Intestinal obstruction caused by disseminated mycobacterium avium complex disease following solid organ transplantation: A case report

Intestinal obstruction caused by disseminated mycobacterium avium complex disease following solid organ transplantation: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Intestinal obstruction caused by disseminated mycobacterium avium complex disease following solid organ transplantation: A case report Akane Mita, Sho Nakakubo, Yusuke Nishimura, Hideki Shima, Masaaki Watanabe, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4950132/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Jan, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 12 You are reading this latest preprint version Abstract Background Mycobacterium avium complex (MAC) is a common pathogen causing non-tuberculous mycobacterial infections, primarily affecting the lungs. Disseminated MAC disease occurs mainly in immunocompromised individuals, such as those with AIDS, hematological malignancies, or those positive for anti-IFN-γ antibodies. However, its occurrence in solid organ transplant recipients is rare. Herein, we report a rare case of disseminated MAC disease following liver transplantation, which led to an obstructive mass in the intestinal tract that required differentiation from a malignant tumor. Case Presentation A 76-year-old woman, who had undergone living-donor liver transplantation 15 years earlier for primary biliary cirrhosis, presented with persistent fever and vomiting three months before admission. She had a history of pulmonary MAC diagnosed five years earlier but remained untreated due to stable lung lesions. Abdominal CT during her current illness revealed new thickening at the jejuno-jejunal anastomosis site and enlarged mesenteric lymph nodes. PET-CT indicated increased uptake at these sites, suggesting a possible malignancy. Endoscopy revealed an elevated lesion with circumferential ulcers, leading to a suspicion of primary malignant lymphoma. However, biopsies showed CD68-positive histiocyte-like cells with numerous acid-fast bacilli, confirming disseminated MAC infection. Despite ongoing antimicrobial therapy, the patient's intestinal lesions persisted, and she required prolonged hospitalization and interventions for bile drainage and enteral nutrition. Conclusion This case underscores the importance of considering disseminated MAC as a potential complication in solid organ transplant recipients, even when a long period has passed since transplantation. Disseminated MAC can mimic malignancy, presenting with significant lesions causing intestinal obstruction. Awareness and thorough differential diagnosis are essential for timely and accurate management in such complex cases. The patient's outcome emphasizes the need for vigilance in managing long-term immunosuppressed patients, particularly when they present with atypical infections. Disseminated Mycobacterium Avium Complex Disease Solid Organ Transplantation Bowel Obstruction Case Report Figures Figure 1 Background Mycobacterium avium complex (MAC) is the most common causative pathogen of non-tuberculous mycobacterial infection (NTM), which mainly affects the lungs. Disseminated MAC disease can occur in immunocompromised individuals, such as those with acquired immunodeficiency syndrome (AIDS), hematological malignancies, and those who are positive for anti-interferon gamma (IFN-γ) antibody. However, little is known about the occurrence of NTM in recipients of solid organ transplantations. Disseminated MAC disease often involves the duodenum as an entry point, but rarely forms massive lesions. Herein, we present a case of disseminated MAC disease following liver transplantation, which resulted in an obstructive mass in the intestinal tract that required differentiation from a malignant tumor. Case presentation The patient was a 76-year-old woman who had undergone living-donor liver transplantation 15 years prior, to treat primary biliary cirrhosis. Her post-transplant immunosuppressive regimens had included prednisolone, tacrolimus, and mycophenolate mofetil. Five years prior, she was diagnosed with pulmonary MAC disease following the identification of a granular shadow on computed tomography (CT) and multiple positive sputum tests for Mycobacterium avium . The lung lesions did not worsen and were followed up without treatment. She had undergone permanent pacemaker implantation to treat sick sinus syndrome, multiple surgeries to treat bilateral breast cancer and uterine fibroids, and had been diagnosed with diabetes mellitus. She had no history of smoking, or frequent exposure to soil or unsanitary water. Three months before hospital