We encountered a middle-aged afebrile immunocompetent woman with a slight cough. Positron emission tomography (PET)/computed tomography (CT) revealed a broad left upper-lobe consolidation without cavity lesions, small nodules, or bronchiectasis showing a positive fluorodeoxyglucose (FDG) uptake with a maximum standardized uptake value (SUVmax) of 26.9. Percutaneous needle lung biopsy specimens showed caseous granulomas without atypical cells and Mycobacterium avium was cultured from left pleural effusion, which developed after the biopsy. The consolidation significantly decreased following combination chemotherapy for approximately 2 years. Clinicians should remember that pulmonary M. avium infection could result in a large consolidation without other typical radiological findings.ArticleRespiratory Medicine Case Reports.19:49-52(2016)journal articl

Asaka, Shiho

Hanaoka, Masayuki

Ikeda, Mariko

Kato, Akane

Kawakami, Satoshi

Oguchi, Kazuhiro

Tateishi, Kazunari

Ushiki, Atsuhito

Yamamoto, Hiroshi

Yasuo, Masanori

Respiratory Medicine Case Reports

PubMed

AbstractWe encountered a middle-aged afebrile immunocompetent woman with a slight cough. Positron emission tomography (PET)/computed tomography (CT) revealed a broad left upper-lobe consolidation without cavity lesions, small nodules, or bronchiectasis showing a positive fluorodeoxyglucose (FDG) uptake with a maximum standardized uptake value (SUVmax) of 26.9. Percutaneous needle lung biopsy specimens showed caseous granulomas without atypical cells and Mycobacterium avium was cultured from left pleural effusion, which developed after the biopsy. The consolidation significantly decreased following combination chemotherapy for approximately 2 years. Clinicians should remember that pulmonary M. avium infection could result in a large consolidation without other typical radiological findings

