(549) Mycobacterium avium Complex Bacteremia in an HIV-Positive Patient With Normal CD4 Count

Introduction: Mycobacterium Avium Complex (MAC) is an uncommonly encountered pathogen found in environment including water and soil. It is an established cause of pulmonary infections and disseminated disease in immunocompromised hosts however, it is exceedingly rare in HIV-positive patient with normal CD4 count

Description: We report case of MAC bacteremia in 34 years old female with past medical history of HIV, on highly active antiretroviral therapy (HAART) and end-stage renal disease (ESRD) on hemodialysis. She presented with dizziness, fever, nausea and vomiting for one week. Patient was intermittently adherent to HAART. On admission, vitals showed blood pressure: 103/69 mmHg, temperature: 100.9 F and respiratory rate: 20 beats per minute. Physical examination was benign. Complete blood count showed Hb 11.1g/dl, WBC 8.8 k/ul and platelets 121,000/µL. Chest CT scan showed multiple pulmonary nodules. Blood culture, CD4 count and viral load was obtained. Patient was started on Genvoya and empiric microbial coverage was initiated with cefepime and diflucan. CD4+ T-cell count was 491 cells/µL. Her fever continued to wax and wane, prompting repeat blood cultures which grew MAC after 20 days. Days it took to get culture report posed a diagnostic challenge. She was started on Ethambutol and Azithromycin and was transferred to ICU due to hypotension requiring vasopressor support. She had pulseless electrical activity arrest due to ongoing septic shock. ROSC was obtained but patient required intubation for airway protection. Due to patient's co-morbidities and poor prognosis, family decided on hospice care, and patient expired after long battle with HIV and MAC bacteremia

Discussion: Potentiating factors for MAC infection in HIV patients include CD4 count < 50 cells/microL, HIV RNA >1000 copies/mL or ongoing viral replication. Our case is unique because patient had CD4 count of 491 cells/µL and diagnosis of MAC bacteremia with CD4 count >50 cells/microL is not reported commonly. Our goal is to highlight that although MAC is commonly seen in HIV-positive patients with CD4 count < 50cells /microL, it cannot be excluded in patients with normal CD4 count. Persistent fever and atypical symptoms unresponsive to empiric antibiotics should prompt evaluation for opportunistic infections including MAC bacteremia