admission, the patient experienced persistent fever and occasional vomiting. Chest CT revealed worsening granular shadows in the right middle and lower lobes and the left lingular lower lobe. Abdominal CT revealed new thickening of the small intestinal wall at the jejuno-jejunal anastomosis site that had been constructed during her liver transplantation procedure, as well as enlargement of multiple mesenteric lymph nodes. A positron emission tomography (PET)-CT indicated increased uptake (maximum standardized uptake value = 13.8) at these sites (Fig. 1 a). Endoscopy of the small intestine revealed an elevated lesion with circumferential ulcers at the jejuno-jejunal anastomosis site, accompanied by intestinal stenosis (Fig. 1 b). A primary malignant lymphoma of the small intestine was initially suspected, prompting a biopsy. Persistent fever led to hospital admission because of nausea, vomiting, and poor oral intake. During her hospital stay, the patient’s body mass index was 17.5 kg/m². She exhibited a fever of 38.5°C, heart rate of 81 beats per minute, blood pressure of 103/48 mmHg, oxygen saturation (SpO 2 ) of 97% on room air, and a respiratory rate of 31 breaths per minute. Chest auscultation revealed no abnormalities in her heart or lung sounds, and a soft mass was palpable in the left midline of her abdomen. Her white blood cell count was within normal limits (3,800/µL), but showed an elevated neutrophil percentage of 86.0%. Her actual CD4-positive T-cell count was 1,809/µL. Her C-reactive protein level was 6.61 mg/dL, and her serum was positive for procalcitonin. Liver function tests were normal (total bilirubin, 0.5 mg/dL; aspartate aminotransferase, 23 U/L; alanine aminotransferase, 14 U/L; lactate dehydrogenase, 165 U/L; gamma-glutamyltransferase, 28 U/L; alkaline phosphatase, 79 U/L). Her renal function was normal (blood urea nitrogen, 10 mg/dL; creatinine, 0.51 mg/dL). Her soluble interleukin-2 receptor level was elevated (4,975 U/mL). Tests for human immunodeficiency virus antibodies and anti-interferon gamma (IFN-γ) neutralizing autoantibodies were negative. Pathological findings from a small intestine biopsy showed diffuse infiltration and clustering of CD68-positive histiocyte-like cells within the lamina propria of the mucosa, interspersed with numerous neutrophils. No caseous necrosis or granulomas were observed, and the cytoplasm contained numerous acid-fast bacilli, as confirmed by positive Ziehl-Neelsen staining (Fig. 1 c). Blood cultures obtained on admission showed M. avium , confirming a diagnosis of disseminated MAC. Furthermore, pathological examination of a liver biopsy revealed a non-caseating granuloma, and cultures yielded M. avium. Treatment with oral ethambutol (15 mg/kg), azithromycin (250 mg/day), and rifabutin (7.5 mg/kg), supplemented with intravenous amikacin (10 mg/kg), was initiated. Despite this ongoing treatment, the patient’s fever persisted. Given the possibility of poor drug absorption caused by her intestinal condition, the route of azithromycin administration was switched to intravenous on day 55, and levofloxacin (500 mg/day) was also administered. Following treatment adjustment, her fever gradually subsided. However, her bowel lesions did not improve, and the ileus symptoms persisted. A percutaneous transhepatic cholangio-drainage tube was placed for bile drainage at the site of the small intestinal stenosis, and a percutaneous enteral tube was placed for stable nutritional infusion and drug administration. The patient was discharged on day 207 of her hospitalization. Her intestinal stenosis has been gradually improving, and she continues to receive antimicrobial treatment and enteral nutrition through outpatient care. Discussion and Conclusions This case highlights the following two key findings: first, disseminated MAC infections can manifest after liver transplantation and, second, they can present with occupying lesions large enough to cause intestinal obstruction capable of mimicking malignancy. Disseminated MAC infections are predominantly observed in patients with AIDS, and are relatively rare in solid organ transplant recipients ( 1 ) . Among transplant recipients, those with liver transplants have a lower incidence of nontuberculous mycobacterial infections than those with kidney or lung transplants ( 2 , 3 ) , likely because of the less intensive immunosuppressive therapy generally used ( 4 ) . In this case, the patient's preexisting pulmonary MAC infection combined with the immunosuppressive regimen of liver transplantation, compounded by her advanced age, likely contributed to the development of disseminated MAC. Notably, disseminated MAC can occur as a