The patient was a 19-year-old male with productive cough, shortness of breath, and low-grade fever for several weeks in Iran. His history showed that he kept many birds at home and also fed a cockatiel mouth-to-mouth for several years. He had shown axillary lymph node involvement when he was 16 years old. After seven months, he complained of joint involvement, and two months later, he presented with shortness of breath, sputum, weight loss (8 kg), chest pain, and night perspiration. Bronchoscopy was carried out, while polymerase chain reaction (PCR), acid-fast staining, and culture for M. tuberculosis were all negative. Treatment with many drugs, including doxycycline, ceftriaxone, cefixime, co-amoxiclav, was initiated at different intervals; however, it was not successful.

Six months later, the patient’s status gradually deteriorated. He presented with shortness of breath with 92% oxygen saturation in ambient air, besides productive cough; the C-reactive protein (CRP) level (80.2 mg/L) and erythrocyte sedimentation rate (ESR) (95 mm/h) were also determined. The result of purified protein derivative (PPD) test was equal to 15 mm.

The computed tomographic (CT) scan indicated bronchiectasis, nodular opacities, consolidation, and cavitary lesions on both sides. Newly collected three sputum and three bronchoalveolar lavage samples were sent for further evaluation of the presence of mycobacterial infections. Contrary to previous findings, the results of acid-fast staining and culture on Lowenstein-Jensen medium were positive for all six samples. We observed four different colonies with rapidly growing mycobacteria (one scotochromogen and three nonchromogens) in the Lowenstein-Jensen medium (Fig. 1).

Showing four colonies of nontuberculous mycobacteria over Lowenstein-Jensen media slant

The hsp65, rpoB and full 16S rDNA genes were used for molecular identification, as previously described in the literature [3]. The sequencing results of four isolates of colonies showed more than 99% similarity with M. fortuitum, M. chelonae, M. mucogenicum, and M. bacteremicum.

We then performed drug susceptibility testing (DST), according to the Clinical & Laboratory Standards Institute (CLSI) guidelines [4] for amikacin, levofloxacin, clarithromycin, cefoxitin, ciprofloxacin, doxycycline, linezolid, imipenem, minocycline, trimethoprim sulfamethoxazole, and vancomycin. We found that all four strains were susceptible to amikacin, cefoxitin, ciprofloxacin, clarithromycin, imipenem, and linezolid. Based on the susceptibility data for all four NTM isolates, treatment was initiated with ciprofloxacin, clarithromycin, and amikacin, along with Montelukast, for five months. The patient reported complete resolution of the signs and a weight gain of 5 kg; also, the CRP and ESR were normal. Nine months after the infection diagnosis, a new CT scan revealed further improvements. Also, the culture and smear results for the presence of NTM was negative.