Abstract: SA-PO091
Return of the MAC: Granulomatous Interstitial Nephritis Secondary to Disseminated Mycobacterium Avium Complex (MAC) Infection
Session Information
- AKI: Epidemiology, Risk Factors, Prevention - II
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 101 AKI: Epidemiology, Risk Factors, and Prevention
Authors
- Monk, Muhammad A., HCA Houston Healthcare Kingwood, Kingwood, Texas, United States
- Soodi, Catherine, HCA Houston Healthcare Kingwood, Kingwood, Texas, United States
- Torres, Jordan, HCA Houston Healthcare Kingwood, Kingwood, Texas, United States
- Shyamkumar, Srinidhi, HCA Houston Healthcare Kingwood, Kingwood, Texas, United States
- Al Shaarani, Majd, The University of Texas Health Science Center at Houston, Houston, Texas, United States
- Puthalapattu, Sowmya, HCA Houston Healthcare Kingwood, Kingwood, Texas, United States
Introduction
Mycobacterium Avium Complex (MAC) is a group of non-tuberculous mycobacteria with the potential to cause severe infection in the immunocompromised, notably with HIV and AIDS. MAC is mostly known as a respiratory pathogen, however can disseminate in the bloodstream and has been seen in nearly all organ systems.
Case Description
A 27-year-old male with a history of HIV on antiretroviral therapy (ART) presented with 2 weeks of painful swelling of his left jaw. He was diagnosed with HIV 5 months prior and discharged on ART. After discharge, the patient’s blood cultures became positive for MAC but he was never informed or treated.
Vital signs were stable, and physical exam showed a tender subcutaneous mandibular mass. CT of the face showed a 3.8 cm abscess adjacent to the mandible. A chest radiograph showed no acute findings. Labs showed BUN of 78 mg/dL, serum Creatinine of 12.2 mg/dL, and an estimated 24-hour proteinuria of 1g/day. Kidney function was previously normal. Ultrasound showed enlarged kidneys without hydronephrosis. HIV PCR was undetectable, and CD4 testing could not be calculated due to severe lymphopenia
The abscess was drained, and cultures were positive for MRSA and MAC. The patient was started on cefazolin, ethambutol, and azithromycin, and symptoms improved rapidly. Testing for other opportunistic infections was negative. ART was held until definitive diagnosis for AKI was made on biopsy, which showed granulomatous tubulointerstitial nephritis and crystalline nephropathy. Renal function stabilized, ART was resumed, and outpatient follow-up was arranged.
Discussion
Given the positive MAC culture found in subcutaneous abscess drainage and severe granulomatous inflammation seen on kidney biopsy disseminated MAC infection was the likely underlying etiology of the patient's AKI.
MAC is less commonly known to affect the skin, though several case descriptions can be found in the literature. Granulomatous interstitial nephritis is a rare finding, occurring in less than 1% of all biopsies. Other considered etiologies of AKI included HIV associated nephropathy, sarcoidosis, and granulomatosis with polyangiitis.
Clinicians should be aware of extrapulmonary manifestations of MAC and ensure prompt outpatient follow-up at the time of HIV diagnosis in order to prevent adverse outcomes.