Search

We analyzed routine statutory health insurance claim data to determine prevalence of nontuberculous mycobacterial pulmonary disease in Germany. Documented prevalence rates of this nonnotifiable disease increased from 2.3 to 3.3 cases/100,000 population from 2009 to 2014. Prevalence showed a strong association with advanced age and chronic obstructive pulmonary disease.

Tickborne relapsing fever caused by Borrelia species is rarely reported in travelers returning from Africa. We report a case of a 71-year-old woman who sought treatment at University Medical Center in Freiburg, Germany, in 2015 with recurrent fever after traveling to southern Africa. We detected spirochetes in Giemsa-stained blood smears. Treatment with doxycycline for suspected tickborne relapsing fever was successful. Sequence analyses of several loci (16S rRNA, flagellin, uvrA) showed high similarity to the recently described Candidatus Borrelia kalaharica, which was found in a traveler returning from the same region earlier that year. We provide additional information regarding the genetic relationship of Candidatus B. kalaharica. Sequence information for an additional 6 housekeeping genes enables improved comparability to other borrelial species that cause relapsing fever. Our report underlines the importance and possible emergence of the only recently delineated pathogen in southern Africa.

To the Editor: Cysticercosis-like human infections with the tapeworm Taenia crassiceps, which infects foxes as terminal hosts, have been reported (1,2). We report a case of a cysticercosis-like eye infection caused by the tapeworm T. martis (marten tapeworm) in a woman. The patient was a 43-year-old German woman who sought care during July 2010, after 4 days of perceiving flashing lights in her visual field and a paracentral scotoma in her left eye. Visual acuity in both eyes was 20/20. Examination of the left fundus revealed a mobile subretinal tumor at the temporal upper retinal branch vessel with adjacent intraretinal and subhyaloid bleeding (Figure, panels A–C; Video). The subretinal tumor resembled a cestode larva. Figure Cysticercosis-like eye infection caused by the tapeworm Taenia martis in a woman. A) Fundus at the patient’s initial visit, before medical therapy. The cyst lies subretinally at the temporal upper branch vessels; adjacent intraretinal and subretinal ... Video Taenia martis tapeworm cyst in woman with cysticercosis–like eye infection, before and after medical therapy. Although the cyst decreased in size after medical therapy, movements of the larva persisted. Video is 100 seconds long, taken with a ... The patient reported no other symptoms at that time. Laboratory evaluation found no eosinophilia or elevation of total IgE. Serologic testing results were negative for antibodies against the following parasites: Taenia solium, Echinococcus multilocularis, E. granulosus, Dirofilaria immitis, Strongyloides spp., and Toxocara canis. Fecal testing results were negative for worm eggs. Images from ultrasonography of the liver and magnetic resonance imaging of the head were unremarkable. The patient’s travel history included—in addition to southern European countries—trips to Nepal and Thailand 15 years previously. At the time of examination, the patient lived in a small village near Freiburg (im Breisgau) in southwestern Germany. She grew vegetables in the family garden, which was next to a forest. Her 3 children and husband did not report any health problems. For the past 6 years, the family had owned a dog, which received antiparasitic medications on a regular basis; recent checks for intestinal parasitic infection found no ova. The suspected cause of the woman’s illness was cysticercosis caused by the larva of T. solium; systemic antiparasitic therapy was started (albendazole 400 mg 2×/d, dexamethasone 20 mg/d). The size of the larva diminished (Figure, panel D; Video), but