Mycobacterium iranicum Infection in HIV-infected Patient, Iran

To the Editor: The species My-cobacterium iranicum was described in 2013 (1) on the basis of 8 clinical strains isolated in various countries (Iran, Italy, Greece, the Netherlands, Sweden, and the United States). Recently , the isolation of M. iranicum from the sputum of a woman also was reported (2). We report the isolation of this newly recognized species from an HIV-positive patient. A scotochromogenic, rapidly growing strain was isolated in 2012 from respiratory specimens of an HIV-positive 44-year-old Iranian man with chronic pulmonary disease. The patient had been found to be HIV seropositive (viral load >1,000 cop-ies/mL, CD4 lymphocyte count 120/ µL) in 2004 when he was hospitalized because of fever, weight loss, and oral candidiasis. Treatment with antiretroviral drugs, including stavu-dine, lamivudine, and nevirapine, was begun. The patient rapidly improved; the fever disappeared, he gained weight, and he was discharged from the hospital. At a 6-month follow-up visit, viral load was 1,000 copies/ mL and CD4 lymphocyte count was 420/µL. He continued to receive an-tiretroviral treatment until 2010 when treatment was discontinued because of its high cost. The man was hospitalized again in 2012 with mild fever, weight loss, chronic chest pain, and nonproduc-tive cough. At that time, the viral load was >100,000 copies/mL, and CD4 count was 5 lymphocytes/µL. Tuber-culin skin test results were negative, radiograph of the chest showed no abnormalities, and routine cultures of sputum and blood were negative for common bacteria. Lactate dehy-drogenase level (98 U/L [reference <600 U/L]) was within normal limits, whereas liver function was abnormal (alanine aminotransferase level 95 U/L [reference <36 U/L], L-aspar-tate aminotransferase level 85 U/L [reference <29 U/L], alkaline phos-phatase 180 U/L [reference 44–147 U/L], and total bilirubin 1.4 mg/dL [reference 0.3–1mg/dL]). Antiret-roviral therapy was resumed, which led to an increase in CD4 cells (205 lymphocytes/µL after 1 month). The examination by microscopy (Ziehl-Neelsen staining) of 3 sputum samples did not reveal acid-fast bacilli; culture for mycobacteria was not done. Oral treatment with tetracycline was started, but the patient's fever and chest pain remained unchanged. After bronchoscopy, 2 of 3 bronchial lavage (BAL) samples were found to be positive for acid-fast coc-cobacilli by microscopy, and rapidly growing, deep orange mycobacteria grew in all 3 cultures. Giemsa stain did not show Pneumocystis jirovecii in BAL samples. A standard antituber-culosis regimen was undertaken but did not result in substantial improvement. At 1 month follow-up, 1 spu-tum sample was negative for …