serious late complication even in patients who have been stable for extended periods following transplantation. Regarding its intestinal manifestations, lesions in disseminated MAC typically develop in the duodenum and present as ulcers or inflammatory lesions ( 5 ) . A previous report attributed intestinal obstruction to disseminated MAC ( 6 ) ; however, that case involved patients with prior histories of recurrent intestinal obstruction, in whom a direct causal relationship with MAC lesions could not be definitively established. By contrast, our case had endoscopic confirmation of obstruction caused by occupying lesions. Histopathological analysis did not reveal epithelioid granulomas, but did show aggregates of CD68-positive histiocyte-like cells loaded with intracellular mycobacteria, thus confirming direct MAC infiltration ( 7 , 8 ) . Typically, macrophage activation leads to the formation of granulomas as a containment strategy that prevents the formation of large occupying lesions ( 9 ) . However, in this case, it was hypothesized that the patient’s immunosuppressed state hindered the formation of granulomas, leading to excessive bacterial proliferation and an overabundance of reactive histiocytes within the tissue. Initially, our clinical and radiological findings led to a tentative diagnosis of malignant intestinal lymphoma. However, the diagnostic process, which included cultures and biopsies from multiple organs, facilitated an accurate diagnosis. This case highlights the critical need for increased awareness of atypical infectious presentations in immunosuppressed patients that may closely mimic more conventional pathologies, such as malignancy. We present a case of disseminated MAC infection following liver transplantation. It resulted in the formation of a tumorous lesion that then led to intestinal obstruction. This case highlights the importance of recognizing disseminated MAC as a potential posttransplant complication. Thorough consideration of disseminated MAC should be included in the differential diagnosis for such cases, particularly those with atypical presentations that mimic malignancy. Abbreviations AIDS Acquired Immunodeficiency Syndrome CT Computed Tomography IFN-γ Interferon Gamma MAC Mycobacterium Avium Complex NTM Non-Tuberculous Mycobacterial PET-CT Positron Emission Tomography-Computed Tomography SpO 2 Oxygen Saturation Declarations Ethics approval and consent to participate Written informed consent was obtained from the patients for the publication of this case report series and any accompanying images. Consent for publication Written informed consent was obtained from the patients for the publication of this case report series and any accompanying images. Availability of data and materials Not applicable. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions A.M. conceived the concept, provided patient care, collected data, and drafted the manuscript. S.N. contributed to the concept, drafted, and revised the manuscript. Y.N. was responsible for data collection. H.S. was involved in data collection and patient care. M.W. contributed to data collection and patient care. T.S. was responsible for data collection. S.K. revised the manuscript and provided supervision. All authors reviewed the manuscript. Acknowledgements Not applicable. Clinical trial number not applicable. References Henkle E, Winthrop KL. Nontuberculous mycobacteria infections in immunosuppressed hosts. Clin Chest Med. 2015;36:91–9. https://doi.org/10.1016/j.ccm.2014.11.002 . Ingilizova M, Epstein S, Heun Lee D, Patel N, Patel Babariya S, Morgenstern R, et al. A rare case of disseminated Mycobacterium avium complex with colitis in a renal transplant recipient. Transpl Infect Dis. 2019;21:e13011. https://doi.org/10.1111/tid.13011 . Neau-Cransac M, Dupon M, Carles J, Le Bail B, Saric J. Disseminated Mycobacterium avium infection after liver transplantation. Eur J Clin Microbiol Infect Dis. 1998;17:744–6. https://doi.org/10.1007/s100960050177 . Longworth SA, Daly JS, AST Infectious Diseases Community of Practice. Management of infections due to nontuberculous mycobacteria in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transpl. 2019;33:e13588. https://doi.org/10.1111/ctr.13588 . Sun HY, Chen MY, Wu MS, Hsieh SM, Fang CT, Hung CC, et al. Endoscopic appearance of GI mycobacteriosis caused by the Mycobacterium avium complex in a patient with AIDS: case report and review. Gastrointest Endosc. 2005;61:775–9. https://doi.org/10.1016/s0016-5107(04)02786-5 . Bhatia A, Shah H, Mehra D, Ogunjemilusi O. Disseminated Mycobacterium avium intracellulare infection with concurrent small bowel obstruction: Case, Pathophysiology, and Clinical Considerations. Cureus. 