Jpn. J. Infect. Dis., 54, 2001

Laboratory and Epidemiology Commumicatioms

Pulmonary Mycobacterium avium Infection in an Immunocompetent
Ybung Adult Related to Use of Home Bath witha Circulating Water System
Aya Watando, Emiko Toyota*, Namiko Mori, Aki Kaneko,
Tadatoshi Kuratsuji, TeruO Kirikae and Koichiro Kudo
lnternational Medical Center ofJapan,

Toyama 1‑21‑1, Shinjluku‑ku, Too)0 162‑8655
Communicated by Hiroshi Ybshikura(Accepted August 13, 2001)

Unsuitable management of bath water occasionally causes
waterborne infectious diseases, such as leglOnellosis andinfections due to non‑tuberculosis mycobacteria. (The draftguideline is available with thefull text of this article at h仕p://www･ cdc ･ gov/ncidodnlip/enviro/envTguide‑draft･pdf )( 1 ) ･A 2 1 ‑year‑old female student (patlent A) was referred tothe co汀eSpOnding author in May 2000, with a routine chest

radiograph revealing left lobe shadowlng, and with mild

fever and a productive cough that had continued since March.

She was a nonsmoker. She had a history of Mycoplasma
pneumoniae infection at 12 years of age. At hospitalization,a tuberculin skin test was negative (0 × 0 induration with 9× 8 mm of redness), and a test fわr HIV antibody was also

negative. The lungs were clear with no crackles or wheezes.

Routine laboratory tests disclosed no abnormalities.
A chest radiograph revealed le氏 lower lobe consolidation(Fig. la). A CT scan revealed an infiltration with thickened
wall of left B9 (Fig. lb). Her sputum smear was acid‑fastbacilli (AFB) negative. However, by diagnostic tests basedon polymera.se chain reaction (PCR) (COBAS AMPLICORT"

MTB, M. avlum and M. intracellulare tests: Roche Diagnostics,
Branchburg, NJ･, USA), the sputum was positive f♭r 〟.

avium. It was, however, negative for M. tuberculosis and M.
intracellulare. The bronchial asplrateS Were AFBand M. avium
complex (MAC) culture positive. Four drug chemotherapy
consistlng Of clarithromycln, rifampln, Streptomycin, andethambutol was started immediately. The MAC isolate wasresistant torifampin (MIC: >50 LLg/ml), streptomycin (MIC:>20 LLg/ml), and ethambutol (MIC: >5 LLg/ml), but relatively
sensitive to clarithromycin(MIC: 4 LLg/ml). ARer 3 months oftreatment, she became asymptomatic, and her chest radiographand CT scan improved.
The patient and her family used a bath with a circulating
and filterlng Water System in their home. The bath water was

found MAC culture positive. PCR‑based diagnosis revealed
that the MACs both from the bath water and the patient wereM. avium. To determine whether these isolates were derived

Fig. L Chest radiograph (a) and chest CT scan (b) befbrc therapy.

from a clone, chromosomal DNA's derived from these twoisolates and two more M. avium clinical isolates not associatedwith the present case were analyzed by pulsed‑field gel electro‑restriction fragment length polymorphism (RFLP) typing (2)phoresis (PFGE) (CHEF MapperTM: Bio‑Rad Laboratories,(Fig. 3a), lS1311 RFLP typing (3) (Fig. 3b), andtyping based

Hercules, Calif., USA) of Asel digests (Fig. 2), IS1245

on length polymorphism of ribosomal DNA spacer reglOnS*ComSpOnding author: Fax: +81 ‑3‑3202‑7364, E‑mail: etoyotabetween repetitive lS1245 and IS1311 (LPRS) (4) (Fig. 4).
The PFGE pattern of the lung specimen from patient A@imcj.hosp.go.jp(No. 1 ) and that of the bath water‑derived specimen (No. 2) were■151

Jpn. J. Infect. Dis., 54, 2001
M

1

2

34

M

M

1

2

3

4

M

Fig. 4. Typing of M. avium isolates by PCR. Genomic sequences
located between IS1245 and IS1311 were amplifiedusing PCR. Lanel: M. avium from patientA (No. 1), lane 2: isolatefrom water bath(No. 2), lane 3: clinical isolate No. 3, lane 4: clinica一 isolate No･ 4,

M: DNA markers consistlng loo‑bp ladders.

identical except for one band differenence in size (indicatedby an arrow in Fig. 2). Meanwhile, other two clinical isolates(Nos. 3 and 4) were entirely different from isolates Nos･ I
and 2 in PEGE pattem. The pattems obtained by IS1245 RFLP,

IS1311 RFLP and LPRS were identical for the patient A's
isolate and the bath water‑derived isolate (Figs. 3 and 4).

Isolates Nos. 3 and 4 showed entirely different pattemsfrom

Fig. 2. Pulsed‑field gel electrophoresis ofAseI‑digested genomic DNAfrom M. avium isolates. Lane 1 : M. avium &om patient A (No･ 1),isolate Nos. 1 and 2 in all the assays (Figs. 3 and 4). The datalane 2: isolate舟om water bath (No. 2), lane 3: clinical isolate No. 3,

indicated that the M. avium isolate from patient A and thatlane 4: clinical isolate No. 4, M: tow range PFG marker.

from bath water were of the same clone. Probably, patient A

acquired the M. avium infection from the bath water･ It
remains unknown why only patient A, but not other family
a1234b1

234members, contracted the disease.

1■f〜REFERENCES
1. Centers for Disease Controland Prevention and Healthcare
lnfection Control Practices Advisory Committee (200 I ):Draft guideline for environmental infection control inhealthcare facilities, 200 1.

2. van Soolingen, D., Bauer, J., Ritacco, V･, Leao, S･ C.,
Pavlik, I., Vincent, V., Rastogi, N., Gori, A･, Bodmer, T･,

Garzelli, C. and Garcia, M. J. (1998): IS1245 restriction
fragment length polymorphismtyping ofMycobacteriumavium isolates: proposal for standardization. J･ Clin･Microbio1., 36, 305 113054.
3. Roiz, M. P., Palenque, E., Guerrero, C. and Garcia, M･ J･( I 995): Use ofrestrictionfragment length polymorphism

as a genetic marker for typlng Mycobacterium aviumstrains. ∫. Clin. Microbio1., 33, 1389‑1391.

4. Picardeau, M. and Vincent, V. (1996): Typing ofMyco‑bacterium avium isolates by PCR. J. Clin. Microbio1.,
34, 389‑392.

Fig. 3. ISJ245 and IS1311 restriction &agment length polymorphism(RFLP) typing. fhIIJigested gcnomic DNA was analyzed by Southernblot hybridizationwithperoxydase‑labeled DNA probe for IS1245 (a)and IS131] (b). Lane 1: M. avium from patientA(No. I), lane 2:
isolate from waterbath (No. 2), lane 3: clinical isolate No. 3, 1ane 4:
climical isolate No. 4.

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