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Atypical Mycobacterium

Learn about different species of atypical mycobacteria, including nontuberculous mycobacteria, laboratory diagnosis, common clinical syndromes, and treatment options.

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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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