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Atypical Mycobacterium

Atypical Mycobacterium. Ali Somily MD. Nontuberculous Mycobacteria. All mycobacterial species except those that cause tuberculosis (TB) Mycobacterium tuberculosis complex includes M. tuberculosis including M. tuberculosis subsp canetti M.bovis M. bovis BCG strain M. africanum

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Atypical Mycobacterium

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  1. Atypical Mycobacterium Ali Somily MD

  2. Nontuberculous Mycobacteria • All mycobacterial species except those that cause tuberculosis (TB) • Mycobacterium tuberculosis complex includes M. tuberculosis • including M. tuberculosis subsp canetti • M.bovis • M. bovis BCG strain • M. africanum • M. caprae • M. microti • M. pinnipedii • Leprosy (M. leprae).

  3. Nontuberculous Mycobacteria • 1954 Runyon first NTM classification • >100 NTM species • Other names • Mycobacteria other than tuberculosis (MOTT) • Atypical • Environmental • Opportunistic • Variable pathogenicity and geographic regions • 40% cause diseases in human • Immunosuppressed host

  4. Nontuberculous Mycobacteria • Water, soil, food and animals • Does not spread from person to another • Relatively resistant to chlorination and ozonization • Outbreak and Pseudo-outbreak in the hospital • HIV and dialysis patients • Improve laboratory methods  reporting • MAC 40%,rapidly growing 10%,15% unknown,25% M.gordonae,2.5% M.kansasii(MW USA and UK) and 1% M.xenopi (Ontario)

  5. Laboratory Diagnosis • Rapid Growers • Days in broth and < 1 week in solid media • M.abscessus • M.chelonae • M.fortutum • Slow Growers • 1-2 weeks in broth and 2-4 weeks in solid media • M.avium • M.kansasii • M.scrofulaceum • M.ulcerans • M.xenopi • M.gordonae

  6. Special Diagnostic Problems • M.leprae cannot be cultured • M.marinum lower temperature required • M.haemophilum lower temperature required and iron need to be added • M.ulcerans lower temperature required • M.genavense very slow growth in broth • DNA probes for MAC, M. kansasii and M. gordonae available • Identification and sensitivity

  7. Nontuberculous Mycobacteria • Risk factors • Immunosuppression ( HIV, Medications ) • Aging • BCG vaccination • Cystic fibrosis • Fibronodular bronchiectasis

  8. Nontuberculous Mycobacteria • Common clinical syndromes: • Lymphadenopathy • Chronic pulmonary disease • Skin and soft tissue infections (often associated with trauma or a foreign body) sometimes with extension to bone and joint • Disseminated disease.

  9. Nontuberculous Mycobacteria • Pulmonary disease • Definition • Usually adults • Symptoms of cough, sputum production, weight loss • Two or more sputum isolates or one isolate from,BAL,Bx, sterile site • Distribution of isolates varies regionally

  10. Nontuberculous Mycobacteria • Pulmonary disease • Common etiological agents • M. avium complex(MAC) • M. kansasii • M. abscessus • M. xenopi

  11. M.Avium complex (MAC) • Elderly men with COPD • Middle aged to elderly Non- smoking women • CF patients • Hypersensitivity pneumonitis

  12. M.Kansasii • Similar to TB • US midwest and south • AFB positive • Probe positive • HIV CD4 <200 pulmonary and disseminated • M..xenopi • UK, Northern Europe and Canada, less common in US • Rural /farm area • Very good outcome

  13. Nontuberculous Mycobacteria • Pulmonary disease • Treatment • Treatment with combined antimicrobials • Resection if localized

  14. Nontuberculous Mycobacteria • Lymph node disease • Definition • Usually < 5 years of age • Unilateral, submandibular site most common • Onset of symptoms subacute • Skin induration and sinus tract formation may occur • R/O TB • MAC (80%) is the most common followed by M. scrofulaceum • Dx Fine needle or excisional Bx

  15. Nontuberculous Mycobacteria • Lymph node disease • Common etiological agents • MAC • M. kansasii • M. malmoense • M. haemophilum • Uncommon etiological agents • M. scrofulaceum • M.fortuitum/ peregrinum • M.abscessus/ chelonae