Elsevier - Publisher Connector 

lable at ScienceDirect
Respiratory Medicine Case Reports 19 (2016) 49e52Contents lists avaiRespiratory Medicine Case Reports
journal homepage: www.elsevier .com/locate/rmcrCase reportA case of pulmonary Mycobacterium avium infection in an
immunocompetent patient who showed a huge consolidation with a
high FDG uptake on PET/CT
Akane Kato a, Hiroshi Yamamoto a, *, Mariko Ikeda a, Kazunari Tateishi a, Atsuhito Ushiki a,
Masanori Yasuo a, Satoshi Kawakami b, Shiho Asaka c, Kazuhiro Oguchi d,
Masayuki Hanaoka a
a First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
b Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
c Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
d Positron Imaging Center, Aizawa Hospital, Matsumoto, Japana r t i c l e i n f o
Article history:
Received 6 December 2015
Accepted 5 July 2016
Keywords:
Mycobacterium avium
Angiogram sign
Positron emission tomography (PET)/
computed tomography (CT)
Maximum standardized uptake value
(SUVmax)* Corresponding author. First Department of Intern
sity School of Medicine, 3-1-1 Asahi, Matsumoto, 390
E-mail addresses: akanekat@shinshu-u.ac.jp (A. Ka
jp (H. Yamamoto), mikeda@shinshu-u.ac.jp (M. Ike
(K. Tateishi), atsuhito@shinshu-u.ac.jp (A. Ushiki)
(M. Yasuo), kawasato@shinshu-u.ac.jp (S. Kawak
(S. Asaka), pet-dr@ai-hosp.or.jp (K. Oguchi),
(M. Hanaoka).
http://dx.doi.org/10.1016/j.rmcr.2016.07.004
2213-0071/© 2016 The Authors. Published by Elseviera b s t r a c t
We encountered a middle-aged afebrile immunocompetent woman with a slight cough. Positron
emission tomography (PET)/computed tomography (CT) revealed a broad left upper-lobe consolidation
without cavity lesions, small nodules, or bronchiectasis showing a positive ﬂuorodeoxyglucose (FDG)
uptake with a maximum standardized uptake value (SUVmax) of 26.9. Percutaneous needle lung biopsy
specimens showed caseous granulomas without atypical cells and Mycobacterium avium was cultured
from left pleural effusion, which developed after the biopsy. The consolidation signiﬁcantly decreased
following combination chemotherapy for approximately 2 years. Clinicians should remember that pul-
monary M. avium infection could result in a large consolidation without other typical radiological
ﬁndings.
© 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. Introduction
Nontuberculous mycobacteria (NTM), especially Mycobacterium
(M.) avium complex (MAC), are being recognized with increasing
frequency as clinical pathogens of chronic lung disease in immu-
nocompetent patients [1,2]. The common ﬁndings of immunocom-
petent patients with NTM infection in chest computed tomography
(CT) are cavity lesions, endobronchial spread or randomly distrib-
uted small nodules with bronchiectasis, and consolidation [1e4].
The maximum standardized uptake values (SUVmax) of ﬂuo-
rodeoxyglucose (FDG) in positron emission tomography (PET) were
approximately 5e10 in the lesions of NTM infection [5,6].al Medicine, Shinshu Univer-
-8621, Japan.
to), yama5252@shinshu-u.ac.
da), tateishi@shinshu-u.ac.jp
, yasumasa@shinshu-u.ac.jp
ami), ydash831@gmail.com
masayuki@shinshu-u.ac.jp
Ltd. This is an open access article uWe herein report a case of pulmonary M. avium infection in an
immunocompetent woman with a non-disseminated broad
consolidation on chest CT and a high FDG uptake (SUVmax: 26.9) in
this consolidation on PET/CT.2. Case presentation
A 41-year-old Korean woman complained of a slight cough
without dyspnea or a fever. She was referred to our department by
her primary care physician. She was affected by tuberculosis when
she was 34 years of age in Korea and treated with unspeciﬁed
chemotherapy; no signs of relapses occurred until 41 years of age.
The precise data regarding her past clinical history in Korea were
unavailable. Her hearing ability was lost completely due to un-
known reasons. She had no history of diabetes mellitus or other
immunosuppressive diseases. Physical examinations at the initial
visit showed a height of 162.0 cm, body weight of 58.0 kg, arterial
blood pressure of 102/58 mmHg, pulse rate of 74/min, and body
temperature of 36.5 C. The breath sounds were decreased in the
left lung. No lymphadenopathy was found. Her laboratorynder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e5250examinations are shown in Table 1. The white blood cell count was
within the normal range and C-reactive protein (CRP) level was
