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The Three Faces of Lady Windermere: Pulmonary Non-tuberculous Mycobacterial Syndromes

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The Three Faces of Lady Windermere: Pulmonary Non-tuberculous Mycobacterial Syndromes

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    1. The Three Faces of Lady Windermere: Pulmonary Non-tuberculous Mycobacterial Syndromes Respirology Grand Rounds January 20, 2006 Ted Marras, MD FRCPC Toronto Western Hospital / University Health Network

    2. To review: Epidemiology Pathogenesis Clinical manifestations Treatment Different syndromes of pulmonary NTM disease Pulmonary infection With underlying lung disease Without underlying lung disease Hypersensitivity pneumonitis

    3. Pulmonary NTM: Epidemiology

    6. Published epidemiology of NTM

    7. Published epidemiology of NTM – trends

    8. Published epidemiology of NTM – trends

    10. Pulmonary NTM: Pathogenesis

    12. “Infectious” Underlying lung disease Emphysema Bronchiectasis No known underlying lung disease “Lady Windermere” Pectus excavatum Recurrent aspiration “Inflammatory” HP / HP-like Hot tub lung Machine worker’s lung ? Shower taker’s lung

    13. “Disease vs Colonization” In the presence of infecting organism: Disease = clinically important illness Colonization = absence of symptoms “Stage of Infection”

    14. Early Subclinical Minimal radiographic change Difficult to recover organism

    16. “Infectious” Underlying lung disease Emphysema Bronchiectasis No known underlying lung disease “Lady Windermere” Pectus excavatum Recurrent aspiration “Inflammatory” HP / HP-like Hot tub lung Machine worker’s lung ? Shower taker’s lung

    17. “Infectious” Underlying lung disease Emphysema Bronchiectasis No known underlying lung disease “Lady Windermere” Pectus excavatum Recurrent aspiration “Inflammatory” HP / HP-like Hot tub lung Machine worker’s lung ? Shower taker’s lung

    18. “Infectious” Underlying lung disease Emphysema Bronchiectasis No known underlying lung disease “Lady Windermere” Pectus excavatum Recurrent aspiration Sociologic? Anatomic? Immunologic? Fastidious lady windermereFastidious lady windermere

    19. Pulmonary NTM: Management of “Infectious” Syndromes

    20. When the infection causes problems: Finding the germ Repeatedly isolated (?) Smear positive Significant symptoms Systemic – fever, sweats, weight loss, fatigue Local – cough, sputum, hemoptysis, dyspnea Significant pulmonary burden Radiology Consolidation, nodules, severe peribronchial thickening Progression

    21. Non-destructive infection Cure Localized destructive infection Cure Diffuse destructive infection Suppress Severe drug intolerance Suppress

    24. “Infectious” Underlying lung disease Emphysema Bronchiectasis No known underlying lung disease “Lady Windermere” Pectus excavatum Recurrent aspiration “Inflammatory” HP / HP-like Hot tub lung Machine worker’s lung ? Shower taker’s lung

    29. 1. Not colonized ? possibly indolent infection 2. Diagnose aggressively Sputum / BAL CT 3. Treatment Do: Consider objectives Treat aggressively (usually) Use adjuvant modalities Re-evaluate regimen and objectives Don’t Start too soon Wait too long Suppress the host more than the pathogen 4. Follow-up Clinical / Radiographic / Microbiologic / Physiologic

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