  16. Nontuberculous Mycobacteria • Lymph node disease • Treatment • Surgical resection is usually curative

  17. Nontuberculous Mycobacteria • Skin/soft tissue/bone/joint and tendons • Definition • History of trauma or superficial laceration • Presence of a foreign body

  18. Nontuberculous Mycobacteria • Skin/soft tissue/bone/joint and tendons • Common etiological agents • M. marinum • M. fortuitum/peregrinum • M. abscessus/chelonae • M. ulcerans • Uncommon etiological agents • MAC • M. kansasii • M. terrae • M. haemophilum

  19. M.marinum • Water ,fish • Lake, bay,ocean,pool,aquarium • 1-2 month IP  granulomatous nodular – ulcerative lesions (hands) • Bx for diagnosis

  20. Fish tank granuloma/ M.marinum

  21. Buruli ulcer /M.ulcerans • Chronic cutanous ulcer • Africa mostly • Debridment

  22. Nontuberculous Mycobacteria • Skin/soft tissue/bone/joint and tendons • Treatment • Debridement plus combined drug therapy

  23. Nontuberculous Mycobacteria • Disseminated • Definition • HIV or other immunosuppressive disease • Symptoms: fever, weight loss, diarrhea • Any site possible • No trauma necessary

  24. Nontuberculous Mycobacteria • Disseminated • Prevention & treatment • Prevention of MAC in HIV by prophylaxis • Treat positive blood culture aggressively

  25. Nontuberculous Mycobacteria • Disseminated • Common etiological agents • MAC • M. genavense • M. abscessus/chelonae • M. haemophilum • Any mycobacterium may cause disease in association with significant immunosuppression HIV CD4 < 50), and any localized lesion may disseminate.

  26. Rapid Growers • M.fortutum • M.abscessus • M.chelonae • Skin and soft tissue infection after truma , post-op,cardiac ,mammoplasty and cosmotic • Pulmonary M.abscessus>M.fortutum • Indolent, progressive • Cavitary uncommon • Mild systemic symptoms

  27. Leprosy • Worldwide –esp in tropical countries • Transmission rout unknown • Can not be cultured • Syndromes • Lepromatous • Tuberculoid • Mixed • Treatment 6-months to 2 years • Dapsone + Rif +/- clofazimine

  28. Lepromatous

  29. Tuberculoid

  30. Borderline lepromatous leprosy (BL/MB)

  31. Nontuberculous Mycobacterial Disease • Principles of Treatment of NTM Disease • 1. Patients should be carefully evaluated to determine the significance of an NTM isolate. The presence of the organism in a sterile site or repeatedly from airway secretions in association with a compatible clinical and radiologic picture confirms the diagnosis. • 2. Treatment of rapidly growing mycobacteria should be guided by in vitro susceptibilities. Other drug susceptibility testing is not standardized.

  32. Nontuberculous Mycobacterial Disease • 3. Treatment should usually combine at least two drugs of proven efficacy. • 4. Contact follow-up is not necessary since NTM are not transmitted from person to person. • 5. Duration of therapy has not been determined; in general, 6-12 months is required following negative cultures.

  33. Nontuberculous Mycobacterial Disease • 6. In soft tissue infections, because of rapidly growing mycobacteria, a combination of debridement and treatment with antimicrobials is recommended. For selection of antimicrobial agents, consultation with the laboratory should be undertaken regarding the reliability of in vitro testing.

  34. Antimycobacterium • MAC Clarithromycin or azithromycin + ethambutol+Rifampin • M. xenopiRifampin+Ethambiotol +INH • M. kansasiiRifampin + Ethambutol • M. malmoenseRifampin or Ethambutol • M. marinumRifampin or Clari + Ethambutol 2-3 months • Rapid growersdoxycycline, amikacin, imipenem, quinolones, sulfonamides, cefoxitin, clarithromycin

  35. Antimycobacterium • M. haemophilumClarithromycin, Rifampin Cipro or Amikacin • M. genavense Clarithromycin, Rifabutin or AmikacinEthambutol • M. ulceransClarithromycin, Rifampin, Ethambutol or PAS ( Paraaminosalicylic acid) • MAC prophylaxisAzithromycin , Clarithromycin or Rifabutin 300 if CD4 <50x 106/L

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