2021;13:e13469. https://doi.org/10.7759/cureus.13469 . Fujita Y, Matsumoto H, Asano T, Sato S, Yashiro-Furuya M, Matsuoka N, et al. Hemophagocytic lymphohistiocytosis associated with disseminated nontuberculous mycobacterial infection in a patient with mesenteric panniculitis. Tohoku J Exp Med. 2021;253:151–7. https://doi.org/10.1620/tjem.253.151 . Ohara K, Kimura T, Sakamoto K, Okada Y. Nontuberculous mycobacteria-associated spindle cell pseudotumor of the nasal cavity: a case report. Pathol Int. 2013;63:266–71. https://doi.org/10.1111/pin.12059 . Parker H, Lorenc R, Ruelas Castillo J, Karakousis PC. Mechanisms of antibiotic tolerance in Mycobacterium avium complex: lessons from related mycobacteria. Front Microbiol. 2020;11:573983. https://doi.org/10.3389/fmicb.2020.573983 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Jan, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 20 Dec, 2024 Reviews received at journal 23 Oct, 2024 Reviewers agreed at journal 13 Oct, 2024 Reviewers agreed at journal 12 Oct, 2024 Reviewers agreed at journal 22 Sep, 2024 Reviews received at journal 29 Aug, 2024 Reviewers agreed at journal 24 Aug, 2024 Reviewers invited by journal 23 Aug, 2024 Editor invited by journal 23 Aug, 2024 Editor assigned by journal 22 Aug, 2024 Submission checks completed at journal 22 Aug, 2024 First submitted to journal 21 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4950132","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":357067277,"identity":"be3e99f3-fc2e-4e59-b193-f9bf89df6c9c","order_by":0,"name":"Akane Mita","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Akane","middleName":"","lastName":"Mita","suffix":""},{"id":357067278,"identity":"dd1a4047-c799-4e00-b3e5-f8171204de12","order_by":1,"name":"Sho Nakakubo","email":"data:image/png;base64,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","orcid":"","institution":"Hokkaido University","correspondingAuthor":true,"prefix":"","firstName":"Sho","middleName":"","lastName":"Nakakubo","suffix":""},{"id":357067279,"identity":"cec61047-f4fe-4bda-809c-51b41d099ef0","order_by":2,"name":"Yusuke Nishimura","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Nishimura","suffix":""},{"id":357067281,"identity":"732ad55b-e4fd-4f09-95cb-0e0dd5e36fdb","order_by":3,"name":"Hideki Shima","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Hideki","middleName":"","lastName":"Shima","suffix":""},{"id":357067283,"identity":"15e6ae8b-dd93-44fe-aaaf-5c07ba3e0f47","order_by":4,"name":"Masaaki Watanabe","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Masaaki","middleName":"","lastName":"Watanabe","suffix":""},{"id":357067284,"identity":"1cf3bd2d-b9c0-4db1-9c8d-8986b9fdc551","order_by":5,"name":"Tsuyoshi Shimamura","email":"","orcid":"","institution":"Hokkaido University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tsuyoshi","middleName":"","lastName":"Shimamura","suffix":""},{"id":357067286,"identity":"7593e177-b8e0-4da0-b58e-63de67980bc3","order_by":6,"name":"Satoshi Konno","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Konno","suffix":""}],"badges":[],"createdAt":"2024-08-21 08:55:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4950132/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4950132/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-10488-3","type":"published","date":"2025-01-25T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66745531,"identity":"dd91ba2f-a5a0-4083-b5b3-7a0195627de5","added_by":"auto","created_at":"2024-10-16 06:30:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":645779,"visible":true,"origin":"","legend":"\u003cp\u003ea: Positron emission tomography-computed tomography revealed focal uptake with a maximum standardized uptake value of 13.8, corresponding to thickened small intestinal walls and enlarged mesenteric lymph nodes. b: Endoscopic examination of the small bowel identified a protruding lesion with circumferential ulcers near the jejuno-jejunal anastomosis of the elevated jejunum. c: Histopathological analysis showed diffuse infiltration and aggregation of CD 68-positive histiocytic cells within the lamina propria. Numerous acid-fast bacilli densely populate the vesicles, highlighted by the arrows.