the patient remained symptomatic. Therefore, after 8 days of therapy, the cyst was removed by retinotomy. A few days later, peripheral retinal detachment occurred and was treated by a second vitrectomy and intravitreal gas injection. Because of the repeated gas tamponade, a gas cataract developed, which necessitated cataract surgery. At the end of March 2011, the patient’s visual acuity had returned to 20/20 in both eyes. The removed cyst showed the characteristic macroscopic and histologic features of a cysticercus bladder wall (Figure, panels E, F). To determine the exact species by using molecular methods, we isolated DNA from the cyst, conducted different PCRs selective for mitochondrial genes, determined the corresponding sequences, and used a BLAST search (3) to compare these sequences with publically available sequences. Sequences of the following mitochondrial genes were determined by using the given primers and later submitted to GenBank: small ribosomal subunit (primers 12S Taenia FF 5′-CACAGTGCCAGCATCYGCGGT-3′ and 12S Taenia RR 5′-GAGGGTGACGGGCGGTGTGTAC-3′, PCR product of 426 bp, GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"JX415820","term_id":"407316738"}}JX415820); NADH dehydrogenase subunit 1 (primers: NAD1-FF 5′-ATTGGKTTATTTCAGAGTTTTTCTGATTTA-3′ and NAD1-RR 5′-CTCMCCATAATCAAATGGACTACG-3′, 394 bp, GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"JX415819","term_id":"407316736"}}JX415819); and the cytochrome-c oxidase subunit 1 (determined by using previously published primers [4,5]; 376 bp, GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"JX415821","term_id":"407316739"}}JX415821). All sequences showed highest identity with T. martis (99%–100%) but substantially lower identity with T. crassiceps (91%–97%) and T. solium (87%–89%) tapeworms. Thus, molecular methods unequivocally identified the larva as that of a T. martis tapeworm. T. martis tapeworms (cestodes) live and produce eggs in the intestines of definitive hosts, weasels (family Mustelidae), which also includes pine martens, stone martens, polecats, badgers, wolverines, and stoats (6). The intermediate hosts are prey animals of the definitive hosts, such as arvicoline (voles and muskrats) or murid rodents. When intermediate hosts ingest eggs, cysticerci develop in the pleural and peritoneal cavities. T. martis tapeworms probably occur worldwide wherever suitable definitive and intermediate hosts are present (6,7). A study in southwest Germany reported that 36% of stone martens were infected with T. martis tapeworms (6). Although nearly all patients who had cysticercosis-like infections caused by T. crassiceps tapeworms were immunosuppressed (1,2), we found no signs of immunosuppression in the patient reported here. The only identified risk factor for this patient was consumption of homegrown vegetables, which could have been contaminated by marten feces. The clinical and histologic appearance of the organism in this patient suggested cysticercosis caused by a T. solium tapeworm. However, the specific diagnosis of T. martis tapeworm infection was possible only by use of molecular methods. Thus, human infections with T. martis and other animal tapeworms might occur at times but might be misdiagnosed as T. solium cysticercosis. For therapy, the rules and considerations are probably the same as those for T. solium cysticercosis, as described (8,9). Concerning antiparasitic therapy, one must be aware of possible complications caused by intraocular immunologic reactions. As demonstrated by the case reported here, surgical removal of a subretinal larva is connected with the risk for retinal detachment and cataract formation. The identification of the responsible tapeworm is useful for epidemiologic reasons, for determining the source of infection. We therefore suggest using molecular methods to determine the exact species of parasites removed from human tissue.

