In this study we report the case of a male patient whose primary clinical presentation was suggestive of BA, but who was infected with four different agents at the same time. The four infections included HIV infection, BA with B. quintana isolation, MAC infection, and CMV infection. All four infections were eventually diagnosed unambiguously with several microbiological methods including culture, PCR, anatomopathology and immunodetection. The different methods used in this study have been previously validated for the diagnosis of these diseases and remain the reference techniques for such investigation.
Mycobacterial disease is a frequent cause of illness in AIDS patients with the majority of these patients having disseminated disease caused by MAC. Before the introduction of preventive antibiotic regimens, disseminated MAC disease was the most common clinical manifestation of MAC and the most common bacterial disease among patients with AIDS. Disseminated MAC occurs almost exclusively in patients with severe depression on CD4
+ cell count: the median CD4
+ cell count among patients with disseminated MAC and AIDS is 10 cells/mm
3. Cutaneous disease due to MAC is uncommon and is not easily differentiated from other chronic skin lesions. Lesions may be ulcers, nodules, plaques, pustules or abscesses. When observed, cutaneous lesions are usually caused by dissemination of MAC; primary cutaneous infections with MAC are extremely rare. Although disseminated MAC infection is one of the most common infections identified in HIV-infected patients with fever and low CD4+ cell count, one study stated that more than one-half of the MAC culture-positive patients also had another cause of fever identified [
6]. Rarely, coinfections with
Bartonella spp. have been reported. Koehler
et al [
7] described 1% coinfection with
Bartonella spp. and MAC in a series of 382 HIV patients but MAC was obtained solely from blood. To our knowledge, only 2 cases of bacillary angiomatosis and mycobacterium infection coexisting in a cutaneous lesion in patient with AIDS have been reported [
8,
9]. Clinically, lesions in all reported cases were consistent with a presomptive diagnosis of BA and a differential diagnosis of Kaposi's sarcoma. As for our patient, the lesion was characterized by capillary proliferation compatible with BA. Although Ziehl-Neelsen staining was negative, the presence of foamy macrophages in our patient suggested that MAC was also a possible etiologic agent responsible for the development of skin lesions [
10]. Therefore, we can not assume that the skin lesion in our patient represents a lesion of BA with secondary involvement by
Mycobacterium avium or whether the two organisms are implicated in the development of such lesions. In our case, the patient presented with BA and evidence of disseminated
Bartonella infection since we retrieved either by culture or PCR,
B. quintana in blood, cutaneous biopsy, gluteus muscle and bone marrow. The clinical significance of the presence of cytomegalovirus in cutaneous lesions of BA is unclear [
11]. Cytomegalovirus skin lesions are rarely described in acquired immunodeficiency syndrome in contrast with the high frequency of ocular and visceral involvement [
12]. To our knowledge, only one case of coinfection with
Bartonella, Mycobacterium avium and CMV has been reported in a patient with AIDS [
13]. Diagnosis was made by histology and immunohistochemistry but the different organisms could not be cultured. Another case reported the association of 3 organisms (
Staphylococcus aureus, cytomegalovirus and acid-fast bacilli) in a single skin biopsy specimen [
14].