increased to 2.91 mg/dL. The carcinoembryonic antigen (CEA)
value was normal, however, the soluble interleukin-2 receptor
(sIL-2R) value was increased to 1094 U/mL. The blood glucose level
was normal and HIV antibody was negative. The serum immuno-
globulin levels were normal. Both CD4þ and CD8þ lymphocyte
counts were in the normal ranges. An interferon-gamma release
assay (Cellestis Company, QuantiFERON® TB Gold) was negative.
The antigens for urine Streptococcus pneumoniae and Legionella
pneumophila were negative. The bacterial culture, acid-fast bacilli
smear and culture, and polymerase chain reaction (PCR) tests for
Mycobacterium tuberculosis, M. avium, and Mycobacterium intra-
cellulare of the sputumwere all negative. A chest X-ray and CT scan
showed a broad consolidation with an angiogram sign throughout
the upper-lobe of left lung, however, other imaging ﬁndings such
as cavity lesions, small nodules, and bronchiectasis were not
observed (Fig. 1AeC). Lymph nodes around the arch of the aorta
and under the carina of the trachea were slightly enlarged. PET/CT
showed a high SUVmax of 26.9 on the consolidation shadow
(Fig. 1D). Transbronchial aspiration cytology (TBAC) could not
obtain adequate specimens from the consolidation due to stenosis
of the left upper lobe bronchus. The cytodiagnosis, common bac-
terium culture, acid-fast bacilli smear and the PCR tests for
M. tuberculosis, M. avium, and M. intracellulare of the lavage ﬂuid
were all negative. Furthermore, the acid-fast bacilli culture of the
lavage ﬂuid was negative. Thus, a CT-guided percutaneous needle
lung biopsy was performed and the biopsy specimens showed
caseous granulomas without atypical cells by hematoxylin and
eosin (H&E) staining (Fig. 2), but no bacteria by Kinyoun staining.
The bacterial culture, acid-fast bacilli smear, acid-fast bacilli cul-
ture and PCR tests for M. tuberculosis, M. avium, and
M. intracellulare of the biopsy specimens were negative. The
consolidation of the left lung enlarged and left pleural effusion
developed one week following the lung biopsy (Fig. 1E). Thus, we
performed a diagnostic puncture in the left thorax. The pleural
effusion was lymphocyte predominant and serological tests
showed a total protein (TP) concentration of 5.0 g/dL, albumin of
2.5 g/dL, lactate dehydrogenase (LD) of 223 IU/L, glucose of 95 mg/
dL, immunoglobulin G (IgG) of 1216 mg/dL, and adenosine
deaminase (ADA) of 84.3 U/L. Effusion specimens were negative for
antinuclear antibody (ANA) and rheumatoid factor (RF). The acid-
fast bacilli smear and PCR tests forM. tuberculosis,M. avium, andM.
intracellulare of the effusionwere all negative Finally,M. aviumwasTable 1
The patient’s laboratory data at the initial visit.
Hematology Blood Chemistry
WBC 5660 /mL TP 6.
Neutrophil 63.7 % ALB 3.
Monocyte 7.6 % UN 10
Eosinophil 4.4 % Cre 0.
Basophil 0.4 % AST 13
Lymphocyte 23.9 % ALT 9
CD4 29 % g-GTP 15
CD8 44 % T-bil 0.
RBC 479  104 /mL ALP 19
Hb 12.3 LDH 16
Plt 38.7 /mL Na 13
K 4.
Tumor marker Cl 98
CEA (<3.4) 1.6 ng/mL 88
CA19-9 (<37.0) 153.3 U/mL
sIL-2R (<421) 1094 U/mL Glu 88
ESR
1h 40 mm
2h 76 mmcultured from the left pleural effusion and we diagnosed the pa-
tient with M. avium infection.
Because ethambutol (EB) was thought to be unsuitable due to
her complete hearing loss, combination chemotherapy with
rifampicin (RFP) 450 mg, clarithromycin (CAM) 800 mg, and levo-
ﬂoxacin (LVFX) 500 mg were administered. The chest image
signiﬁcantly improved after two years of this chemotherapy
(Fig. 1F).
3. Discussion
NTM may cause both asymptomatic infection and symptomatic
disease in humans [2]. It has been reported that the incidence of a
fever was approximately 10e20% in NTM patients without HIV
infection [7e9] and 74% in NTM patients with HIV infection [9].
Thus, there is a danger of unintentionally overlooking this infec-
tious disease, especially in afebrile immunocompetent patients
with mild symptoms like our case.
Several investigators have reported the CT ﬁndings of NTM pa-
tients without underlying lung disease and micronodules
(95e100%), bronchiectasis (65e94%), cavity formation (13e43%),
air space consolidation (22e62%), and pleural thickening (17e52%)
were frequently observed in these communications [8]. A study of
59 Japanese patients withM. avium complex infection reported that
the rates of small nodules, nodules, bronchiectasis, atelectasis,
cavity formation, consolidation, and pleural effusion were 100%,
