NTM-Nitiwat

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 yellow-

orange pigment when exposed to light •  M. kansasii, M. marinum, M. simiae

Runyon II: Scotochromogens •  slow growing, and produce a yellow-

orange 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

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 •  1991 : สมชัย บวรกิตติ รวบรวม NTM 10 รายงาน จาก 44 ราย มี 38 ราย มีหลักฐานเพียงพอ ให้วินิจฉัยโรค

•  1999 : เจริญ ชูโชติถาวร และคณะ รายงานการติดเชื้อ MAC ใน HIV 58 รายจาก ทั้งหมด 334 ราย (17.4%)

•  2007 เพลินจันทร์ เชษฐ์โชติศักดิ์ และคณะ รวบรวมผู้ป่วย NTM แบบแพร่กระจาย พบถึง 129 ราย จากทั่วประเทศไทย

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

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

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)

•  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

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)

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

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

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 และคณะ : Clinical ID 2007

Sweet‘s 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 ; ศ.พญ. เพลินจันทร์ เชษฐ์โชติศักดิ์ , 2552

•  ตําราโรคติดเชื้อ : NTM ; ศ.พญ. เพลินจันทร์ เชษฐ์โชติศักดิ์ . 2548

NTM-Nitiwat

Documents

Transcript of NTM-Nitiwat