Case Report: Urinary Mycobacterium Gordonae

摘要

Mycobacterium gordonae, a non-tuberculous mycobacterium (NTM), is the third most commonly isolated acid-fast bacilli, comprising 14.6% of all isolates13. It rarely causes disease, as most of the isolates are commensals3 ,it is the few patients in whom disease occurs that prohibit one from always attributing isolates to contamination or colonization2. We describe a case of a 40-year old HIV-negative man who presented with hematuria, dysuria, and right lower quadrant pain with a history of ureteral stenosis and hydronephrosis. M. gordonae was isolated from the urine, and the patient was started on antituberculosis medications. This case highlights the difficulty in diagnosing NTM and the obstacles in treating NTM in a patient with borderline cognitive function. Case Report A 40-year old Latin American male with a history of toluene inhalation for over fifteen years with subsequent borderline cognitive function, renal tubular acidosis type one secondary to toxic insult from toluene inhalation, recurrent urinary tract infections, and multiple contractures throughout his lower extremities began frequenting the emergency department in 2008 with complaints of altered mental status secondary to toluene inhalation, epigastric pain secondary to gastritis, and hematuria of unknown origin. The patient was unemployed and frequently institutionalized at the local detention center. He smoked cigarettes occasionally, but denied drinking alcohol or using any other illicit drugs aside from toluene inhalation.In November 2008 he presented to the emergency room with altered mental status and hypothermia. Upon resolution of the altered mental status, the patient complained of urinary retention. A renal ultrasound showed a stone in the right proximal ureter with minimal right hydronephrosis and worsening left hydronephrosis when compared to an ultrasound from the previous month. CT of the abdomen showed minimal fullness of the renal pelvis, worse on the left side, and a thickened bladder wall. To relieve urinary retention, urologists recommended intermittent catheterizations and tamulsosin for the patient with endoscopic and urodynamic studies to determine the origin of the urinary retention and hydronephrosis.The patient returned to the emergency room in February of 2009 with altered mental status complaining of stranguria, hematuria, and urinary retention. CT of abdomen revealed left hydronephrosis secondary to a ureteral stricture ( see figure 1 ) and a left sided ureteral stent was placed. Cystoscopy revealed inflammatory erosisve cystits and cobblestone appearance of the bladder. Retrograde pyelogram revealed left distal ureteral obstruction without presence of a stone and left hydroureteronephrosis. Bladder biopsy showed non-specific histological changes consistent with an inflammatory or infiltrative process. Urine cytology and acid-fast bacilli (AFB) cultures were ordered at that time as the diagnosis of renal tuberculosis was aroused. The patient was discharged after left ureteral stent was placed with recommendations to continue intermittent catheterizations and tamulsosin for urinary retention with nitrofurantoin for infection.In March of 2009, the patient again visited the emergency department complaining of left lower quadrant pain that was sharp, constant, and without radiation for the last few months. Five days prior he noted intermittent gross hematuria, dysuria, and stanguria with progressive urinary retention, for which a urinary catheter was placed by a nurse at his detention center. The patient denied recent weight loss, cough, or hemoptysis, but did report intermittent fevers and night sweats.Physical exam was remarkable for left-sided costovertebral angle tenderness, mild lower abdominal tenderness with palpable bladder, but no hepatosplenomegaly or masses were detected. Rectal exam revealed guaiac-negative stool with no prostate hypertrophy. There was no blood at the urethral meatus. Mild normocytic anemia with hemoglobin of