CRA44 GRANULOMAS AND GREENERY: UNRAVELING AN INTRICATE BATTLE OF DISSEMINATED NON-TUBERCULOUS MYCOBACTERIA (NTM) IN AN IMMUNOCOMPROMISED PATIENT

Ryan MF Lee, Ad Rian Chong, Khai Lip Ng, Nor Husna Mohd Aminudin, Kasuma Mohamed Nordin

Respiratory Unit, Department of Medicine, Hospital Melaka

Background
Non-tuberculous mycobacteria (NTM) are increasingly recognized as opportunistic pathogens, especially in immunocompromised individuals. Disseminated NTM infections can present with diverse clinical features, including skin involvement. This case describes a 62-year-old lady with a history of hypertension, hypothyroidism, discoid lupus erythematosus, and previous tuberculosis (TB) lymphadenopathy, who developed disseminated NTM involving her skin and lymph nodes.

Case Presentation
The patient, a plant enthusiast, presented with generalized pruritic rashes, recurrent fever, and weight loss. Her medical history included previous TB lymphadenopathy, treated in 2022. In 2023, she developed multiple lymphadenopathies and skin manifestations, prompting referral to dermatology and rheumatology. Initial biopsies, including a skin biopsy in July 2023, suggested granulomatous inflammation but yielded negative results for Mycobacterium tuberculosis. Further investigations revealed Mycobacterium fortuitum in a lymph node biopsy (August 2023), while a later skin biopsy (June 2024) identified Mycobacterium intracellulare. Imaging studies showed thoracic, abdominal and inguinal lymphadenopathies with hypodense splenic lesions suggestive of splenic abscesses. Despite initial negative TB PCR results, cultures confirmed NTM involvement. The patient was started on a tailored antimicrobial regimen based on culture sensitivities. She tolerated the treatment well, with clinical improvement in her skin lesions. A multidisciplinary approach was crucial in managing her systemic complications.

Conclusion 
This case highlights the diagnostic challenges of disseminated NTM infections, particularly in immunocompromised patients with prior TB and autoimmune diseases. The absence of typical granulomatous features in initial biopsies underscores the need for a high index of suspicion and comprehensive molecular testing. Early recognition and appropriate treatment with tailored antimicrobials are essential for managing complex NTM infections.