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Letter
Mycobacterium haemophilum:
Emerging or Underdiagnosed in Brazil?
Suggested citation for this article: Sampaio JLM, Alves
VAF, Leão SC, de Magalhães VD, Martino MDV, Mendes CMF, et al. Mycobacterium
haemophilum: emerging or underdiagnosed in Brazil? Emerg Infect Dis
[serial online] 2002 Nov [date cited];8. Available from: URL: http://www.cdc.gov/ncidod/EID/vol8no11/02-0492.htm
To the Editor: Mycobacterium haemophilum was first
described in 1978 by Sompolinsky et al. (1) as the cause
of cutaneous infections in a patient with Hodgkin disease. Since then,
fewer than 100 cases have been reported worldwide, mostly among immunocompromised
patients (2), although M. haemophilum infection
has also been described in immunocompetent patients as the cause of cervical,
submandibular, and perihilar lymphadenopathy in children and of pulmonary
nodules in an adult (3–5). Cases have been reported from
United States, Australia, Canada, France, Israel, and the United Kingdom,
but to date no reports have originated in South America.
The most frequent clinical sign of M. haemophilum infection in
adults is a skin or joint lesion. Less common sites for isolation of M.
haemophilum include the respiratory tract, blood, bone marrow, bone,
and central venous catheters (2,6). M. haemophilum
is unique among Mycobacterium species owing to its special growth
requirements: it grows best at 30°C and requires an iron supplement (hemin
or ferric ammonium citrate).
We report here the characterization of three strains of M. haemophilum
isolated from patients living in three states in two distinct regions
of Brazil, Rio de Janeiro and São Paulo (southeast region) and Bahia (northeast
region). The first strain was detected in Rio de Janeiro in December 2000
from a blood culture of a 67-year-old man who had received a kidney transplant
in 1988 at the age of 55 years and was undergoing immunosuppressive treatment
with prednisolone and mycophenolate mofetil. The second strain was detected
in São Paulo in March 2001 in a 43-year-old HIV-seropositive man from
a biopsied specimen of a nasal ulcer. A direct acid-fast stain showed
many acid-fast bacilli. At time of diagnosis, the patient’s CD4+ cell
count was 8/mm3 and his viral load was 290.000 copies/mL. The
third isolate was detected in Bahia in a 30-year-old HIV-seropositive
man who had osteomyelitis in an elbow. A direct acid-fast stain showed
rare acid-fast bacilli.
The isolate from the Rio de Janeiro patient grew only in Myco/F Lytic
media (Becton Dickinson Microbiology Systems, Sparks, MD) plus
blood in primary isolation and subculture; it failed to grow on chocolate
agar at 30°C after 6 weeks. The isolates from São Paulo and Bahia showed
a slight growth in 12B media on primary isolation; this growth was likely
supported by the iron provided by the biopsied tissue. Subcultures on
chocolate agar showed good growth after 2–3 weeks at 30°C. The isolates
did not grow on Middlebrook 7H10 agar without hemin and grew on the same
media when supplemented with 60 µM of hemin. Both strains showed
a negative catalase reaction.
The species of all isolates was identified through polymerase chain reaction
amplification of the gene encoding for the 65-kDa heat shock protein,
followed by restriction analysis with the enzymes BstEII and HaeIII
as described by Telenti et al. (7), with minor modifications.
The three isolates showed the same restriction pattern as that obtained
for M. haemophilum American Type Culture Collection 29548 prototype
strain. Isolates from Rio de Janeiro and São Paulo were also molecularly
characterized as previously described by Roth et al. (8),
corroborating M. haemophilum species identification.
To our knowledge, these M. haemophilum isolates are the first
to be reported in Brazil. These three patients came from cities 429–962
km apart, demonstrating the dispersion of M. haemophilum infection
in Brazil. Given the specific requirements of M. haemophilum for
its growth in culture, our findings suggest that its true incidence in
Brazil is greatly underestimated. Consequently, we strongly recommend
that clinical laboratories in Brazil include an iron-supplemented medium,
such as chocolate agar, incubated at 30ºC, for primary isolation of Mycobacterium
spp in samples from selected patients.
Jorge Luiz Mello Sampaio,*† Venâncio Avancini Ferreira Alves,‡ Sylvia
Cardoso Leão,† Vanda Dolabela de Magalhães,§ Marinês Dalla Valle Martino,§
Caio Marcio Figueiredo Mendes,*Antonio Carlos de Oliveira Misiara,¶
Kozue Miyashiro,* Jacyr Pasternak,§ Eliana Rodrigues,‡
Ronaldo Rozenbaum,# Carlos Alberto Sant´Anna Filho,**
Sônia Regina Marques Teixeira,* Adriano Cunha Xavier,††
Mauro Silvério Figueiredo,* and José Paulo Gagliardi
Leite††,‡‡
*Fleury - Centers for Diagnostic Medicine, São Paulo, Brazil; †Federal
University of São Paulo, São Paulo, Brazil; ‡Oswaldo Cruz Hospital, São
Paulo, Brazil; §Albert Einstein Hospital, São Paulo, Brazil; ¶Sírio Libanês
Hospital, São Paulo, Brazil; #Servidores do Estado Hospital, Rio de Janeiro,
Brazil;**Aliança Hospital, Salvador, Bahia, Brazil; ††Lâmina Laboratory,
Rio de Janeiro, Brazil; ‡‡Oswaldo Cruz Institute, Rio de Janeiro, Brazil
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