in september 1998 , a 36-year - old male soldier in the french foreign legion with hemoptysis was sent back to france from djibouti .
when the patient was hospitalized , 2 weeks after the initial symptoms , he began to experience progressive fatigue .
he did not experience fever , weight loss , night sweats , anorexia , cough , dyspnea , or chest pain , and did not produce sputum .
the mantoux test , performed with 10 iu of purified tuberculin ( aventis - pasteur - msd , lyon , france ) , yielded a maximum transverse diameter of induration of 15 mm .
the chest x - ray showed a triangular consolidation of the left upper lobe with blurred limits and small cavitary lesions .
a computed tomographic scan confirmed the cavitary syndrome : three excavated nodular images showed radiating spicules within a micronodular infiltrate .
bronchoscopy showed a moderate inflammation of airway mucosa , especially in the left upper lobe .
a bronchial washing smear from the left upper lobe was positive for acid - fast bacilli .
no evidence of disease was found elsewhere ; the patient did not experience bone pain .
results of neurologic and ophthalmologic examinations were normal ; no lymphadenopathy or hepatosplenomegaly were found and the genitalia were normal .
the urinary sediment contained < 1,000 red blood cells / l and < 5,000 leukocytes / l .
antituberculosis chemotherapy was begun with four drugs : rifampicin , isoniazid , ethambutol , and pyrazinamide .
therefore , rifampicin and isoniazid were continued for 3 more months for a total treatment period of 6 months .
the patient s response to treatment was favorable , and he remained asymptomatic . a 55-year - old male soldier in the french foreign legion , who returned from djibouti , was hospitalized in september 1999 after his chest x - ray showed abnormal findings .
he was a nurse and had been occasionally in charge at the djibouti hospital for 2 years .
eight months before he returned to france , he experienced asthenia , anorexia , and a weight loss of 3 kg .
the symptoms resolved spontaneously after 2 months , and he had been asymptomatic since then .
he had no history of cough , sputum production , hemoptysis , dyspnea , fever , or night sweats .
results of a clinical examination and of laboratory studies were normal ( table ) , except for hypereosinophilia .
serologic tests for schistosomiasis , hydatidosis , distomiasis , amebiasis , toxocariasis , and trichinosis were negative , and parasites were not found in stool samples .
thoracic radiographs performed when he came back from djibouti showed parenchymal consolidation of the right upper lobe with small cavities .
a gastric aspirate smear was negative for acid - fast bacilli , and a bronchial aspiration smear was positive for acid - fast bacilli .
drug therapy was initiated with rifampicin , isoniazid , ethambutol , and pyrazinamide for 2 months .
cultures of bronchial aspirates were positive within 14 days ; later , cultures of two gastric aspirates were positive for acid - fast bacilli .
first , the samples were decontaminated with n - acetyl - l - cysteine / naoh .
acid - fast bacilli were detected by auramine staining , the positive smears also were stained with ziehl - nielsen stain .
the samples were then seeded onto lwenstein - jensen and coletsos slants and also into a liquid system , the bbl mycobacterial growth indicator tube ( mgit , bd diagnostic systems , sparks , md ) .
the mycobacteria were identified by using a specific dna probe ( gen - probe , gen - probe incorporated , san diego , ca ) and by performing the usual biochemical tests ( nitrate reduction , 68c catalase resistance , niacin production ) .
the pasteur institute of paris used two methods for typing : restriction fragment length polymorphism ( rflp ) analysis and spoligotyping . in rflp analysis , after digestion of the m. tuberculosis strain 's genomic dna with pvuii restriction enzyme and agarose gel migration , the dna was transferred on a membrane , according to the southern method , and then hybridized with an insertion sequence is6110 probe ( 4 ) . in the spoligotyping method , after dna direct repeat amplification , the labeled polymerase chain reaction product was used as a probe to hybridize with 43 synthetic spacer oligonucleotides ( dna sequences derived from the direct repeat [ dr ] region of m. tuberculosis , h37rv and m. bovis bcg p3 ) , which were attached to a carrier membrane ( 5 ) . the sensitivity to antituberculous drugs
mgit results were positive for the two cultures in 9 and 12 days , respectively .
on lwenstein - jensen slants , the cultures were positive in 12 and 14 days , respectively .
the two strains had the same phenotypic and genotypic pattern ; 68c catalase was negative , and they reduced nitrate , as do other m. tuberculosis species , but they did not produce niacin .
the dna probe , gen - probe , confirmed that these strains belonged to the m. tuberculosis complex .
colony morphology on lwenstein - jensen slants , showing m. canetti and m. tuberculosis strains .
