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Ali Somily MD
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All mycobacterial species except those that cause tuberculosis (TB)
Mycobacterium tuberculosis complex includes M. tuberculosis including M. tuberculosis subsp canettiM.bovisM. bovis BCG strainM. africanumM. capraeM. microti M. pinnipedii
Leprosy (M. leprae).
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1954 Runyon first NTM classification >100 NTM species Other names
Mycobacteria other than tuberculosis (MOTT)
AtypicalEnvironmentalOpportunistic
Variable pathogenicity and geographic regions
40% cause diseases in human Immunosuppressed host
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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)
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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
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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
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Risk factors Immunosuppression ( HIV, Medications )AgingBCG vaccinationCystic fibrosisFibronodular bronchiectasis
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Common clinical syndromes:1. Lymphadenopathy2. Chronic pulmonary disease3. Skin and soft tissue infections (often
associated with trauma or a foreign body) sometimes with extension to bone and joint
4. Disseminated disease.
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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
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Pulmonary disease Common etiological agents M. avium complex(MAC) M. kansasii M. abscessus M. xenopi
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Elderly men with COPD Middle aged to elderly Non- smoking
women CF patients Hypersensitivity pneumonitis
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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
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Pulmonary disease Treatment Treatment with combined antimicrobials Resection if localized
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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
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Lymph node disease
Common etiological agents
MAC M. kansasii M. malmoense M. haemophilum
Uncommon etiological agents
M. scrofulaceum M.fortuitum/
peregrinum M.abscessus/
chelonae
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Lymph node disease Treatment Surgical resection is usually curative
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Skin/soft tissue/bone/joint and tendons
Definition History of trauma or superficial
laceration Presence of a foreign body
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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
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Water ,fish Lake, bay,ocean,pool,aquarium 1-2 month IP granulomatous nodular
– ulcerative lesions (hands) Bx for diagnosis
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Fish tank granuloma/ M.marinum
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Buruli ulcer /M.ulcerans
Chronic cutanous ulcer
Africa mostly Debridment
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Skin/soft tissue/bone/joint and tendons
Treatment Debridement plus combined drug
therapy
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Disseminated Definition HIV or other immunosuppressive
disease Symptoms: fever, weight loss, diarrhea Any site possible No trauma necessary
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Disseminated Prevention & treatment Prevention of MAC in HIV by prophylaxis Treat positive blood culture aggressively
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Disseminated Common etiological agents
MACM. genavenseM. abscessus/chelonaeM. haemophilum
Any mycobacterium may cause disease in association with significant immunosuppression HIV CD4 < 50), and any localized lesion may disseminate.
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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, progressiveCavitary uncommonMild systemic symptoms
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Worldwide –esp in tropical countries Transmission rout unknown Can not be cultured Syndromes
Lepromatous TuberculoidMixed
Treatment 6-months to 2 years Dapsone + Rif +/- clofazimine
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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.
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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.
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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.
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MAC Clarithromycin or azithromycin + ethambutol+Rifampin
M. xenopi Rifampin+Ethambiotol +INH
M. kansasii Rifampin + Ethambutol M. malmoense Rifampin or Ethambutol M. marinum Rifampin or Clari +
Ethambutol 2-3 months Rapid growers doxycycline, amikacin,
imipenem, quinolones, sulfonamides, cefoxitin, clarithromycin
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M. haemophilum Clarithromycin, Rifampin Cipro or Amikacin
M. genavense Clarithromycin, Rifabutin or AmikacinEthambutol
M. ulcerans Clarithromycin, Rifampin, Ethambutol or PAS ( Paraaminosalicylic acid)
MAC prophylaxis Azithromycin , Clarithromycin or Rifabutin 300 if CD4 <50x 106/L