81.3%, 76.2%, 59.3%, 37.3%, 22.0%, and 8.5%, respectively, on chest CT
[8]. Interestingly, all of the patients with consolidation showed
other common CT ﬁndings of NTM infection in this study [8].
Although consolidation is one of the common CT ﬁndings in NTM
infection, we believe that it is rare for patients with M. avium
infection to present with common CT ﬁndings of NTM infection
other than the consolidation of the left lung.
The broad consolidation with a positive angiogram sign on
chest CT suggested that the pulmonary structures of the bronchus
and blood vessels might not be destroyed, which might be
observed in pneumonia and malignant neoplasms such as malig-
nant lymphoma and invasive mucinous adenocarcinoma [10].
Because the present case clinically showed fewer respiratory
symptoms without a fever, her large consolidation on chest CT was
suspected to be malignant neoplasms, such as malignant lym-
phoma, at the beginning visit. We speculated that acid-fast bacillus
infections could show a FDG accumulation on PET/CT, however, we
had not previously experienced such a high SUVmax in aSerological tests
8 g/dL CRP 2.91 mg/dL
2 g/dL IgA 207 mg/dl
mg/dL IgM 136 mg/dl
57 mg/dL IgG 1422 mg/dl
IU/L IgD 0.8 mg/dl
IU/L IgE 35 IU/ml
IU/L
47 mg/dL HIV antibody e
IU/L
0 IU/L Urinalysis
6 mEq/L PH 7.0
3 mEq/L SG 1.010
mEq/L Protein e
Glucose e
Occult blood e
mg/dL Bacteria e
Urine testing for bacterial antigens
S. pneumoniae e
L. pneumophila e
Fig. 1. A chest X-ray (A) and CT (B, C) scan at the initial visit revealed broad consolidation with a positive angiogram sign (arrow) throughout the upper-lobe of the left lung. PET/CT
showed a high SUVmax of 26.9 on the consolidation of the left lung (D). A subsequent chest X-ray one week after the percutaneous lung biopsy showed the consolidation getting
broader and the development of left pleural effusion (E). A chest X-ray taken two years after chemotherapy revealed a signiﬁcant improvement in the consolidation and pleural
effusion (F).
Fig. 2. Percutaneous lung biopsy specimens showed caseous granulomas without
atypical cells on hematoxylin and eosin (H&E) staining. Scale bar ¼ 250 mm.
A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e52 51consolidation. To the best of our knowledge, this SUVmax value is
the highest value observed on chest CT of the lesions in NTM
infection.Although acid-fast bacillus infections could be suspected ac-
cording to the evidence of caseous granulomas from percutaneous
biopsies specimens, acid-fast bacilli were not detected in the smear
of the biopsy specimen or PCR tests. Although tuberculous pleural
effusion may occur in up to 30% of patients with tuberculosis [11],
the incidence of pleural effusion in NTM infection is relatively low
[8]. Combination chemotherapy for tuberculosis in this patient was
administered primarily regarding her history of tuberculosis and
high levels of ADA in the pleural effusion, which were suitable
markers in the diagnosis of tuberculous pleuritis [11e14].M. avium
was cultured from the gastric ﬂuid, which is not listed in the diag-
nostic criteria of NTM infection approved by the American Thoracic
Society (ATS)/Infectious Diseases Society of America (IDSA) [1], and
we eventually observed M. avium in the pleural effusion culture as
well. The present casewas diagnosedwith pulmonary infection and
pleurisy due toM. avium infection according to the strong laboratory
evidence of M. avium culture. A previous report showed that a pa-
tientwithM. avium pleuritis had a normal level of ADA in the pleural
effusion [15]. Conversely, several caseswithNTMinfections revealed
high ADA concentrations in the pleural effusion [16], such as in our
case. Thus, our case reafﬁrms that ADA concentrations in the pleural
effusion of patients with NTM infections could be high.
4. Conclusion
We presented an immunocompetent afebrile patient with
M. avium infection showing a non-disseminated broad consolida-
tion without other typical sings of NTM infection in chest CT im-
ages. Furthermore, M. avium infection may reveal a large
consolidation with high FDG uptake in chest PET/CT images.
Funding sources
No ﬁnancial support was received.
A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e5252Conﬂict of interest
The authors declare that they have no conﬂicts of interest.
Acknowledgment
The authors thank Dr. Yunden Droma for help with manuscript
preparation.
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Japanese.