( a ) colonies of m. tuberculosis are rough , thick , wrinkled , have an irregular margin , and are faintly buff - colored .
spoligotyping showed that they shared only 2 of the 43 oligonucleotides reproducing the spacer dna sequences of m. tuberculosis , h37rv and m. bovis bcg p3 .
lanes 3 and 4 , the strains isolated from french legionnaires with pulmonary tuberculosis ( tb ) .
in september 1998 , a 36-year - old male soldier in the french foreign legion with hemoptysis was sent back to france from djibouti .
when the patient was hospitalized , 2 weeks after the initial symptoms , he began to experience progressive fatigue .
he did not experience fever , weight loss , night sweats , anorexia , cough , dyspnea , or chest pain , and did not produce sputum .
the mantoux test , performed with 10 iu of purified tuberculin ( aventis - pasteur - msd , lyon , france ) , yielded a maximum transverse diameter of induration of 15 mm .
the chest x - ray showed a triangular consolidation of the left upper lobe with blurred limits and small cavitary lesions .
a computed tomographic scan confirmed the cavitary syndrome : three excavated nodular images showed radiating spicules within a micronodular infiltrate .
bronchoscopy showed a moderate inflammation of airway mucosa , especially in the left upper lobe .
a bronchial washing smear from the left upper lobe was positive for acid - fast bacilli .
no evidence of disease was found elsewhere ; the patient did not experience bone pain .
results of neurologic and ophthalmologic examinations were normal ; no lymphadenopathy or hepatosplenomegaly were found and the genitalia were normal .
the urinary sediment contained < 1,000 red blood cells / l and < 5,000 leukocytes / l .
antituberculosis chemotherapy was begun with four drugs : rifampicin , isoniazid , ethambutol , and pyrazinamide .
therefore , rifampicin and isoniazid were continued for 3 more months for a total treatment period of 6 months .
a 55-year - old male soldier in the french foreign legion , who returned from djibouti , was hospitalized in september 1999 after his chest x - ray showed abnormal findings .
he was a nurse and had been occasionally in charge at the djibouti hospital for 2 years .
eight months before he returned to france , he experienced asthenia , anorexia , and a weight loss of 3 kg .
the symptoms resolved spontaneously after 2 months , and he had been asymptomatic since then .
he had no history of cough , sputum production , hemoptysis , dyspnea , fever , or night sweats .
results of a clinical examination and of laboratory studies were normal ( table ) , except for hypereosinophilia .
serologic tests for schistosomiasis , hydatidosis , distomiasis , amebiasis , toxocariasis , and trichinosis were negative , and parasites were not found in stool samples .
thoracic radiographs performed when he came back from djibouti showed parenchymal consolidation of the right upper lobe with small cavities .
a gastric aspirate smear was negative for acid - fast bacilli , and a bronchial aspiration smear was positive for acid - fast bacilli .
drug therapy was initiated with rifampicin , isoniazid , ethambutol , and pyrazinamide for 2 months .
cultures of bronchial aspirates were positive within 14 days ; later , cultures of two gastric aspirates were positive for acid - fast bacilli .
first , the samples were decontaminated with n - acetyl - l - cysteine / naoh .
acid - fast bacilli were detected by auramine staining , the positive smears also were stained with ziehl - nielsen stain .
the samples were then seeded onto lwenstein - jensen and coletsos slants and also into a liquid system , the bbl mycobacterial growth indicator tube ( mgit , bd diagnostic systems , sparks , md ) .
the mycobacteria were identified by using a specific dna probe ( gen - probe , gen - probe incorporated , san diego , ca ) and by performing the usual biochemical tests ( nitrate reduction , 68c catalase resistance , niacin production ) .