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4950132/v1/27b8732d2befd9a34647a630.jpg"},{"id":74858503,"identity":"395896a3-6b94-46f6-8efa-52bf0baf50de","added_by":"auto","created_at":"2025-01-27 16:10:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":970126,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4950132/v1/93aa30e0-c881-497b-9c88-d3f3133aaaff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intestinal obstruction caused by disseminated mycobacterium avium complex disease following solid organ transplantation: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eMycobacterium avium complex (MAC) is the most common causative pathogen of non-tuberculous mycobacterial infection (NTM), which mainly affects the lungs. Disseminated MAC disease can occur in immunocompromised individuals, such as those with acquired immunodeficiency syndrome (AIDS), hematological malignancies, and those who are positive for anti-interferon gamma (IFN-γ) antibody. However, little is known about the occurrence of NTM in recipients of solid organ transplantations. Disseminated MAC disease often involves the duodenum as an entry point, but rarely forms massive lesions. Herein, we present a case of disseminated MAC disease following liver transplantation, which resulted in an obstructive mass in the intestinal tract that required differentiation from a malignant tumor.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a 76-year-old woman who had undergone living-donor liver transplantation 15 years prior, to treat primary biliary cirrhosis. Her post-transplant immunosuppressive regimens had included prednisolone, tacrolimus, and mycophenolate mofetil. Five years prior, she was diagnosed with pulmonary MAC disease following the identification of a granular shadow on computed tomography (CT) and multiple positive sputum tests for \u003cem\u003eMycobacterium avium\u003c/em\u003e. The lung lesions did not worsen and were followed up without treatment. She had undergone permanent pacemaker implantation to treat sick sinus syndrome, multiple surgeries to treat bilateral breast cancer and uterine fibroids, and had been diagnosed with diabetes mellitus. She had no history of smoking, or frequent exposure to soil or unsanitary water.\u003c/p\u003e\u003cp\u003eThree months before hospital admission, the patient experienced persistent fever and occasional vomiting. Chest CT revealed worsening granular shadows in the right middle and lower lobes and the left lingular lower lobe. Abdominal CT revealed new thickening of the small intestinal wall at the jejuno-jejunal anastomosis site that had been constructed during her liver transplantation procedure, as well as enlargement of multiple mesenteric lymph nodes. A positron emission tomography (PET)-CT indicated increased uptake (maximum standardized uptake value = 13.8) at these sites (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). Endoscopy of the small intestine revealed an elevated lesion with circumferential ulcers at the jejuno-jejunal anastomosis site, accompanied by intestinal stenosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). A primary malignant lymphoma of the small intestine was initially suspected, prompting a biopsy. Persistent fever led to hospital admission because of nausea, vomiting, and poor oral intake.\u003c/p\u003e\u003cp\u003eDuring her hospital stay, the patient’s body mass index was 17.5 kg/m². She exhibited a fever of 38.5°C, heart rate of 81 beats per minute, blood pressure of 103/48 mmHg, oxygen saturation (SpO\u003csub\u003e2\u003c/sub\u003e) of 97% on room air, and a respiratory rate of 31 breaths per minute. Chest auscultation revealed no abnormalities in her heart or lung sounds, and a soft mass was palpable in the left midline of her abdomen.\u003c/p\u003e\u003cp\u003eHer white blood cell count was within normal limits (3,800/µL), but showed an elevated neutrophil percentage of 86.0%. Her actual CD4-positive T-cell count was 1,809/µL. Her C-reactive protein level was 6.61 mg/dL, and her serum was positive for procalcitonin. Liver function tests were normal (total bilirubin, 0.5 mg/dL; aspartate aminotransferase, 23 U/L; alanine aminotransferase, 14 U/L; lactate dehydrogenase, 165 U/L; gamma-glutamyltransferase, 28 U/L; alkaline phosphatase, 79 U/L). Her renal function was normal (blood urea nitrogen, 10 mg/dL; creatinine, 0.51 mg/dL). Her soluble interleukin-2 receptor level was elevated (4,975 U/mL). Tests for human immunodeficiency virus antibodies and anti-interferon gamma (IFN-γ) neutralizing autoantibodies were negative.\u003c/p\u003e\u003cp\u003ePathological findings from a small intestine biopsy showed diffuse infiltration and clustering of CD68-positive histiocyte-like cells within the lamina propria of the mucosa, interspersed with numerous neutrophils. No caseous necrosis or granulomas were observed, and the cytoplasm contained numerous acid-fast bacilli, as confirmed by positive Ziehl-Neelsen staining (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e\u003cp\u003eBlood cultures obtained on admission showed \u003cem\u003eM. avium\u003c/em\u003e, confirming a diagnosis of disseminated MAC. Furthermore, pathological examination of a liver biopsy revealed a non-caseating granuloma, and cultures yielded \u003cem\u003eM. avium.