A case of pulmonary Mycobacterium avium infection in an immunocompetent patient who showed a huge consolidation with a high FDG uptake on PET/CT 

Akane Kato

Hiroshi Yamamoto

Mariko Ikeda

Kazunari Tateishi

Atsuhito Ushiki

Masanori Yasuo

Satoshi Kawakami

Shiho Asaka

Kazuhiro Oguchi

Masayuki Hanaoka

Crossref

A case of pulmonary Mycobacterium avium infection in an immunocompetent patient who showed a huge consolidation with a high FDG uptake on PET/CT

Shinshu University Institutional Repository

lable at ScienceDirectRespiratory Medicine Case Reports 19 (2016) 49e52Contents lists avaiRespiratory Medicine Case Reportsjournal homepage: www.elsevier .com/locate/rmcrCase reportA case of pulmonary Mycobacterium avium infection in animmunocompetent patient who showed a huge consolidation with ahigh FDG uptake on PET/CTAkane Kato a, Hiroshi Yamamoto a, *, Mariko Ikeda a, Kazunari Tateishi a, Atsuhito Ushiki a,Masanori Yasuo a, Satoshi Kawakami b, Shiho Asaka c, Kazuhiro Oguchi d,Masayuki Hanaoka aa First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japanb Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japanc Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japand Positron Imaging Center, Aizawa Hospital, Matsumoto, Japana r t i c l e i n f oArticle history:Received 6 December 2015Accepted 5 July 2016Keywords:Mycobacterium aviumAngiogram signPositron emission tomography (PET)/computed tomography (CT)Maximum standardized uptake value(SUVmax)* Corresponding author. First Department of Internsity School of Medicine, 3-1-1 Asahi, Matsumoto, 390E-mail addresses: akanekat@shinshu-u.ac.jp (A. Kajp (H. Yamamoto), mikeda@shinshu-u.ac.jp (M. Ike(K. Tateishi), atsuhito@shinshu-u.ac.jp (A. Ushiki)(M. Yasuo), kawasato@shinshu-u.ac.jp (S. Kawak(S. Asaka), pet-dr@ai-hosp.or.jp (K. Oguchi),(M. Hanaoka).http://dx.doi.org/10.1016/j.rmcr.2016.07.0042213-0071/© 2016 The Authors. Published by Elseviera b s t r a c tWe encountered a middle-aged afebrile immunocompetent woman with a slight cough. Positronemission tomography (PET)/computed tomography (CT) revealed a broad left upper-lobe consolidationwithout cavity lesions, small nodules, or bronchiectasis showing a positive fluorodeoxyglucose (FDG)uptake with a maximum standardized uptake value (SUVmax) of 26.9. Percutaneous needle lung biopsyspecimens showed caseous granulomas without atypical cells and Mycobacterium avium was culturedfrom left pleural effusion, which developed after the biopsy. The consolidation significantly decreasedfollowing combination chemotherapy for approximately 2 years. Clinicians should remember that pul-monary M. avium infection could result in a large consolidation without other typical radiologicalfindings.© 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. IntroductionNontuberculous mycobacteria (NTM), especially Mycobacterium(M.) avium complex (MAC), are being recognized with increasingfrequency as clinical pathogens of chronic lung disease in immu-nocompetent patients [1,2]. The common findings of immunocom-petent patients with NTM infection in chest computed tomography(CT) are cavity lesions, endobronchial spread or randomly distrib-uted small nodules with bronchiectasis, and consolidation [1e4].The maximum standardized uptake values (SUVmax) of fluo-rodeoxyglucose (FDG) in positron emission tomography (PET) wereapproximately 5e10 in the lesions of NTM infection [5,6].al Medicine, Shinshu Univer--8621, Japan.to), yama5252@shinshu-u.ac.da), tateishi@shinshu-u.ac.jp, yasumasa@shinshu-u.ac.jpami), ydash831@gmail.commasayuki@shinshu-u.ac.jpLtd. This is an open access article uWe herein report a case of pulmonary M. avium infection in animmunocompetent woman with a non-disseminated broadconsolidation on chest CT and a high FDG uptake (SUVmax: 26.9) inthis consolidation on PET/CT.2. Case presentationA 41-year-old Korean woman complained of a slight coughwithout dyspnea or a fever. She was referred to our department byher primary care