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Table 1 Timeline of Case

From: Microscopic polyangiitis secondary to Mycobacterium abscessus in a patient with bronchiectasis: a case report

Time from Presentation Relevant Past Medical History and Interventions
 Presentation First review in Respiratory Clinic- recurrent “chest infections” since 1992
Life-long Non-Smoker
No childhood History of Respiratory Illness
No significant Past Medical History or Family History of note
  Summary of progress Diagnostic Tests Interventions
 Presentation Initial Diagnosis Bronchiectasis
Clinically stable
CT thorax
Normal Baseline Investigations for immunodeficiency
Sputum Culture and Sensitivity testing
Sputum for Acid Fast Bacill (AFB) and NTM culture
Airway Clearance regime initiated
Maintenance Azithromycin therapy started
 Six years from presentation Increasing frequency of Exacerbations HRCT thorax: progression of disease with right middle lobe atelectasis, right upper lobe cylindrical bronchiectasis and reticulo-nodular densities in both lower lobes
Serial growth of S. aureus in sputum samples
Trial of Nebulised Tobramycin- stopped after 15 months due to cough
 Eleven years from presentation First Isolation of M.abscessus from Sputum Further Sputum Samples for AFB/NTM Culture Eradication therapy under consideration
 Three months from first M.abscessus culture Development of paraesthesia in hands, purpuric rash on limbs and small joint arthropathy ESR 49
P-ANCA highly positive 80AI
MPO-ANCA was > 8 AI; PR3-ANCA < 0.2 AI
Nerve conduction studies - axonal loss sensorimotor neuropathy
Renal Function and Urine microscopy Normal
Diagnosis of microscopic polyangiitis
Commenced on immunosuppression-high dose Prednisolone and Cyclophosphamide
 Four months from first M.abscessus culture All sputum samples culture positive for M.abscessus, 66% samples smear positive CRP raised at 86.2 mg/l
CT thorax: extensive bronchiectasis with underlying collapse in the right upper and lower lobes.
Induction Phase Treatment for M.abscessus initiated
(IV Cefoxitin/Amikacin/ Oral Clarithromycin/ Minocycline)
Maintenance therapy initiated
(Nebulised Amikacin,Oral Moxifloxacin/Minocycline/Clarithromycin)
 Six months from first M.abscessus culture Attended ED with Achilles tendon rupture Non-surgical management with immobilization Moxifloxacin stopped
Replaced with Linezolid
 Seven months from first M.abscessus culture Developed significant Alopecia   Minocycline Discontinued
Nebulised Meropenem added
 Two years from first M.abscessus culture (Seventeen months into treatment) Sputum became culture positive for M.abscessus
Presented to ED with right sided visual loss – 1 month later (18 months into treatment)
Right branch retinal vein occlusion secondary to vasculitis confirmed on fluorescein angiography
P-ANCA titre = 160; MPO > 8 AI (highly positive)
Higher level of Immunosuppression initiated
(IV Methylprednisolone and 6 monthly Rituximab infusions)
 Three years from first M.abscessus culture Clinically stable
Smear and culture positive for M.abscessus
Further assessment of immunological function:
• Very low interferon-gamma (IFN-γ) level, with low production of Interleukin-17(IL-17) but no autoantibodies to IFN-γ.
• Normal Vaccination response
• Normal Respiratory oxidative burst, Mannan Binding Lectin, Alternative and innate signalling pathways
Evidence of efficacy of Rituximab
• CD19 count reduced from 46 to 0%
• P-ANCA and MPO titres suppressed
Remained on maintenance antibiotic regime
Ongoing immunosuppression with Rituximab
 Four years from first M.abscessus culture Persistent M. abscessus smear and culture positivity Clarithromycin resistance detectable on sputum culture Cessation of Clarithromycin
Further 3 weeks IV Amikacin/Cefoxitin/Tigecycline.
Maintenance nebulised Meropenem and Amikacin
 Current (Five years from first M.abscessus culture) Intermittent M.abscessus smear positivity
Persistent culture positivity
Sensitivity of M.abscessus being monitored
No growth of other organisms including S.aureus in sputum since 2012
Pulsed IV antibiotics at intervals determined by clinical symptoms and smear positivity