Mycobacterium tuberculosis bacteremia in a human immunodeficiency virus-negative patient with liver cirrhosis:A case report

lNTRODUCTlON

Despite intense worldwide efforts for treatment and prevention of this disease by the medical community, tuberculosis remains one of the most common causes of death from a single infectious pathogen. China has the third-highest burden of tuberculosis in the world, after India and Indonesia[1].() can directly invade the human gastrointestinal tract, respiratory tract, and skin. It can also infect other parts of the body through spread of this bacterium from the primary lesions through the blood.bacteremia is commonly found in acquired immunodeficiency syndrome (AIDS) patients, and it can also occur in patients with malignant tumors, diabetes, and rheumatic diseases[2]. However,has been rarely reported in patients with liver disease. In this report, we describe a human immunodeficiency virus (HIV)-negative, cirrhotic patient withbacteremia.

No, said the West Wind; so far as that have I never blown; but if you like I will go with you to the South Wind, for he is much stronger than either of us, and he has roamed far and wide, and perhaps he can tell you what you want to know

CASE PRESENTATlON

Chief complaints

A 55-year-old man reported persistent abdominal distension of one week duration, with no obvious underlying cause; the distension was accompanied by diarrhea, shortness of breath, and occasional fever.

History of present illness

The patient showed no symptoms of illness other than the one-week duration of persistent abdominal distension with diarrhea, shortness of breath, and occasional fever.

History of past illness

Medical records indicated a two-year history of abnormal liver function without treatment.

Personal and family history

The patient had a history of smoking and alcohol abuse. There was no family history of other diseases.

Physical examination

Physical examination of the skin showed the evidence of spider nevi, jaundice of skin or sclera, and facial features associated with liver disease, but no evidence of palmar erythema. Auscultation revealed abnormal breath sounds over both lungs and a decreased breath sounds over the right lower lung. Examination of the abdomen showed abdominal distension but no tenderness or rebound pain, splenomegaly, or percussion pain in the liver area. There were also no signs of asterixis.

I shut off the recorder and Rebekah sighed deeply. Thank you, Nan, she said with a weak smile. You ll give this one to them, won t you? she murmured as she slid into sleep.

Laboratory examinations

The findings presented here can raise the awareness of doctors to the possibility that even HIVnegative patients, including HIV-negative patients with liver cirrhosis, may developbacteremia.

She was one of those people who always despise5 their own family and surroundings, and take pleasure in thinking that they themselves are made of finer material than the rest of the world

In 2005, Hanscheid[16] reported thatcan grow in conventional BacT/ALERT FA blood culture bottles, which can be used to reliably diagnosebacteremia. However, because of sparse subsequent reports, few clinicians are aware thatcan grow in conventional BacT/ALERT FA blood culture bottles. Our detection ofin the patient’s blood with next-generation sequencing indicates that the use of advanced technologies can also greatly assist in clinical testing for elusive or unknown pathogens.

Imaging examinations

The patient was treated with supplementary oxygen delivered by a nasal cannula. He was also treated with spironolactone (40 mg, three times a day) and torasemide (10 mg, once a day) for diuretic therapy and magnesium isoglycyrrhizinate (200 mg, once a day) for hepatoprotective therapy. To control the large volume of ascites, the patient’s excess fluid was treated by abdominal puncture drainage, and the infection was treated with piperacillin sulbactam (6 g, every 12 h), biapenem (300 mg, every 6 h) and micafungin (150 mg, once a day).

FlNAL DlAGNOSlS

Chronic liver failure, spontaneous bacterial peritonitis, pulmonary infection, pleural effusion, ascites.

After I returned, my husband proudly reported that he had completed every job. When I saw the list, however, each item except No.5 had been crossed off. What s this! I exclaimed, Didn t you think about me while I was gone?