physician. She was affected by tuberculosis whenshe was 34 years of age in Korea and treated with unspecifiedchemotherapy; no signs of relapses occurred until 41 years of age.The precise data regarding her past clinical history in Korea wereunavailable. Her hearing ability was lost completely due to un-known reasons. She had no history of diabetes mellitus or otherimmunosuppressive diseases. Physical examinations at the initialvisit showed a height of 162.0 cm, body weight of 58.0 kg, arterialblood pressure of 102/58 mmHg, pulse rate of 74/min, and bodytemperature of 36.5 C. The breath sounds were decreased in theleft lung. No lymphadenopathy was found. Her laboratorynder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e5250examinations are shown in Table 1. The white blood cell count waswithin the normal range and C-reactive protein (CRP) level wasincreased to 2.91 mg/dL. The carcinoembryonic antigen (CEA)value was normal, however, the soluble interleukin-2 receptor(sIL-2R) value was increased to 1094 U/mL. The blood glucose levelwas normal and HIV antibody was negative. The serum immuno-globulin levels were normal. Both CD4þ and CD8þ lymphocytecounts were in the normal ranges. An interferon-gamma releaseassay (Cellestis Company, QuantiFERON® TB Gold) was negative.The antigens for urine Streptococcus pneumoniae and Legionellapneumophila were negative. The bacterial culture, acid-fast bacillismear and culture, and polymerase chain reaction (PCR) tests forMycobacterium tuberculosis, M. avium, and Mycobacterium intra-cellulare of the sputumwere all negative. A chest X-ray and CT scanshowed a broad consolidation with an angiogram sign throughoutthe upper-lobe of left lung, however, other imaging findings suchas cavity lesions, small nodules, and bronchiectasis were notobserved (Fig. 1AeC). Lymph nodes around the arch of the aortaand under the carina of the trachea were slightly enlarged. PET/CTshowed a high SUVmax of 26.9 on the consolidation shadow(Fig. 1D). Transbronchial aspiration cytology (TBAC) could notobtain adequate specimens from the consolidation due to stenosisof the left upper lobe bronchus. The cytodiagnosis, common bac-terium culture, acid-fast bacilli smear and the PCR tests forM. tuberculosis, M. avium, and M. intracellulare of the lavage fluidwere all negative. Furthermore, the acid-fast bacilli culture of thelavage fluid was negative. Thus, a CT-guided percutaneous needlelung biopsy was performed and the biopsy specimens showedcaseous granulomas without atypical cells by hematoxylin andeosin (H&E) staining (Fig. 2), but no bacteria by Kinyoun staining.The bacterial culture, acid-fast bacilli smear, acid-fast bacilli cul-ture and PCR tests for M. tuberculosis, M. avium, andM. intracellulare of the biopsy specimens were negative. Theconsolidation of the left lung enlarged and left pleural effusiondeveloped one week following the lung biopsy (Fig. 1E). Thus, weperformed a diagnostic puncture in the left thorax. The pleuraleffusion was lymphocyte predominant and serological testsshowed a total protein (TP) concentration of 5.0 g/dL, albumin of2.5 g/dL, lactate dehydrogenase (LD) of 223 IU/L, glucose of 95 mg/dL, immunoglobulin G (IgG) of 1216 mg/dL, and adenosinedeaminase (ADA) of 84.3 U/L. Effusion specimens were negative forantinuclear antibody (ANA) and rheumatoid factor (RF). The acid-fast bacilli smear and PCR tests forM. tuberculosis,M. avium, andM.intracellulare of the effusionwere all negative Finally,M. aviumwasTable 1The patient’s laboratory data at the initial visit.Hematology Blood ChemistryWBC 5660 /mL TP 6.Neutrophil 63.7 % ALB 3.Monocyte 7.6 % UN 10Eosinophil 4.4 % Cre 0.Basophil 0.4 % AST 13Lymphocyte 23.9 % ALT 9CD4 29 % g-GTP 15CD8 44 % T-bil 0.RBC 479  104 /mL ALP 19Hb 12.3 LDH 16Plt 38.7 /mL Na 13K 4.Tumor marker Cl 98CEA (<3.4) 1.6 ng/mL 88CA19-9 (<37.0) 153.3 U/mLsIL-2R (<421) 1094 U/mL Glu 88ESR1h 40 mm2h 76 mmcultured from the left pleural effusion and we diagnosed the pa-tient