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTreatment with oral ethambutol (15 mg/kg), azithromycin (250 mg/day), and rifabutin (7.5 mg/kg), supplemented with intravenous amikacin (10 mg/kg), was initiated. Despite this ongoing treatment, the patient’s fever persisted. Given the possibility of poor drug absorption caused by her intestinal condition, the route of azithromycin administration was switched to intravenous on day 55, and levofloxacin (500 mg/day) was also administered. Following treatment adjustment, her fever gradually subsided. However, her bowel lesions did not improve, and the ileus symptoms persisted. A percutaneous transhepatic cholangio-drainage tube was placed for bile drainage at the site of the small intestinal stenosis, and a percutaneous enteral tube was placed for stable nutritional infusion and drug administration. The patient was discharged on day 207 of her hospitalization. Her intestinal stenosis has been gradually improving, and she continues to receive antimicrobial treatment and enteral nutrition through outpatient care.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThis case highlights the following two key findings: first, disseminated MAC infections can manifest after liver transplantation and, second, they can present with occupying lesions large enough to cause intestinal obstruction capable of mimicking malignancy. Disseminated MAC infections are predominantly observed in patients with AIDS, and are relatively rare in solid organ transplant recipients\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e. Among transplant recipients, those with liver transplants have a lower incidence of nontuberculous mycobacterial infections than those with kidney or lung transplants\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e, likely because of the less intensive immunosuppressive therapy generally used\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. In this case, the patient's preexisting pulmonary MAC infection combined with the immunosuppressive regimen of liver transplantation, compounded by her advanced age, likely contributed to the development of disseminated MAC. Notably, disseminated MAC can occur as a serious late complication even in patients who have been stable for extended periods following transplantation.\u003c/p\u003e\u003cp\u003eRegarding its intestinal manifestations, lesions in disseminated MAC typically develop in the duodenum and present as ulcers or inflammatory lesions\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. A previous report attributed intestinal obstruction to disseminated MAC\u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e; however, that case involved patients with prior histories of recurrent intestinal obstruction, in whom a direct causal relationship with MAC lesions could not be definitively established. By contrast, our case had endoscopic confirmation of obstruction caused by occupying lesions. Histopathological analysis did not reveal epithelioid granulomas, but did show aggregates of CD68-positive histiocyte-like cells loaded with intracellular mycobacteria, thus confirming direct MAC infiltration\u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. Typically, macrophage activation leads to the formation of granulomas as a containment strategy that prevents the formation of large occupying lesions\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. However, in this case, it was hypothesized that the patient’s immunosuppressed state hindered the formation of granulomas, leading to excessive bacterial proliferation and an overabundance of reactive histiocytes within the tissue.\u003c/p\u003e\u003cp\u003eInitially, our clinical and radiological findings led to a tentative diagnosis of malignant intestinal lymphoma. However, the diagnostic process, which included cultures and biopsies from multiple organs, facilitated an accurate diagnosis. This case highlights the critical need for increased awareness of atypical infectious presentations in immunosuppressed patients that may closely mimic more conventional pathologies, such as malignancy.