ITS AN

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ITS AN ENVIRONMENTAL MYCOBACTERIUM WHAT DO I
DO..?
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16th October 2008 Letter from GP
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48, 90 days post BMTx Recurrent pneumonia post
Tx Been on HDU Renal Tx 20 yrs before
Vasculitis Now well Isolate from sample when
ill 1/12 ago
26.3
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Patient JW Age 53 10/52 history of cough,
sputum, haemoptysis smoker alcoholic CXR
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Patient JW Age 53 10/52 history of cough,
sputum, haemoptysis smoker alcoholic CXR
Sputum AAFB Quadruple anti-TB Rx commenced
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Patient JW Age 53 10/52 history of cough,
sputum, haemoptysis smoker alcoholic CXR
Sputum AAFB 6/52 later Mycobacterium
malmoense isolated
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
131 species listed to date M avium /
intracellulare M kansasii M xenopi M malmoense M
chelonei M gordonae
http//www.bacterio.cict.fr/m/mycobacterium.html
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
131 species listed to date M cosmeticum cosmeti
c infection, nail salon M elephantis elephant M
neworleansense New Orleans M senuense Seoul
National University M psychrotolerans pond near
uranium mine M brumae (not from Birmingham!) M
branderi (nothing to do with Russell!)
http//www.bacterio.cict.fr/m/mycobacterium.html
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
PULMONARY
CUTANEOUS / MUSCULOSKELETAL
DISSEMINATED
M avium complex M kansasii M xenopi M malmoense M
abscessus M fortuitum M celatum M asiaticum M
sulgai
M avium complex M kansasii M genavense M
chelonae M abscessus M haemophilum M
scrofulaceum M celatum M simiae M malmoense
M marinum M ulcerans M fortuitum M abscessus M
chelonae M avium complex M kansasii M malmoense M
terrae
LYMPH NODE
M avium complex M malmoense M scrofulaceum M
genavense
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MYCOBACTERIAL ISOLATES MRI - 2005
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Contaminant Progressive lung disease Extrapulmona
ry disease Disseminated disease Immunosuppressed
CD4 lt 50 IF gamma or IL-12 mutations
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Is it a contaminant Is it M tuberculosis Is it
an environmental mycobacterium
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Is the patient at risk Is the clinical illness
compatible Is it an environmental mycobacterium
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Is the patient at risk - smoking /
alcohol structural lung disease immune
suppression Is the clinical illness
compatible Is it an environmental mycobacterium
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Is the patient at risk Is the clinical illness
compatible - symptoms radiology Is it an
environmental mycobacterium
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIAL LUNG DISEASE
Cough sputum Fatigue, malaise,
dyspnoea, Fever, haemoptysis, chest pain, weight
loss Smoking, alcohol Radiology Thin walled
cavities Nodular consolidation Volume
loss Pleural thickening
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M avium intracellulare (MAI / MAC)
Lady Windermere syndrome Nodular infiltrates
in R ML or lingula Postmenopausal,
non-smoking white females
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Mycobacterium avium intracellulare (MAI / MAC)
Cervical lymphadenopathy (children) Hot Tub Lung
(hypersensitivity) standing water
sources younger patients cough, dyspnoea and
fever Diffuse infiltrates nodules Ground
glass change on CT
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Mycobacterium avium intracellulare (MAI / MAC)
Immune suppressed CD4 lt 50
Disseminated disease Fever, night sweats, weight
loss Abdominal pain, diarrhoea,
hepatosplenomegaly Anaemia, pancytopaenia Clinic
al and radiographic lung involvement uncommon
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ENVIRONMENTAL / ATYPICAL / OPPORTUNIST /
NON-TUBERCULOUS MYCOBACTERIA
Is the patient at risk Is the clinical illness
compatible Is it an environmental mycobacterium
smear growth rate molecular
biology culture
Is it in more than one sample?