with M. avium infection.Because ethambutol (EB) was thought to be unsuitable due toher complete hearing loss, combination chemotherapy withrifampicin (RFP) 450 mg, clarithromycin (CAM) 800 mg, and levo-floxacin (LVFX) 500 mg were administered. The chest imagesignificantly improved after two years of this chemotherapy(Fig. 1F).3. DiscussionNTM may cause both asymptomatic infection and symptomaticdisease in humans [2]. It has been reported that the incidence of afever was approximately 10e20% in NTM patients without HIVinfection [7e9] and 74% in NTM patients with HIV infection [9].Thus, there is a danger of unintentionally overlooking this infec-tious disease, especially in afebrile immunocompetent patientswith mild symptoms like our case.Several investigators have reported the CT findings of NTM pa-tients without underlying lung disease and micronodules(95e100%), bronchiectasis (65e94%), cavity formation (13e43%),air space consolidation (22e62%), and pleural thickening (17e52%)were frequently observed in these communications [8]. A study of59 Japanese patients withM. avium complex infection reported thatthe rates of small nodules, nodules, bronchiectasis, atelectasis,cavity formation, consolidation, and pleural effusion were 100%,81.3%, 76.2%, 59.3%, 37.3%, 22.0%, and 8.5%, respectively, on chest CT[8]. Interestingly, all of the patients with consolidation showedother common CT findings of NTM infection in this study [8].Although consolidation is one of the common CT findings in NTMinfection, we believe that it is rare for patients with M. aviuminfection to present with common CT findings of NTM infectionother than the consolidation of the left lung.The broad consolidation with a positive angiogram sign onchest CT suggested that the pulmonary structures of the bronchusand blood vessels might not be destroyed, which might beobserved in pneumonia and malignant neoplasms such as malig-nant lymphoma and invasive mucinous adenocarcinoma [10].Because the present case clinically showed fewer respiratorysymptoms without a fever, her large consolidation on chest CT wassuspected to be malignant neoplasms, such as malignant lym-phoma, at the beginning visit. We speculated that acid-fast bacillusinfections could show a FDG accumulation on PET/CT, however, wehad not previously experienced such a high SUVmax in aSerological tests8 g/dL CRP 2.91 mg/dL2 g/dL IgA 207 mg/dlmg/dL IgM 136 mg/dl57 mg/dL IgG 1422 mg/dlIU/L IgD 0.8 mg/dlIU/L IgE 35 IU/mlIU/L47 mg/dL HIV antibody eIU/L0 IU/L Urinalysis6 mEq/L PH 7.03 mEq/L SG 1.010mEq/L Protein eGlucose eOccult blood emg/dL Bacteria eUrine testing for bacterial antigensS. pneumoniae eL. pneumophila eFig. 1. A chest X-ray (A) and CT (B, C) scan at the initial visit revealed broad consolidation with a positive angiogram sign (arrow) throughout the upper-lobe of the left lung. PET/CTshowed a high SUVmax of 26.9 on the consolidation of the left lung (D). A subsequent chest X-ray one week after the percutaneous lung biopsy showed the consolidation gettingbroader and the development of left pleural effusion (E). A chest X-ray taken two years after chemotherapy revealed a significant improvement in the consolidation and pleuraleffusion (F).Fig. 2. Percutaneous lung biopsy specimens showed caseous granulomas withoutatypical cells on hematoxylin and eosin (H&E) staining. Scale bar ¼ 250 mm.A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e52 51consolidation. To the best of our knowledge, this SUVmax value isthe highest value observed on chest CT of the lesions in NTMinfection.Although acid-fast bacillus infections could be suspected ac-cording to the evidence of caseous granulomas from percutaneousbiopsies specimens, acid-fast bacilli were not detected in the smearof the biopsy specimen or PCR tests. Although tuberculous pleuraleffusion may occur in up to 30% of patients with tuberculosis [11],the incidence of pleural effusion in NTM infection is relatively low[8]. Combination chemotherapy