13. Final Diagnosis

FINAL DIAGNOSIS:

Findings of acid-fast bacilli in marrow and esophagus were consistent with mycobacterium avium intracellulare
Bone marrow culture: + MAI 7H12
Stool cultures eventually became positive: MAI 7H12

Patient Outcome

  1. Pt was placed empirically on fluconazole 200 mg iv on admission, without any improvement in esophageal symptoms.
  2. After the BM and esophageal biopsy revealed AFB (4 days after admission) he was placed on treatment for both MAI or MTB: INH 300 mg po qd, PZA 25mg/kg po qd, ethambutol 25 mg/kg po qd and azithromycin 500 mg po qd
  3. anti-AFB treatment was discontinued due to persistence of fever and diarrhea and side effects attributed to antibiotics: elevation of bilirubin (INH), elevation of uric acid (PZA) and elevation of creatinine (4.6 to 6.3). In addition, FK507 levels were also elevated. Plan was to restart azithromycin and ethambutol as soon as FK506 level returned to normal limits.
  4. Severe hypotensive episode and transferred to ICU; over the following days he developed worsening of renal function, thrombocytopenia, coagulopathy, elevated LFTs (bilirubin, SGOT, SGPT), and lactic acidosis. The patient was consistently febrile, and hemodynamic parameters were consistent with septic picture.
    Differential diagnosis: disseminated MAI infection and sepsis
    sepsis due to nosocomial infection
    AFB involvement of the hepatobilliary system
  5. ethambutol and azithromycin were restarted.
  6. pulmonary failure and persistent hypotension occurred.
  7. Episodes of bradycardia and cardiac arrest. Patient succumbed.