TREATMENT

Computed tomography (CT) scans showed abdominal (Figure 3) and pelvic effusion and bilateral pleural effusion, with greater effusion in the right pleura. Multiple patchy high-density shadows were seen in both lungs, with blurred borders. Although there were no obvious signs of swollen lymph node shadows in the mediastinum, there were multiple areas of inflammation in both lungs (Figure 4). CT scans indicated liver cirrhosis and multiple cystic foci in the liver.

OUTCOME AND FOLLOW-UP

Although the patient was in severe condition at high risk of respiratory and cardiac arrest at any time, he discharged himself from the hospital against medical advice.

DlSCUSSlON

Bacteremia is a serious systemic infectious disease. The most commonly observed pathogen in bacteremia is, followed byand[3].

Your grandchild, Little Red Riding Hood, replied the wolf, counterfeiting4 her voice; who has brought you a cake and a little pot of butter sent you by mother.

Compared to AIDS patients, there have been fewer reports ofbacteremia in HIVnegative patients[11,12]. Chiu[10] have pointed out that the incidence ofbacteremia in HIV-positive patients is significantly higher than that in HIV-negative patients.bacteremia can also occur in other immunocompromised patients, such as those with malignant tumors, diabetes, and rheumatic diseases[2].

Cirrhosis of the liver is an immunocompromised condition that increases the vulnerability of patients to various infections[13]. The most common bacteremia pathogens in patients with liver cirrhosis include,and[14]. Compared with non-cirrhotic patients, cirrhotic patients with bacteremia show significantly higher mortality as well as greater risk of morbidity and longer hospital stays[3].

Several less common pathogens are also more prevalent and more virulent in patients with liver cirrhosis. Studying liver patients in a hospital in France, Κovacevic and Lakshmanan[14] found that methicillin-resistantbacteremia is present in 35% of patients with liver cirrhosis. Citing several studies in Scandinavia and the United States, Bunchorntavakul and Chavalitdhamrong[15] reported that patients with liver cirrhosis show an increased incidence and heightened virulence ofinfection, which frequently manifests as peritonitis. However, there have been very few reports ofbacteremia in patients with liver cirrhosis.

The clinical symptoms of the patient in this study included pulmonary abnormalities, abdominal distension, and occasional fever, and lymphopenia, similar to the reports of Chiu[10] in HIVnegative patients. Our patient did not show any of the typical symptoms ofinfection such as cough, sputum expectoration, fatigue, or night sweats. However, use of next generation sequencing to screen the patient’s blood samples for microbial pathogens revealed infection with.was later isolated from samples of the patient’s blood grown in conventional BacT/ALERT FA blood culture bottles, thus confirming the sequencing results. We were unable to determine whether the primary disease ofin this patient was an intrapulmonary or extrapulmonary infection because both ascites and blood cultures eventually showed growth ofandcan spread to different sites in the bloodstream. Although the patient's conventional sputum culture showed no abnormal colony growth, it was possible that laboratory culture time was insufficient to obtain.

Examination of ascites fluid showed a positive Rivalta test; ascites cell counts showed 1.6 × 10/L nucleated cells, 76% of which were neutrophils, 10% mononuclear macrophages, 12% lymphocytes, and 2% mesothelial cells. Conventional cultures of the patient’s blood and ascitic fluid were negative for bacterial growth; sputum culture did not show any pathogenic bacteria. However, screening for microbial pathogens in blood samples with next generation sequencing demonstrated the presence ofinfection in this patient (Table 1). The presence of acid-fast bacilli in these samples was confirmed by blood smears (Figure 1A) and by fluorescence microscopy (Figure 1B) of blood cultured in conventional BacT/ALERT FA blood culture bottles. Blood cultured on Lowenstein-Jenden medium yielded white colonies, which were identified asby MALDI-TOF MS (France, Bio-Mé rieux) (Figure 2).