the pasteur institute of paris used two methods for typing : restriction fragment length polymorphism ( rflp ) analysis and spoligotyping . in rflp analysis , after digestion of the m. tuberculosis strain 's genomic dna with pvuii restriction enzyme and agarose gel migration , the dna was transferred on a membrane , according to the southern method , and then hybridized with an insertion sequence is6110 probe ( 4 ) . in the spoligotyping method , after dna direct repeat amplification , the labeled polymerase chain reaction product was used as a probe to hybridize with 43 synthetic spacer oligonucleotides ( dna sequences derived from the direct repeat [ dr ] region of m. tuberculosis , h37rv and m. bovis bcg p3 ) , which were attached to a carrier membrane ( 5 ) . the sensitivity to antituberculous drugs
mgit results were positive for the two cultures in 9 and 12 days , respectively .
on lwenstein - jensen slants , the cultures were positive in 12 and 14 days , respectively .
the two strains had the same phenotypic and genotypic pattern ; 68c catalase was negative , and they reduced nitrate , as do other m. tuberculosis species , but they did not produce niacin .
the dna probe , gen - probe , confirmed that these strains belonged to the m. tuberculosis complex .
colony morphology on lwenstein - jensen slants , showing m. canetti and m. tuberculosis strains .
( a ) colonies of m. tuberculosis are rough , thick , wrinkled , have an irregular margin , and are faintly buff - colored .
spoligotyping showed that they shared only 2 of the 43 oligonucleotides reproducing the spacer dna sequences of m. tuberculosis , h37rv and m. bovis bcg p3 .
canetti ( figure 2 ) . ( a ) is6110 hybridization patterns of pvuii - digested genomic dna .
lanes 3 and 4 , the strains isolated from french legionnaires with pulmonary tuberculosis ( tb ) .
in 1997 , van soolingen reported a case of lymph node tb in a 2-year - old somali child on the child s arrival in the netherlands in 1993 ( 2 ) . in 1998 , pfyffer described abdominal lymphatic tb in a 56-year - old swiss man ( who lived in kenya ) with stage c2 hiv infection ( 3 ) .
these strains of m. canetti ( so93 from the somali child and nzm 217/94 from the swiss man ) have been studied extensively . in culture
they appear smooth , white , and glossy because of the high amount of lipooligosaccharides in the membrane ( 6 ) ; the so93 rough colonies lack this amount ( 2 ) .
two copies of the is6110 insertion sequence were found in the nzm 217/94 and so93 genome .
this fingerprint matched none of the 5,000 other strains preserved in the laboratory of van soolingen ( bilthoven , the netherlands ) ( 2 ) .
so93 , nzm 217/94 , and our two strains share only 2 of 43 identical repeated sequences that have been observed by spoligotyping .
study of the is6110 rflp patterns and of the spacer dna sequences of the dr locus confirmed that m. tuberculosis , m. bovis , m. africanum , m. microti , and m. canetti represent a closely related group of mycobacteria that are clearly distinct from other mycobacterial species . in the m. tuberculosis complex
we believe that this is the first published report of pulmonary disease caused by m. canetti .
our two cases confirm that m. canetti is able to involve lungs , like any other other member of the m. tuberculosis complex and is able to affect immunocompetent subjects .
the clinical features of these two pulmonary cases of tb caused by m. canetti are not specific .
tb caused by m. canetti appears to be an emerging disease in the horn of africa .
a history of a visit to the region should cause this strain to be considered promptly . as travel to this area becomes more frequent , and mycobacterial identification techniques improve , the number of diagnosed cases will likely increase .
 we identified an unusual strain of mycobacteria from two patients with pulmonary tuberculosis by its smooth , glossy morphotype and , primarily , its genotypic characteristics . 
 spoligotyping and restriction fragment length polymorphism typing were carried out with the insertion sequence is6110 patterns . 
 all known cases of tuberculosis caused by mycobacterium canetti have been contracted in the horn of africa . 
The Study
Patient 1
Patient 2
Conclusion