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Mycobacterium saskatchewanense strain associated with a chronic kidney disease patient in an Italian transplantation hospital and almost misdiagnosed as Mycobacterium tuberculosis
Giuseppina Di Mento BSc1,a, Anna Paola Carreca BSc2,a, Francesco Monaco BSc1, Nicola Cuscino BSc1,
Francesca Cardinale BSc1, Pier Giulio Conaldi MD, PhD1 and Bruno Douradinha PhD1,2 1Unità di Medicina Rigenerativa e Biotecnologie Avanzate, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy and 2Unità di Medicina Rigenerativa ed Immunologia, Fondazione
Ri.MED, Palermo, Italy
— To the Editor During an evaluation for a solid organ transplant
(SOT) procedure,weidentified a rare, opportunistic nontuberculous (NTM) strain, Mycobacterium saskatchewanense. The patient, who suffered fromchronic renal disease, was tested for several pathogens, Mycobacterium tuberculosis included. Transplantation procedures rely on immunosuppressive therapies, which increase the success of the surgery and the survival of the patient.1 However, they also render the patients more susceptible to microbial infections, such asmultidrug-resistant bacterial species likeKlebsiella pneumoniae.2,3 Thus, patients require rigorous evaluations to confirmthat they are not infected with pathogenic microorganisms that might compro- mise their health or lead to the rejection of the transplanted organ. One of the most opportunistic pathogens that can cause complica- tions
inSOTisM.tuberculosis,whichinfectsupto 6.4%of transplant recipients in developed countries and up to 15% in areas where tuberculosis is highly endemic.4 Thus, exhaustive investigations, including the use of classical diagnosticmicrobiological andmolecu- lar assays are essential to ensuring that patients are fit for a SOT pro- cedure or that they receive the correct antimicrobial therapy. At the Istituto Mediterraneo per i Trapianti e Terapie ad Alta
Specializzazione (IRCCS-ISMETT), in Palermo, Italy, a 46-year- old man with hereditary chronic renal disease requiring dialysis for the previous 2 years was evaluated for renal transplantation. He had a positive interferon-γ release assay, suggesting prior expo- sure to M. tuberculosis. This patient had no previous history of tuberculosis infection, and his chest imaging did not show any signal of M. tuberculosis infection in the lungs. To confirm the presence of mycobacterial antigens in the blood, an ELISpot and T-SPOT.TB (Oxford Immunotec, Oxford, UK) were performed according to the manufacturer’s instructions. Samples of sputum
Author for correspondence:
B.Douradinha,Email:
bdouradinha@fondazionerimed.com aAuthors of equal contribution.
Cite this article: Di Mento G, et al. (2019). Mycobacterium saskatchewanense strain
associated with a chronic kidney disease patient in an Italian transplantation hospital and almost misdiagnosed as Mycobacterium tuberculosis. Infection Control & Hospital Epidemiology, 40: 496–497,
https://doi.org/10.1017/ice.2019.6
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
and urine were also inoculated into liquid BBL mycobacteria growth indicator tubes (Becton Dickinson, Milan, Italy) according to the supplier’s instructions to identify potential Mycobacteria. We obtained positive results for the presence of M. tuberculosis antigens in the blood and observed mycobacterial growth in the urine sample. Sputum samples were negative. Because no M. tuberculosis was present in the patient’s sputum
and because this particular ELISpot has previously shown some limitations,5 we decided to extract the genomic material of this strain for sequencing. Total mycobacterial DNA was extracted using a QIAamp UCP Pathogen Mini Kit (Qiagen, Venlo, Netherlands), as specified by the kit’s manual. Next-generation sequencing (NGS, full genome) and Sanger sequencing (16S rRNA gene, internal transcribed spacer (ITS1) 16S-23S and hsp65) were performed as published elsewhere.2,6 The sequences derived from both techniques showed a homology >99% with the publicly available sequences of previously identified NTM M. saskatchewanense, from the complex M. simiae,7 previously only reported in the United States8 and Canada.6 This particular NTM had been isolated from a bronchiectasis patient, both from sputum and from thoracenthesis fluid, and was thought to have contributed to the deterioration of the patient.6 Genomic sequen- ces of the M. saskatchewanense ISMETT strain were deposited in the NCBI public database (accession no. SRP149411). The ELISpot was repeated 3 weeks later, yielding a negative
result. Thus, and since we had confirmed that he was not infected with M. tuberculosis, the patient was not subjected to any antimy- cobacterial therapy. Because these interferon-γ release assays do not allow proper distinction between colonization and infection,9 we can only assume, due to its brevity, that the patient underwent aself-resolving episode of M. saskatchewanense colonization. To the best of our knowledge, this is the first time this particular
NTMhas beendetectedoutsideNorthAmerica.Weassessedits anti- microbial sensitivity to several antibiotics. The minimal inhibitory concentrations (MIC) were determined using SlowMyco Sensititre plates (Thermo Fisher Scientific, Waltham, MA), according to the
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