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Morning Report. Anne Lachiewicz January 25, 2010. Mycobacteria. Except for MTB & M. leprae, generally free-living orgs ubiquitous in the environment Recovered from water, soil, domestic/wild animals, milk, and food >100 species in the genus Species vary by geography. Mycobacteria.

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Morning report

Morning Report

Anne Lachiewicz

January 25, 2010


Mycobacteria

Mycobacteria

  • Except for MTB & M. leprae, generally free-living orgs ubiquitous in the environment

  • Recovered from water, soil, domestic/wild animals, milk, and food

  • >100 species in the genus

  • Species vary by geography


Mycobacteria1

Mycobacteria

  • Acid fast bacillus = mycobacterium

    (ex for Nocardia, weakly or variably AF)

  • Refractile GP or gram neutral rods “gram variable rods”

  • Slightly bent, often beaded rods 2-4 microns long under 100x

  • Over the past 15 years, labs are isolating less MTB & more NTM


Mycobacteria2

Mycobacteria

Isolate rates

NTM isolates are more common than MTB isolates

Report rates of isolates are not verified with clinical significant of the report

Disease rates

NTM dz is not communicable thus not reportable

In industrialized countries: 1-1.8/100,000 of NTM disease vs. 3.5/100,000 of active MTB


Mycobacteria3

Mycobacteria

  • 4 groups of human pathogens

    • MTB complex

    • M. leprae

    • Slow growing NTM

    • Rapidly growing NTM

  • IFN-g & IL-12 control mycobacteria via up-regulation of TNF-a from monocytes/macrophages


Morning report

The most common disease causing NTM in the US are

MAC & M. kansasii.


Ntm 4 clinical syndromes

NTM – 4 clinical syndromes

Pulmonary disease (75-94%)

Older persons +/- underlying lung dz

CF patients

MAC, M. kansasii

Disseminated disease (5%)

Severely immunocompromised

MAC, RGM spp. (M. abscesses, M. fortuitum, M. chelonae)

Skin & soft tissue infection (2-3%)

Direct inoculation

M. marinum, M. ulcerans

RGM spp. (may be nosocomial, surgical site infections)

Superficial lymphadenitis, esp. cervical (0.4-3%)

Children

MAC, M. scrofulaceum


Ntm lung disease

NTM lung disease

MAC, M. kansasii, M. abscessus

>50 years, ?M vs. F

Symptoms

variable, nonspecific

chronic or reoccurring cough

sputum production, fatigue, malaise, dyspnea, fever, hemoptysis, chest pain, wt loss

more constitutional symptoms with advancing disease

evaluation complicated by sx of coexisting lung disease

CXR

Fibrocavitary – often like MTB, but may be dense airspace dz or solitary cavity w/o cavitation

Nodular/bronchietatic – typical MAC, usu. mid-lower lung fields, +/- cavitation


Treatment of ntm lung dz

Treatment of NTM lung dz

Indications for treatment

Compatible respiratory or constitutional sx w/ XR abnormalities

Plus EITHER

Consistent isolation of NTM in mod-high numbers from more than one specimen of pulmonary secretions

lsolation from >1 specimen if there is histological evidence of pulm parenchymal involvement

Susceptibility testing & treament recs vary by species


M simiae

M. simiae

Clustered in Israel, Cuba, SW US

Found in local tap water. Recent pseudo-outbreak in an urban Texas hospital from a contaminated water supply

Usually a contaminant. Causes clinical disease in 9-21% of pts.

Immunocompromised pts: AIDS, underlying lung disease

Usually pulmonary dz, rare intraabdominal infections, and disseminated dz in AIDS

Difficult to treat: No predictably effective drug combos & in vivo response may not correlate with in vitro response

? ATS recs clarithromycin and a fluoroquinolone (moxifloxaxin preferred). Linezolid, SMX may work


M simiae1

M. simiae

M. simiae may be confused with MTB as it is the only niacin-positive NTM

Maoz et al. compared pts in Israel with M. simiae vs MTB. Pts with M. simiae:

More females, older age

Higher rates of smoking, COPD, other dz (DM, CAD, cancer), immunosuppressive drugs

Less HIV

Blunted symptoms

More noncavitary infiltrates in middle/lower lobes

Most M. simiae isolates were contaminants

Treatment with clarithromycin, ethambutol, rifabutin, and streptomycin (with modification for sensitivities)


References

References

  • Griffith, DE et al. An offical ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175:367-416.

  • Griffith, DE and Wallace, RJ. Microbiology of nontuberculous mycobacteria. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.

  • Griffith, DE and Wallace, RJ. Overview of nontuberculous mycobacterial infections in HIV-negative patients. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.

  • Griffith, DE and Wallace, RJ. Treatment of nontuberculous mycobacterial infections of the lung in HIV-negative patients. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009.

  • Maoz, C et al. Pulmonary Mycobacterium simiae infection: comparison with pulmonary tuberculosis. Eur J Clin Infect Dis. 2008;27,945-950.

  • Samra, Z et al. Emergence of Mycobacterium simiae in respiratory specimens. Scan Infect Dis. 2005;37:838-841.


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