\u003c/p\u003e\u003cp\u003eWe present a case of disseminated MAC infection following liver transplantation. It resulted in the formation of a tumorous lesion that then led to intestinal obstruction. This case highlights the importance of recognizing disseminated MAC as a potential posttransplant complication. Thorough consideration of disseminated MAC should be included in the differential diagnosis for such cases, particularly those with atypical presentations that mimic malignancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Immunodeficiency Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIFN-γ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterferon Gamma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMycobacterium Avium Complex\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Tuberculous Mycobacterial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePET-CT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePositron Emission Tomography-Computed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSpO\u003csub\u003e2\u003c/sub\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOxygen Saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for the publication of this case report series and any accompanying images.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for the publication of this case report series and any accompanying images.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003cbr\u003e\u0026nbsp;A.M. conceived the concept, provided patient care, collected data, and drafted the manuscript. S.N. contributed to the concept, drafted, and revised the manuscript. Y.N. was responsible for data collection. H.S. was involved in data collection and patient care. M.W. contributed to data collection and patient care. T.S. was responsible for data collection. S.K. revised the manuscript and provided supervision. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHenkle E, Winthrop KL. Nontuberculous mycobacteria infections in immunosuppressed hosts. Clin Chest Med. 2015;36:91\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ccm.2014.11.002\u003c/span\u003e\u003cspan address=\"10.1016/j.ccm.2014.11.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIngilizova M, Epstein S, Heun Lee D, Patel N, Patel Babariya S, Morgenstern R, et al. A rare case of disseminated Mycobacterium avium complex with colitis in a renal transplant recipient. Transpl Infect Dis. 2019;21:e13011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/tid.13011\u003c/span\u003e\u003cspan address=\"10.1111/tid.13011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeau-Cransac M, Dupon M, Carles J, Le Bail B, Saric J. Disseminated Mycobacterium avium infection after liver transplantation. Eur J Clin Microbiol Infect Dis. 1998;17:744\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s100960050177\u003c/span\u003e\u003cspan address=\"10.1007/s100960050177\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLongworth SA, Daly JS, AST Infectious Diseases Community of Practice. Management of infections due to nontuberculous mycobacteria in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transpl. 2019;33:e13588. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ctr.13588\u003c/span\u003e\u003cspan address=\"10.1111/ctr.13588\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun HY, Chen MY, Wu MS, Hsieh SM, Fang CT, Hung CC, et al. Endoscopic appearance of GI mycobacteriosis caused by the Mycobacterium avium complex in a patient with AIDS: case report and review. Gastrointest Endosc. 2005;61:775\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0016-5107(04)02786-5\u003c/span\u003e\u003cspan address=\"10.1016/s0016-5107(04)02786-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatia A, Shah H, Mehra D, Ogunjemilusi O. Disseminated Mycobacterium avium intracellulare infection with concurrent small bowel obstruction: Case, Pathophysiology, and Clinical Considerations. Cureus. 2021;13:e13469. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.13469\u003c/span\u003e\u003cspan address=\"10.7759/cureus.13469\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFujita Y, Matsumoto H, Asano T, Sato S, Yashiro-Furuya M, Matsuoka N, et al. Hemophagocytic lymphohistiocytosis associated with disseminated nontuberculous mycobacterial infection in a patient with mesenteric panniculitis. Tohoku J Exp Med. 2021;253:151\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1620/tjem.253.151\u003c/span\u003e\u003cspan address=\"10.1620/tjem.253.151\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhara K, Kimura T, Sakamoto K, Okada Y. Nontuberculous mycobacteria-associated spindle cell pseudotumor of the nasal cavity: a case report. Pathol Int. 2013;63:266\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/pin.12059\u003c/span\u003e\u003cspan address=\"10.1111/pin.12059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParker H, Lorenc R, Ruelas Castillo J, Karakousis PC. Mechanisms of antibiotic tolerance in Mycobacterium avium complex: lessons from related mycobacteria. Front Microbiol. 2020;11:573983. