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Anti-tuberculosis Induced Stevens-Johnson Syndrome Due to Misdiagnosis of

Mycobacterium Abscessus Urinary Tract Infection as Tuberculosis

Article in Iranian Journal of Kidney Diseases · May 2021

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 KIDNEY DISEASES

Anti-tuberculosis Induced Stevens-Johnson Syndrome Due

to Misdiagnosis of Mycobacterium Abscessus Urinary Tract
Infection as Tuberculosis
Sara Abolghasemi,1 Shahnaz Sali,1 Arad Mobasher Aghdam,2
Mohammad Amin Shahrbaf2

1Infectious Diseases and Mycobacterium abscessus complex is one of the most important
Tropical Medicine Research groups of non-tuberculosis mycobacteria, which can cause infection
Center, Shahid Beheshti
University of Medial Sciences,
in several organs of the human body. In this study, we report a
Tehran, Iran rare cause of urinary tract infection which was presented with
2Faculty of Medicine, Shahid the chief complaint of hematuria and dysuria. The patient was
Behehsti University of Medical treated by a clarithromycin based approach and the result of
Sciences, Tehran, Iran the culture and polymerase chain reaction were negative after 3
months of treatment. Informed consent was taken from the patient
Keywords. mycobacterium
tuberculosis, mycobacterium
for publishing the case.
abscessus, urinary tract
infection, steven-johnson IJKD 2021;15:235-7
www.ijkd.org
syndrome

INTRODUCTION (UA) were normal and therefore, the patient was

Non-tuberculosis mycobacteria (NTM) are referred to an infectious disease clinic for further
microorganisms commonly found in the soil, tap assessment. The patient was treated as a case

Case Report
water, domestic, wild animal, and food products. 1 of recurrent urinary tract infection (UTI) for 7
There are more than 140 species of NTM which months. Terminal hematuria was added to the
can be pathogen and cause different infections in patient’s complaints and dysuria became more
humans. 2 The mycobacterium abscessus complex severe than before. Some evidences of bladder
(MABc) is one of the most important groups of infection and left ureter obstruction were observed
NTM which is increasing globally.3 MABc is one in further ultrasonography. A urinary smear for
of the rapidly growing mycobacteria causing a acid fast bacillus (AFB) was requested after stent
variety of opportunistic infections in soft tissue, insertion. The urinary smear was +3 positive for
bone, skin and also disseminated infection.4 AFB. Treatment of urinary tuberculosis was started
Urinary tract infection is one of the major causes with fixed-dose drug combinations (pyrazinamide,
of extra-pulmonary infection of tuberculosis. 5 isoniazid, rifampin, ethambutol, and pyridoxine).
However, urinary tract infection caused by NTM is One week later, severe allergic reaction in the form
an extremely rare presentation.6 In this study, we of generalized pruritus, maculopapular, blisters and
report a complicated case of urinary tract infection, pustular skin rash, eye involvement and mucosal
which is caused by mycobacterium abscessus. ulcers were observed. Hence, anti-tuberculosis drugs
were discontinued and the patient was referred to
CASE PRESENTATION our clinic with the primary diagnosis of Stevens-
A 62-year-old male was presented to the Johnson syndrome due to anti-tuberculosis drugs
infectious disease clinic with a chief complaint (Figure). For further investigation, urine PCR for
of dysuria and hematuria since a year ago. His mycobacterium tuberculosis and non-tuberculosis
history of underlying disease such as diabetes was was requested. The result of PCR indicated the
unremarkable. The ultrasonography of kidney, presence of mycobacterium abscessus in the
ureter, and bladder (KUB) and urine analysis urinary tract. Laboratory tests were as follows:

Iranian Journal of Kidney Diseases | Volume 15 | Number 3 | May 2021 235

Mycobacterium Abscessus Infection—Abolghasemi et al

Immunocompromised and immunodeficient

patients are more susceptible to these infections, 10
however; the current case had no history of
immunodeficiency or taking immunosuppressant
drugs.
With regards to antibiotic resistance, treatment
of the UTI caused by mycobacterium abscessus is
a challenging issue. According to the Infectious
A Disease Society of America’s recommendation,
intravenous amikacin administration in combination
with cefoxitin or imipenem is the best choice of
treatment. 11 Furthermore, clarithromycin is also
one of the therapeutic choices that has been used
for the treatment of MABc since 1990s. 12 For extra-
pulmonary cases of MABc, 4 to 6 months treatment
is recommended with the initial administration of
amikacin and cefoxitin or imipenem for the first two
B weeks.13 However, due to the rarity of the current
A) Conjunctivitis Which Seen After Stevens-Johnson Reaction, case, the treatment strategy was so important.
B) Mucosal Ulcers of the Oral Cavity Which Caused by Stevens- For this case, we used intravenous amikacin and
Johnson Syndrome
imipenem for the first two weeks; after that, we
continued the treatment with oral clarithromycin
complete blood count (CBC) and biochemical tests for 4 to 6 months.
were normal. Human immunodeficiency virus After 3 months, the result of urine culture was
antibody (HIV Ab) was negative. Chest X-ray was negative for MABc and the patient was discharged
also unremarkable. The patient was admitted and from the hospital. The patient was followed up
treatment was started with the combination of for one year by a monthly visit in combination
amikacin (500 mg two times, daily) and imipenem with a urine culture. In addition, Stevens-Johnson
(1 gram two times, daily) for 2 weeks. The patient’s syndrome (SJS) after anti-tuberculosis drugs is a
dysuria and hematuria were subsided just 8 days rare phenomenon and is often reported in immune-
after starting the treatment. Then, the treatment deficient patients.14,15 The case of this study was
was continued by clarithromycin for 6 months (500 negative for HIV; moreover, we do not know
mg two times, daily). The patient was followed up exactly which anti-TB drug caused SJS in this case.
monthly by urine culture and after 3 months, the
culture was negative for mycobacterium abscessus. ACKNOWLEDGMENTS
Clarithromycin was continued 3 months after the The authors would like to thank Shahid Beheshti
negative result of culture and polymerase chain University of Medical Sciences and Labbafinejad
reaction (PCR). Hospital for their support, cooperation, and
assistance.
DISCUSSION
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