Nontuberculous Mycobacterial Diseases

Nitiwat Chansuk Internal Medicine KKU July,4 2011

Introduction
Mycobacteria : small, rod-shaped bacilli classified into 3 groups : Mycobacterium tuberculosis : M. tuberculosis, M. bovis, M. africanum, M. microti and M. canetti. M. leprae which causes Hansen's disease or leprosy. Nontuberculous mycobacteria (NTM) other mycobacteria cause pulmonary disease resembling tuberculosis, lymphadenitis, skin disease, or disseminated disease

Introduction
environmental mycobacteria atypical mycobacteria mycobacteria other than tuberculosis (MOTT)

Taxonomy
In 1959, botanist Ernest Runyon put into four groups Photochromogens Scotochromogens Nonphotochromogens Rapid growers mycobacteria

Presumptive identification
Growth rate - < 7 days (rapid grower) - > 7 days (slow grower) Pigmentation - Nonchromogenic - Chromogenic Photoreactive - Nonphotochromogen - Photochromogen - Scotochromogen

Runyon I: Photochromogens
slow growing, and produce a yelloworange pigment when exposed to light M. kansasii, M. marinum, M. simiae

Runyon II: Scotochromogens

slow growing, and produce a yelloworange pigment in light or in the dark. Some become darker with exposure to light M. scrofulaceum, M. gordonae, M. szulgai, M. xenopi, M. celatum, M. flavescens

Runyon III: Nonchromogenic

slow growing, and do not produce pigment., or tan pigment but do not intensify upon light exposure M. avium-intracellulare, M. terrae, M. paratuberculosis, M. shimoidae, M. genavense

Runyon IV: Rapid Growers

rapid growing for mycobacteria (colonies in 7 days). They do not produce pigment. M. fortuitum, M. peregrinum, M. abscessus, M. chelonae, M. thermoresistible

NTM

Slow growing mycobacteria

Rapid growing mycobacteria

Epidemiology
NTM are widely distributed in the environment wet soil, marshland, streams, rivers and estuaries Different species of NTM prefer different types of environment Human disease is believed to be acquired from environmental exposures no evidence of animal-to-human or human-to-human transmission of NTM

Epidemiology
most industrialized countries incidence rates vary from 1.0 to 1.8 cases per 100,000 persons Centers for Disease Control and Prevention (CDC) laboratory 1981-1983 94% reported to the were pulmonary, whereas 3% were lymph node 3% were skin/soft tissue isolates

Epidemiology
In 1980-1990, NTM associated with disseminated disease in AIDS frequently as pulmonary isolates State public health laboratories to the Public Health Laboratory System (PHLIS) database 1993-1996 (CDC :USA) MAC, 29 to 36 isolates; (per 1,000,000 population) M. fortuitum, 4.6 to 6 isolates; and M. kansasii, 2 to 3.1 (per 1,000,000 population) most often from the southeastern United States

Epidemiology
Most NTM disease cases involve the species MAC, M. abscessus, M. fortuitum and M. kansasii. M. abscessus Rapidly growing NTMs are implicated in catheter infections, post-LASIK, skin and soft tissue (especially post-cosmetic surgery) and pulmonary infections

Thailand
NTM 10 44 38 1999 : MAC HIV 58 334 (17.4%) 2007 NTM 129
1991 :

Clinical

Pulmonary disease

Symptoms and signs.

variable and nonspecific chronic or recurring cough sputum production, fatigue, malaise, dyspnea, fever, hemoptysis, chest pain, and weight loss. chest auscultation, findings may include rhonchi, crackles, wheezes, and squeaks nodular/bronchiectatic MAC disease tend to be postmenopausal women

Clinical

Diagnosis

An 81-year-old woman was admitted with weight loss (18 kg in 27 months), hemoptysis, and tubular and diffuse granular shadows on her chest radiograph (Panel A)

Ebihara T and Sasaki H. N Engl J Med 2002;346:1372

 RML bronchiectasis secondary to MAC infection

MAC Treatment

M. Kansasii Treatment

M abscessus

Lymphadenitis
Children often present with infections in the lymph nodes most often in the neck ,usually unilateral, not tender Typically, enlarge slowly and without systemic symptoms

Lymphadenitis

Lymphadenitis

Skin, Soft Tissue, and Bone Disease

usually occur after a puncture of the skin , localized, spread beyond the initial site M. marinum ---- most common M. ulcerans ,M. abscessus , M. fortuitum , M. chelonae

Skin, Soft Tissue, and Bone Disease

Aquarium granuloma
Fish tank granuloma Swimming pool granuloma Long-term intravenous or intraperitoneal(the area containing the abdominal organs) catheters Postinjection abscesses Infections after liposuction Augmentation mammaplasty (breast enhancement) Cardiac bypass surgery Corneal infections after laser in situ keratomileusis (LASIK)

A small, raised, erythematous lesion developed on the dorsum of the hand of a 35-year-old man who worked in a pet shop

Nguyen C. N Engl J Med 2004;350:e8

M. marinum

Treatment :one regimen doxycycline ,minocyclin ,clarithromycin ,Bactrim : 2 regimen rifam , ethambutol 3 month

Buruli ulcer
Bairnsdale ulcer , Searl ulceror Searle's ulcer Mycobacterium ulcerans

 M ulcerans Rx : Surgical , rifampicin , sulfonamides , clofezamine

Dissiminated NTM

Dissiminated NTM in HIV

Disseminated infections (infections that spread beyond one location) most commonly advanced HIV disease. 90% due to MAC in HIV M. kansasii is the second most common in HIV infected patients

MAC Treatment

Dissiminated NTM in non HIV

Immunocompromised host : organ transplant , Leukemia ,immunosuppressive FUO , weight loss , Lymphadenopathy , organomegaly , skin 1. CMIR defect : Leukemia , Lymphoma more severity , high motality 2. Immunocompetent : skin , motality < 10%

NTM in Thailand

Chetchotisaktra : Clinical ID 2007

NTM in Thailand

Chetchotisaktra : Clinical ID 2007

NTM in Thailand

Chetchotisaktra : Clinical ID 2007

Sweets syndrome

Acute, tender, erythematous plaques, nodes, pseudovesicles and, occasionally, blisters with an annular or arciform pattern

AGEP Acute generalised exanthematous

pustulosis

red skin studded with small pustules (small blisters filled with white/yellow fluid).

NTM in Thailand
RGM 99 pt
M abscessus 45 pt M fortuitum 11 pt M Chelonae 9 pt

SGM 34 pt
MAC 9 pt M simiae , M scrofulceum , M szulgai 2 pt M kansasii , M Malmoense , M hemophilum 1 pt

Nosocomial Infection
Surgical site infection Cardiothoracic surgery Plastic surgery Post infection abcess Dialysis Catheter rerated infection Infected FB /prosthetic device Pseudoinfection/Pseudo outbreaks

References
An Official ATS/IDSA Statement: Diagnosis,Treatment, and Prevention of Nontuberculous Mycobacterial Diseases David E. Griffith, This Official Statement of the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA)was adopted by the ATS Board Of Directors, September 2006, and by the IDSA Board of Directors, January 2007
Nontuberculous Mycobacteria : http://knol.google.com/k/nontuberculous-mycobacteria#

An update current practice in ID : NTM ; .. , 2552 : NTM ; .. . 2548