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fmicb.2020.573983\u003c/span\u003e\u003cspan address=\"10.3389/fmicb.2020.573983\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Disseminated Mycobacterium Avium Complex Disease, Solid Organ Transplantation, Bowel Obstruction, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-4950132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4950132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eMycobacterium avium complex (MAC) is a common pathogen causing non-tuberculous mycobacterial infections, primarily affecting the lungs. Disseminated MAC disease occurs mainly in immunocompromised individuals, such as those with AIDS, hematological malignancies, or those positive for anti-IFN-γ antibodies. However, its occurrence in solid organ transplant recipients is rare. Herein, we report a rare case of disseminated MAC disease following liver transplantation, which led to an obstructive mass in the intestinal tract that required differentiation from a malignant tumor.\u003c/p\u003e\n\u003cp\u003eCase Presentation\u003c/p\u003e\n\u003cp\u003eA 76-year-old woman, who had undergone living-donor liver transplantation 15 years earlier for primary biliary cirrhosis, presented with persistent fever and vomiting three months before admission. She had a history of pulmonary MAC diagnosed five years earlier but remained untreated due to stable lung lesions. Abdominal CT during her current illness revealed new thickening at the jejuno-jejunal anastomosis site and enlarged mesenteric lymph nodes. PET-CT indicated increased uptake at these sites, suggesting a possible malignancy. Endoscopy revealed an elevated lesion with circumferential ulcers, leading to a suspicion of primary malignant lymphoma. However, biopsies showed CD68-positive histiocyte-like cells with numerous acid-fast bacilli, confirming disseminated MAC infection. Despite ongoing antimicrobial therapy, the patient's intestinal lesions persisted, and she required prolonged hospitalization and interventions for bile drainage and enteral nutrition.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis case underscores the importance of considering disseminated MAC as a potential complication in solid organ transplant recipients, even when a long period has passed since transplantation. Disseminated MAC can mimic malignancy, presenting with significant lesions causing intestinal obstruction. Awareness and thorough differential diagnosis are essential for timely and accurate management in such complex cases. The patient's outcome emphasizes the need for vigilance in managing long-term immunosuppressed patients, particularly when they present with atypical infections.\u003c/p\u003e","manuscriptTitle":"Intestinal obstruction caused by disseminated mycobacterium avium complex disease following solid organ transplantation: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-16 06:30:14","doi":"10.21203/rs.3.rs-4950132/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-20T06:38:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-23T04:29:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92927050884007121359952213961133545137","date":"2024-10-13T19:01:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298769631388621232021936257777739019302","date":"2024-10-12T16:40:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38482520864254180971149422553484556415","date":"2024-09-23T00:36:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-29T23:09:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279696538063312502919010874844699444236","date":"2024-08-24T16:29:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-23T12:00:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-23T11:16:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-22T23:18:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-22T23:16:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-08-21T08:53:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3826b316-ecae-48e0-b88a-57a804548590","owner":[],"postedDate":"October 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:04:33+00:00","versionOfRecord":{"articleIdentity":"rs-4950132","link":"https://doi.org/10.1186/s12879-025-10488-3","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-01-25 15:57:07","publishedOnDateReadable":"January 25th, 2025"},"versionCreatedAt":"2024-10-16 06:30:14","video":"","vorDoi":"10.1186/s12879-025-10488-3","vorDoiUrl":"https://doi.org/10.1186/s12879-025-10488-3","workflowStages":[]},"version":"v1","identity":"rs-4950132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4950132","identity":"rs-4950132","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}