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NUCLEIC ACID SEQUENCE-BASED AMPLIFICATION IDENTIFI
CATION OF MYCOBACTERIAL SPECIES
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NUCLEIC ACID SEQUENCE-BASED AMPLIFICATION IDENTIFI
CATION OF MYCOBACTERIAL SPECIES
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Initial Sample
AFB Smear ve
Genotyping
Liquid culture LJ slopes
Culture positive
Genotyping
(further identification by staining and
sensitivity patterns)
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CRITERIA FOR DIAGNOSIS OF ENVIRONMENTAL
MYCOBATERIAL LUNG INFECTION
ALL THREE OF Respiratory symptoms Abnormal
radiology At least TWO positive sputum cultures
These criteria fit bestwith M. avium complex
(MAC), M. kansasii, and M. abscessus.
ATS / IDSA 2007
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CRITERIA FOR DIAGNOSIS OF ENVIRONMENTAL
MYCOBATERIAL LUNG INFECTION
Respiratory symptoms Abnormal
radiology (usually nodules or cavities with
exclusion of other plausible causes) At least
TWO positive sputum cultures or (biopsy with
appropriate histology culture)
Seek expert advice
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TREATMENT M avium
Fibrocavitary
Nodular/bronchiectatic
Clarithromycin 500 - 1000mg or Azithromycin
250mg Rifampicin 600mg or Rifabutin 150 300
mg Ethambutol 15 mg / kg od Daily Treat till
culture ve for 1 yr
Clarithromycin 1000mg or Azithromycin
500mg Rifampicin 600mg Ethambutol 25 mg / kg
od x 3 / week Treat till culture ve for 1 yr
ATS / IDSA 2007
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COMPARISON OF FOUR REGIMES IN MAC
R, rifampicin E, ethambutol Cl, clarithromycin
Ci, ciprofloxacin
n Deviation Deaths Death MAC Fail /
Relapse Completion
RE 37 16 32 0 41 27
REH 38 21 39 8 16 34
RECl 83 35 48 2 13 24
RECi 87 43 30 3 23 23
Similar findings for M malmoense and M xenopi
Jenkins et al Thorax 200863627-634
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TREATMENT M kansasii
ATS / IDSA 2007
BTS 1999
Isoniazid 300 mg Rifampicin 600mg Ethambutol
15 mg / kg od Daily Treat till culture ve for
1 yr
Rifampicin 450 mg (lt50kg) or 600mg (gt50 kg)
od Ethambutol 15 mg / kg od M kansasii 9
months M avium, M malmoense and M xenopi 24
months
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48, 90 days post BMTx Recurrent pneumonia post
Tx Been on HDU Renal Tx 20 yrs before
Vasculitis Isolate from sample when ill 1/12
ago (upper CXR) Now well
26.3
10.4
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Patient JW Age 53 10/52 history of cough,
sputum, haemoptysis smoker alcoholic CXR
Sputum AAFB 6/52 later Mycobacterium
malmoense isolated Rifampicin ethambutol for
2 years
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American Thoracic Society Documents An Official
ATS/IDSA Statement Diagnosis,Treatment, and
Prevention of Nontuberculous Mycobacterial
Diseases David E. Griffith, Timothy Aksamit,
Barbara A. Brown-Elliott, Antonino Catanzaro,
Charles Daley, Fred Gordin, Steven M. Holland,
Robert Horsburgh, Gwen Huitt, Michael F.
Iademarco, Michael Iseman, Kenneth Olivier,
Stephen Ruoss, C. Fordham von Reyn, Richard J.
Wallace, Jr., and Kevin Winthrop, on behalf of
the ATS Mycobacterial Diseases Subcommittee
Am J Respir Crit Care Med Vol 175. pp 367416,
2007
Management of opportunist mycobacterial
infections Joint Tuberculosis Committee
Guidelines 1999 Subcommittee of the Joint
Tuberculosis Committee of the British Thoracic
Society
Thorax Vol 55. pp 210-218, 2000