tachycardia (114 beats/minute); examination of her respiratory and lymphatic systems were unrevealing. Initial investigations showed microcytic anemia (10.2 gm/dL), leukocytosis (16.7 K/uL), normal creatinine, and normal urinalysis. Her chest radiograph was concerning for multifocal airspace disease in the right lung and contrast-enhanced chest computed tomography (Figure 1) showed multiple lung cavities in the right lung with concomitant intrathoracic lymph node enlargement. She was empirically started on antibiotics for community-acquired pneumonia and priority was placed on ruling out pulmonary tuberculosis. Her first sputum sample had many acid-fast bacilli; Mycobacterium tuberculosis was not detected via nucleic acid amplification test. Work-up for human immunodeficiency virus and fungal infection were negative. Due to the sputum sample results, the local health department was contacted and it was noted that the patient had a MAC infection 3 years ago. She did not meet the treatment threshold at that time. MAC was later identified in the current sputum samples. She was discharged on ethambutol and clarithromycin. Outpatient appointments with ophthalmology and infectious diseases were also arranged. Discussion: MAC lung disease can present with a chronic cough and a myriad of constitutional symptoms: fever, fatigue, night sweats, weight loss, etc. It can mimic tuberculosis clinically and radiographically. Pulmonary MAC infections are more common in those that have underlying lung disease or are immunocompromised; however, it can occur in seemingly healthy individuals. A high index of clinical suspicion is needed to pursue the correct investigations as initial microbiological and radiological results can be nonspecific or point towards Mycobacterium tuberculosis. Historically, a MAC infection in an elderly woman with no preexisting lung disease was known as Lady Windermere syndrome.