Paenibacillus larvae causes American foulbrood in honey bees. We describe P. larvae bacteremia in 5 injection drug users who had self-injected honey-prepared methadone proven to contain P. larvae spores. That such preparations may be contaminated with spores of this organism is not well known among pharmacists, physicians, and addicts.

To the Editor: Advanced molecular biologic methods have improved the species differentiation and taxonomic classification of microorganisms, including nontuberculous mycobacteria. Identifying and characterizing an increasing number of "new" mycobacterial species of medical importance is now possible. Often, these newly described mycobacteria have been isolated from immunocompromised patients (1,2). Some of those have been difficult to cultivate, and 16S rRNA gene sequencing or similar methods have become of major importance to allow species identification and clinical diagnosis. Here, we report 2 patients with disease likely caused by a novel mycobacterial species that could not been previously cultivated. Diagnosis relied on molecular identification of acid-fast organisms in tissues. We also briefly review 2 similar cases published previously and note that all 4 known patients were from central Europe. A 43-year-old woman without evidence of immunodeficiency reported recurrent episodes of dysuria, hematuria, and abdominal discomfort for >1 year. On cystoscopy, a hyperemic bladder with yellow plaques was observed. Biopsy of the plaques showed granulomatous infiltration of histiocytes. No definite diagnosis was made, and symptomatic relief occurred after a trial of empiric antimicrobial drug therapy. When the patient sought treatment again with persistent abdominal discomfort, endoscopy showed a lesion in the stomach that resembled a healed ulcer and numerous elevated yellow plaques throughout the colon and ileum. Microscopically, a granulomatous inflammation with macrophages filled with many acid-fast rods was seen, but mycobacterial growth did not occur in different media or in a guinea pig. Antituberculous treatment was initiated, and the patient slowly improved. A repeat colonoscopy showed fewer and smaller lesions. Efforts to culture the organism from biopsy specimens were again unsuccessful (different solid and liquid media, blood or chocolate agar, guinea pig, Balb/c mice). Sequencing of polymerase chain reaction (PCR) products of the 16S rRNA gene (3) from the organism represented a previously unknown mycobacterial species (EMBL DNA database: accession number {"type":"entrez-nucleotide","attrs":{"text":"Z50172","term_id":"1480398","term_text":"Z50172"}}Z50172). "Mycobacterium tilburgii" was proposed as the designation of this species because the novel mycobacterium was identified in the city of Tilburg (4). Retrospective analysis of the initial bladder biopsy specimen and of 2 lymph nodes taken during abdominal surgery (which became necessary because of a complicating ileal obstruction) confirmed the presence of "M. tilburgii" 16S rRNA gene sequences. All samples yielding PCR fragments hybridized with a "M. tilburgii"–specific biotinylated DNA probe. A 34-year-old AIDS patient sought treatment for involuntary weight loss. Endoscopy showed white superficial embossments of the duodenal mucosa. Biopsy specimens were negative for acid-fast bacteria and mycobacterial growth (again, different solid and liquid media, extended incubation periods). Antiretroviral therapy was begun, but asthenia, persistent fever, diarrhea, vomiting, and cachexia developed. Repeat endoscopy showed yellow, plaquelike lesions in the duodenum (Figure A1) and esophagus with periodic acid–Schiff (PAS) and acid-fast intracellular bacteria that were nonculturable. PCR of 16S rRNA gene (3) confirmed the presence of mycobacterial DNA; sequencing showed 100% homology to the species with the proposed name "M. tilburgii" (4). Retrospectively, "M. tilburgii"16S rRNA was present in the initial duodenal biopsy specimen, when no mycobacteria were detected microscopically. Combination therapy led to a gradual disappearance of fever and diarrhea. The patient's weight increased, and the lesions disappeared (Table). Control endoscopy results were unremarkable, although duodenal biopsy specimens showed PAS-positive material. Mycobacterial DNA was no longer detectable. Table Characteristics of patients with confirmed "Mycobacterium tilburgii" disease* We believe that the identified acid-fast organism named "M. tilburgii" was the causative agent of illness in the 2 patients. First, the clinical and histopathologic appearance of the lesions is compatible with mycobacterial infection. Second, the finding that the macrophages in these lesions contained large numbers of acid-fast bacteria supports the conclusion that mycobacterial infection caused the lesion. Third, the involvement of normally sterile locations such as lymph nodes, and the improvement after antimycobacterial therapy with disappearance of the lesions, acid-fast organisms, and mycobacterial DNA supports a causative role of the organism rather than a bystander role. Attempts to culture the organism from biopsy specimens and resection materials remained unsuccessful, although specific requirements for organisms like M. genavense, a mycobacterium that also is not cultivable on regular mycobacterial media (5), were met. Diagnosis therefore had to rely on sequencing of PCR products. Based on 16S rRNA homology, "M. tilburgii" shows close relationship to M. sherrisii, a M. simiae–related mycobacterium (6) that probably corresponds to Mycobacterium strain IWGMT 90143 (accession no. {"type":"entrez-nucleotide","attrs":{"text":"X88906","term_id":"1237223","term_text":"X88906"}}X88906) (7). "M. tilburgii" also has a high homology to Mycobacterium sp. Murphy, a mycobacterial species that is considered the cause of canine lepra and that also has not been cultivated so far (8) (accession no. {"type":"entrez-nucleotide","attrs":{"text":"AF144747","term_id":"4769067","term_text":"AF144747"}}AF144747). These 2 patients double the number of patients reported previously (Table). Both previously reported M. tilburgii patients had AIDS, 1 of whom had a disease similar to that of the second patient in this report (9). Taken together, 3 patients had gastrointestinal involvement with yellow mucosal plaques (Figure A1), and 1 patient had pulmonary nodules (10). One of the 4 patients did not have a detectable immunodeficiency, yet had gastrointestinal and urinary bladder lesions. Although complications occurred, treatment was successful in all 4 cases with usual anti–Mycobacterium avium complex therapy. Interestingly, all 4 patients so far are of middle-European descent. This species may be geographically confined, similar to the occurrence of M. malmoense in which most clinical isolates come from northern Europe (1).