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Non- tuberculous mycobacteria (NTMs) and lung disease Turkish Thoracic Society

Non- tuberculous mycobacteria (NTMs) and lung disease Turkish Thoracic Society 16 th Annual Conference. Philip Hopewell, MD Curry International Tuberculosis Center University of California, San Francisco. Non- tuberculous mycobacteria (NTMs). At least 140 species identified

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Non- tuberculous mycobacteria (NTMs) and lung disease Turkish Thoracic Society

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  1. Non-tuberculous mycobacteria (NTMs) and lung disease Turkish Thoracic Society 16th Annual Conference Philip Hopewell, MD Curry International Tuberculosis Center University of California, San Francisco

  2. Non-tuberculous mycobacteria (NTMs) • At least 140 species identified • Pathogenicity is highly variable • Isolated from many environmental sources, generally moist sites • Can cause disease in almost any structure or tissue • At least 40 reported as a cause of lung disease • Distribution differs by geography • Incidence/prevalence appears to be increasing • Diagnosis of disease (vs. colonization) may be difficult • Response to treatment is slow and often incomplete

  3. NTMs and lung disease > 7 days < 7 days 3 frequent 1 more pathogenic MAC 2 2 2 Daley CL, Griffith DE. IJTLD 2010;14

  4. NTMs gross appearance

  5. NTMs in Izmir Isolates in 31 of 77 patients thought to be causative agents of lung disease. • MAC 13 (42%) M. Szulgai 2 (6.5%) M. abcessus 5 (16%) M. Simiae 2 (6.5%) M. Kansasii 5 (16%) M. scrofulaceum 1 (3.2%) • M. fortuitum 2 (6.5%) M. not speciated 1 (3.2%)

  6. NTMs in Istanbul Unidentified 43 (57%) M. fortuitum 3(8%) M. Abcessus 9 (28%) M. Szulgai 3 (8%) M. Avium complex 8 (25%) M. neonarum 1 (2%) M. Kansasii 5 (16%) M. Gordonae 6(16%) Total 75

  7. ATS/IDSA diagnostic criteria Clinical (both required) 1.Pulmonary symptoms, nodular or cavitary opacities on chest radiograph, or a high-resolution CTscan with multifocal bronchiectasisand multiple small nodules and 2. Appropriate exclusion of other diagnoses Microbiological 1. Positive cultures from at least two sputum samples. or 2. Positive culture result from at least one bronchial wash or lavage or Griffith DE et al AJRCCM. 2007;175

  8. ATS/IDSA diagnostic criteria Histological (+ microbiological) 1. Transbronchial or other lung biopsy with mycobacterial histopathologic features (granulomatous inflammation or AFB) and positive culture for NTM or 2. Biopsy showing mycobacterial histopathologic features (granulomatous inflammation or AFB) and one or more sputum or bronchial washings that are culture positive for NTM Griffith DE et al AJRCCM. 2007;175

  9. NTMs and lung disease: Risk factors • Structural defects • Bronchiectasis • COPD • Cystic fibrosis • Previous TB • Lady Windermere syndrome (?) • Impaired systemic immunity • Inherited deficiency • Acquired deficiency: HIV, immunosupressive therapy

  10. MAC disease: Clinical patterns • Bronchiectatic/cavitary disease • Middle lobe/lingular bronchiectasis (“Lady Windermere syndrome”) • Disseminated MAC • Hypersensitivity pneumonitis (“hot tub lung”)

  11. M. avium disease and COPD

  12. M. avium; middle lobe/lingular bronchiectasis

  13. M. avium progression 18 months

  14. Disseminated MAC in HIV

  15. MAC in HIV: lymph node biopsy

  16. M. Avium hypersensitivity pneumonitis Marras TK, et al. Chest. 2005; 127

  17. MAC hot tub lung: findings Marras TK, et al. Chest. 2005; 127

  18. Treatment of MAC pulmonary disease • Nodular/bronchiectatic (“mild”) disease: • clarithromycin (1,000 mg) or azithromycin (500 mg), • rifampin (600 mg), and • ethambutol(25 mg/kg) • Fibrocavitary or severe nodular/bronchiectaticdisease: • clarithromycin (500–1,000 mg) or azithromycin (250 mg), • rifampin (600 mg) or rifabutin (150–300 mg), • ethambutol(15 mg/kg) • consider three times-weekly amikacin or streptomycin early in therapy • Patients should be treated until culture negative on therapy for 1 year. • Hypersensitivity • Macrolide and rifampin + corticosteroid (?) three times weekly daily Griffith DE et al AJRCCM. 2007;175

  19. Treatment and prevention of disseminated MAC disease in HIV • Disseminated MAC disease • clarithromycin (1,000 mg/d) or azithromycin (250 mg/d) and ethambutol (15 mg/kg/d) with or without rifabutin(150–350 mg/d) daily. • Prophylaxis(AIDS with CD4 counts less than 50) • Azithromycin 1,200 mg/week or clarithromycin 1,000 mg/day • Rifabutin 300 mg/day (effective, less well tolerated) Griffith DE et al AJRCCM. 2007;175

  20. MAC surgical treatment • There are no established criteria for patient selection. • There are potentially severe perioperative complications. • There are few centers with extensive experience with mycobacterial surgery. • Surgical resection of limited (focal) disease in a patient with adequate cardiopulmonary reserve to withstand partial or complete lung resection can be successful in combination with multidrug treatment regimens for treating MAC lung disease • Surgical resection of a solitary pulmonary nodule due to MAC is considered curative. • Mycobacterial lung disease surgery should be performed in centers with expertise in both medical and surgical management of mycobacterial diseases.

  21. San Francisco General Hospital

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