Laboratory analysis of blood samples indicated abnormal liver function:total bilirubin, 221.52 μmol/L; direct bilirubin, 138.76 μmol/L; indirect bilirubin, 82.8 μmol/L; total protein, 48.9 g/L; albumin, 21.6 g/L; alanine aminotransferase, 57 U/L; aspartate aminotransferase, 73 U/L; C-reactive protein, 34 mg/L; serum amyloid A, 92 mg/L; procalcitonin, 1.820 ng/mL; total lymphocyte count, 220/μL; HBsAg, 0.00 IU/mL; HBsAb, 29.19 mIU/mL, HBeAg, 0.38 S/CO; HBeAb, 1.30 S/CO; HBcAg, 8.88 S/CO; hepatitis A antibodies immunoglobulin (Ig) M, negative; hepatitis C virus antibody, negative; hepatitis D antigen, negative; hepatitis D antibody, negative; hepatitis E antibody IgM, negative; hepatitis E antibody IgG, weakly positive; cytomegalovirus antibody IgG, positive; cytomegalovirus antibody IgM, negative; coxsackie virus antibody IgG, positive; coxsackie virus antibody IgM, negative; antinuclear antibody, negative; antimitochondrial antibody, negative; anti-Ro-52 antibody, negative; anti-mitochondrial antibody type 2, negative; anti-SSA antibody, negative; anti-SSB antibody, negative; anti-CENP-B antibody, negative; antihistone antibodies, negative; anti-Jo-1 antibody, negative; anti-Sm antibody, negative; anti-Scl-70 antibody, negative; anti-soluble liver antigen/pancreas antigen antibody, negative; anti-smooth muscle antibody, negative; anti-liver and kidney microsome antibodies, negative; anti-PM-Scl antibody, negative; anti-PCNA antibody, negative.

CONCLUSlON

Althoughbacteremia is a common occurrence among AIDS patients, there have been very few reports of HIV-negative cirrhosis patients withbacteremia. We have shown that next-generation sequencing of pathogenic microorganisms can be used when the cause of infection cannot be found by routine laboratory tests. After sequencing indicated the presence ofin patient blood in this clinical case, later isolation offrom blood samples grown in ordinary blood culture media further confirmed the sequencing results.

I, of course, kept shoving peas down my throat. The glares made me nervous, and every single pea made me want to throw up, but the magical image of that five dollars floated before me, and I finally gagged down every last one of them. My grandmother handed me the five dollars with a flourish. My mother continued to glare in silence. And the episode ended. Or so I thought.

The authors declare that they have no conflict of interest.

There have been fewer reports ofbacteremia, which is usually diagnosed by apositive blood culture. With the increasing number of AIDS patients, however, the incidence ofbacteremia has also been gradually increasing[4]. Among AIDS patients,bacteremia is a common and life-threatening disease[5,6], and it is often associated with severe sepsis[7,8] and high mortality[9] in these patients. The common symptoms of AIDS patients infected withbacteremia include fever, lymphopenia, pulmonary symptoms, weight loss, and cough with sputum[2,10].

Informed written consent was obtained from the patient for publication of this report and all accompanying images.

When evening drew near she stole out of the peasant s cottage secretly, and, going to her hiding-place, she put on her dress embroidered with the gold suns, and all her jewels, and loosed her beautiful golden hair, which up to now she had always worn under a kerchief, and, adorned21 thus, she set out for the town

Lin ZZ and Chen D reviewed the literature and contributed to the manuscript draft; Liu S carried out the pathological analysis and interpretation; Yu JH and Liu SR analyzed and interpreted the image data; Zhu ML revised the manuscript for important intellectual content; all authors approved the final manuscript for submission.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

The rolling and moaning of theNorth Sea could be heard for miles inland when the wind was blowing, and then it sounded like the rushing of a thousand waggons over a hard road with a mine underneath

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Zhe-Zhe Lin 0000-0001-9816-0835; Dan Chen 0000-0002-7225-3432; Sai Liu 0000-0001-8610-4721; Jian-Hua Yu 0000-0001-7574-4969; Shou-Rong Liu 0000-0003-2716-0365; Ming-Li Zhu 0000-0002-6758-2274.

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