2nd Department of Internal Medicine, General Hospital of Nikaia-Piraeus "Agios Panteleimon", 3 Andrea Petrou Mantouvalou Street, 185 43, Athens, Greece.
BMC Infect Dis. 2022 Mar 3;22(1):213. doi: 10.1186/s12879-022-07170-3.
Mycobacterial infections can cause significant morbidity when cellular immunity is compromised. Patients with AIDS can be affected directly from infection or through mycobacterial IRIS, especially if they are previously untreated for HIV. Herein a case of tuberculous lymphadenitis is reported, which primarily responded to antimicrobials but complicated by IRIS and cat-scratch disease at a later course.
A 23-year-old man, intravenous drug user with untreated HIV and HCV infection presented with fever and painful cervical lymphadenopathy. Mycobacterium tuberculosis was isolated from PCR and culture of ultrasound-guided lymph node aspirate and a four-drug anti-TB regimen was subsequently administered, leading to complete resolution of clinical and laboratory abnormalities. Given the patient's CD4 count (67 cells per mm), antiretroviral treatment started seven weeks after TB treatment initiation. Within the first month of ART fever recurred along with cervical lymph node inflammation. Paradoxical IRIS was considered as the most probable diagnosis but workup expanded, revealing acute Bartonella infection. A posteriori, the patient remembered being scratched by a stray cat two weeks before his new symptoms started. Doxycycline and corticosteroid monotherapy failed to resolve symptoms, whereas a combination of doxycycline for 3 months and methylprednisolone with long-term tapering led to negative follow-up Bartonella antibodies and complete clinical and biochemical response, without recurrence.
Co-infection with TB and Bartonella presenting with lymphadenitis is unusual. Cat-scratch disease can be a rare clinical presentation of Bartonella infection in patients with AIDS, but coexistence of bartonellosis and paradoxical IRIS has never been reported before. However, physicians treating people living with HIV should be aware of this potential concurrence. Early testing for Bartonella infection could be offered in patients with TB and HIV co-infection in case of acute deterioration or partial response to treatment, especially if they have a history of cat exposure, since clinical picture can be indistinguishable.
当细胞免疫受损时,分枝杆菌感染会导致严重的发病率。艾滋病患者可能会直接受到感染,也可能通过分枝杆菌免疫重建炎症综合征(IRIS)受到感染,尤其是如果他们之前没有针对 HIV 进行治疗的话。本文报告了一例结核性淋巴结炎,该患者最初对抗微生物药物有反应,但在后期过程中因 IRIS 和猫抓病而变得复杂。
一名 23 岁男性,静脉吸毒者,患有未经治疗的 HIV 和 HCV 感染,表现为发热和疼痛性颈部淋巴结病。从超声引导下淋巴结抽吸物的 PCR 和培养中分离出结核分枝杆菌,随后给予四联抗结核方案,导致临床和实验室异常完全缓解。鉴于患者的 CD4 计数(67 个细胞/毫米),在开始 TB 治疗后七周开始了抗逆转录病毒治疗。在 ART 治疗后的第一个月,发热再次出现,同时伴有颈部淋巴结炎症。考虑到最可能的诊断是矛盾性 IRIS,但扩大了检查范围,发现了急性巴尔通体感染。随后,患者回忆起在新症状出现前两周被一只流浪猫抓伤。多西环素和皮质类固醇单药治疗未能缓解症状,而多西环素治疗 3 个月和甲基强的松龙联合长期逐渐减量则导致后续随访时巴尔通体抗体转为阴性,并完全缓解临床和生化反应,且无复发。
同时感染结核分枝杆菌和巴尔通体导致淋巴结炎并不常见。猫抓病可能是艾滋病患者巴尔通体感染的罕见临床表现,但以前从未报道过巴尔通体病和矛盾性 IRIS 共存。然而,治疗 HIV 感染者的医生应该意识到这种潜在的共存情况。对于合并 TB 和 HIV 感染的患者,如果出现急性恶化或治疗反应不完全,尤其是如果他们有猫暴露史,应该早期进行巴尔通体感染检测,因为临床症状可能无法区分。