Mycobacterium haemophilum: Emerging or Underdiagnosed in Brazil?

To the Editor: Mycobacterium haemophilum was first described in 1978 by Sompolinsky et al. (1) as the cause of cutaneous infections in a patient with Hodgkin disease. Since then, fewer than 100 cases have been reported worldwide, mostly among immunocompromised patients (2), although M. haemophilum infection has also been described in immunocompetent patients as the cause of cervical, submandibular, and perihilar lymphadenopathy in children and of pulmonary nodules in an adult (3–5). Cases have been reported from United States, Australia, Canada, France, Israel, and the United Kingdom, but to date no reports have originated in South America.

seropositive man from a biopsied specimen of a nasal ulcer. A direct acid-fast stain showed many acid-fast bacilli. At time of diagnosis, the patient's CD4+ cell count was 8/mm 3 and his viral load was 290.000 copies/ mL. The third isolate was detected in Bahia in a 30-year-old HIV-seropositive man who had osteomyelitis in an elbow. A direct acid-fast stain showed rare acid-fast bacilli.
The isolate from the Rio de Janeiro patient grew only in Myco/F Lytic media (Becton Dickinson Microbiology Systems, Sparks, MD) plus blood in primary isolation and subculture; it failed to grow on chocolate agar at 30°C after 6 weeks. The isolates from São Paulo and Bahia showed a slight growth in 12B media on primary isolation; this growth was likely supported by the iron provided by the biopsied tissue. Subcultures on chocolate agar showed good growth after 2-3 weeks at 30°C. The isolates did not grow on Middlebrook 7H10 agar without hemin and grew on the same media when supplemented with 60 MM of hemin. Both strains showed a negative catalase reaction.
The species of all isolates was identified through polymerase chain reaction amplification of the gene encoding for the 65-kDa heat shock protein, followed by restriction analysis with the enzymes BstEII and HaeIII as described by Telenti et al. (7), with minor modifications. The three isolates showed the same restriction pattern as that obtained for M. haemophilum American Type Culture Collection 29548 prototype strain. Isolates from Rio de Janeiro and São Paulo were also molecularly characterized as previously described by Roth et al. (8), corroborating M. haemophilum species identification.
To our knowledge, these M. haemophilum isolates are the first to be reported in Brazil. These three patients came from cities 429-962 km apart, demonstrating the dispersion of M. haemophilum infection in Brazil. Given the specific requirements of M. haemophilum for its growth in culture, our findings suggest that its true incidence in Brazil is greatly underestimated. Consequently, we strongly recommend that clinical laboratories in Brazil include an iron-supplemented medium, such as chocolate agar, incubated at 30ºC, for primary isolation of Mycobacterium spp in samples from selected patients.

Children and Multidrug-Resistant
Tuberculosis in Mumbai (Bombay), India To the Editor: India has the highest number of tuberculosis (TB) cases in the world. Each year in India, over 2 million new cases of TB are diagnosed, and approximately 500,000 persons die of the disease (1). During the last decade, multidrug-resistant TB has burgeoned in India, resulting in an extremely large number of multidrugresistant TB cases, second only to the number of cases noted in Latvia (2). Since 1993, in response to this epidemic, the government of India has implemented the Revised National Tuberculosis Control Program, which is based on directly observed treatment (short course) principles (1).
Mumbai (formerly Bombay), India, is a densely populated metropolis with a population of approximately 12 million, 4.8 million (40%) of whom reside in overcrowded slums. Since 1990, a resurgence of TB has occurred, characterized by a 70% to 140% increase in the rate of TBrelated deaths among adults aged 25-44 years (3). A vital factor contributing to this phenomenon is HIV infection. A recent review of autopsy reports from Mumbai showed that 85 (59%) of 143 adult patients with AIDS were diagnosed with pulmonary TB (4), indicating that the disease is the most common opportunistic infection for persons with AIDS. Commensurate with the increase in TB cases is a surge in the prevalence of multidrugresistant TB in adult patients. Two reference mycobacterial laboratories in private hospitals in Mumbai have reported a high prevalence of multidrug-resistant TB strains; 56 (11%) of 521 cases in 1991-1995, and 58 (58%) of 100 cases in 1994-1995 (5,6).
The crisis of multidrug-resistant TB in adults in Mumbai has been well documented (7). However, little attention has been directed at children also affected by the resurgent TB epidemic. We think that TB is developing in more children in Mumbai today than a decade earlier. Moreover, close proximity to adult patients with multidrug-resistant TB makes children prone to developing primary multidrug-resistant TB, a vulnerability documented in a South African study (8). Similarly, disseminated TB is occurring in large numbers of children living in overcrowded slums in Mumbai with a consequent high death rate (9); we attribute many of these deaths in children to primary multidrug-resistant TB. However, this conclusion is difficult to document, as most affected children are sputum-negative for acidfast bacilli. Contact tracing to detect the adult source of infection is routinely undertaken; often we can trace the source of infection. Because the facilities for culture and susceptibility testing are not available at affordable rates, proving that the adult contact has multidrug-resistant TB is not feasible in most cases.

The AIDS epidemic in adults in
Mumbai has adversely affected the epidemic within the population of children with TB. HIV infection in young adults has resulted in a large number of HIV-infected infants, the result of a lack of any large-scale program aimed at preventing vertical transmission. To combat the growing problem with HIV-infected infants, India's National AIDS Control Organization is performing feasibility studies for implementing interventions to prevent mother-to-child transmission of HIV infection. Clinical trials with nevirapine are currently being conducted at five major public hospitals in Mumbai.
Multidrug-resistant TB frequently develops in adult AIDS patients (7). Accordingly, many pediatric AIDS patients in Mumbai are also developing primary multidrug-resistant TB. Since most families cannot afford antiretroviral therapy, HIV-infected children in whom TB is diagnosed are prescribed a four-drug TB treatment (consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol) and co-trimoxazole for Pneumocystis carinii pneumonia prophylaxis. Although deaths in these children are being attributed to AIDS, we think that many of these deaths are related to multidrug-resistant TB.
To combat the TB epidemic, the Revised National Tuberculosis Control Program directly observed treatment strategy has been implemented as part of a public health program. However, most patients receive treatment from private physicians and thus remain outside the purview of the strategy. Private physicians seldom refer their patients to centers offering directly observed treatments because of potential for loss of income (3). In 1991, Uplekar and Shepard (10) reported that 100 private physicians in the Dharavi slums in Mumbai prescribed 80 different anti-TB regimens; most were both inappropriate and expensive. Since private physicians have not yet been involved in the gov-