for tuberculosis in this patient wasadministered primarily regarding her history of tuberculosis andhigh levels of ADA in the pleural effusion, which were suitablemarkers in the diagnosis of tuberculous pleuritis [11e14]. M. aviumwas cultured from the gastric fluid, which is not listed in the diag-nostic criteria of NTM infection approved by the American ThoracicSociety (ATS)/Infectious Diseases Society of America (IDSA) [1], andwe eventually observed M. avium in the pleural effusion culture aswell. The present casewas diagnosedwith pulmonary infection andpleurisy due toM. avium infection according to the strong laboratoryevidence of M. avium culture. A previous report showed that a pa-tientwithM. avium pleuritis had a normal level of ADA in the pleuraleffusion [15]. Conversely, several caseswithNTMinfections revealedhigh ADA concentrations in the pleural effusion [16], such as in ourcase. Thus, our case reaffirms that ADA concentrations in the pleuraleffusion of patients with NTM infections could be high.4. ConclusionWe presented an immunocompetent afebrile patient withM. avium infection showing a non-disseminated broad consolida-tion without other typical sings of NTM infection in chest CT im-ages. Furthermore, M. avium infection may reveal a largeconsolidation with high FDG uptake in chest PET/CT images.Funding sourcesNo financial support was received.A. Kato et al. / Respiratory Medicine Case Reports 19 (2016) 49e5252Conflict of interestThe authors declare that they have no conflicts of interest.AcknowledgmentThe authors thank Dr. Yunden Droma for help with manuscriptpreparation.References[1] D.E. Griffith, T. Aksamit, B.A. Brown-Elliott, A. Catanzaro, C. Daley, F. Gordin,S.M. Holland, R. Horsburgh, G. Huitt, M.F. Iademarco, M. Iseman, K. Olivier,S. Ruoss, C.F. von Reyn, R.J. Wallace Jr., K. 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Okazawa, Usefulness of 18F-fluorodeoxyglucosepositron emission tomography for diagnosing disease activity and monitoringtherapeutic response in patients with pulmonary mycobacteriosis, Eur. J. Nucl.Med. Mol. Imaging 36 (4) (2009) 632e639.[6] K. Kaneko, E. Sadashima, K. Irie, A. Hayashi, S. Masunari, T. Yoshida, J. Omagari,Assessment of FDG retention differences between the FDG-avid benign pul-monary lesion and primary lung cancer using dual-time-point FDG-PET im-aging, Ann. Nucl. Med. 27 (4) (2013) 392e399.[7] Y. Lee, J.W. Song, E.J. Chae, H.J. Lee, C.W. Lee, K.H. Do, J.B. Seo, M.Y. Kim, J.S. Lee,K.S. Song, T.S. Shim, CT findings of pulmonary non-tuberculous mycobacterialinfection in non-AIDS immunocompromised patients: a case-controlledcomparison with immunocompetent patients, Br. J. Radiol. 86 (1024) (2013)20120209.[8] S. Kuroishi, Y. Nakamura, H. Hayakawa, M. Shirai, Y. Nakano, K. Yasuda,T. Suda, H. Nakamura, K. Chida, Mycobacterium avium complex disease:prognostic implication of high-resolution computed tomography findings,Eur. Respir. J. 32 (1) (2008) 147e152.[9] A.A. El-Solh, J. Nopper, M.R. Abdul-Khoudoud, S.M. Sherif, A.T. Aquilina,B.J. Grant, Clinical and radiographic manifestations of uncommon pulmonarynontuberculous mycobacterial disease in AIDS patients, Chest 114 (1) (1998)138e145.[10] R.M. Shah, A.C. Friedman, CT angiogram sign: incidence and significance inlobar consolidations evaluated by contrast-enhanced CT, AJR Am. J. Roent-genol. 170 (3) (1998) 719e721.[11] J. Ferrer, Pleural tuberculosis, Eur. Respir. J. 10 (4) (1997) 942e947.[12] J.M. Porcel, Tuberculous pleural effusion, Lung 187 (5) (2009) 263e270.[13] Q.L. Liang, H.Z. Shi, K. Wang, S.M. Qin, X.J. Qin, Diagnostic accuracy of aden-osine deaminase in tuberculous pleurisy: a meta-analysis, Respir. Med. 102(5) (2008) 744e754.[14] A. Trajman, M. Pai, K. 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A case of pulmonary Mycobacterium avium infection in an immunocompetent patient who showed a huge consolidation with a high FDG uptake on PET/CT

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