ATYPICAL COINFECTION BY MYCOBACTERIUM TUBERCULOSIS AND FORTUITUM IN AN IMMUNOSUPPRESSED PATIENT: CASE REPORT

Tuberculosis, caused by Mycobacterium tuberculosis, is a transmissible respiratory disease, while non-tuberculous mycobacteria (NTM) comprise a diverse group of mycobacteria found in the environment, such as water and soil, capable of causing disease especially in immunocompromised individuals or those with preexisting conditions. In this report, we describe an atypical case of coinfection by mycobacterioses in an immunosuppressed patient, highlighting clinical and microbiological aspects and diagnostic challenges, as well as timely treatment to minimize potential deleterious effects of the disease. A 52-year-old female patient, born in Bolivia and residing in São Paulo, with insulin-dependent diabetes mellitus secondary to pancreatectomy for neoplasia, was admitted to the emergency department with diabetic ketoacidosis. Personal history included smoking only (20 pack-years). During clinical investigation, imaging studies revealed cavitation in the right upper lobe, and sputum testing was positive for acid-fast bacilli. Epidemiological surveillance notification revealed prior records of M. tuberculosis (07/2024) and M. fortuitum (10/2024), both without completed treatment. Subsequent cultures confirmed active coinfection. Combined antibiotic therapy (Imipenem + Amikacin + Levofloxacin) and antituberculosis drugs (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) were initiated for the respective mycobacterioses. The patient showed resolution of ketoacidosis and clinical-laboratory improvement after appropriate therapy, was discharged, and continued outpatient follow-up. Coinfection by tuberculosis and non-tuberculous mycobacteria, although uncommon, represents a diagnostic and therapeutic challenge, particularly in the context of chronic immunosuppression such as insulin-dependent diabetes. This case reinforces the importance of epidemiological surveillance, clinical suspicion, and individualized treatment based on cultures, imaging, and susceptibility profiles. Multidisciplinary management and rigorous laboratory monitoring are essential for therapeutic responsiveness and prevention of complications.