Nontuberculous mycobacterial infections of man

The Diagnosis and Treatment of Scrofula (Mycobacterial Cervical Lymphadenitis)

Mycobacterial cervical lymphadenitis, or scrofula, may be caused by Mycobacterium tuberculosis, or the atypical mycobacteria. It is important to distinguish between tuberculous cervical lymphadenitis and atypical mycobacterial cervical lymphadenitis, since medical and surgical treatment of each of these entities is different. The two types of scrofula are compared and contrasted. The appropriate treatment of each is discussed, and the complications of improper management are described.

Diagnosing nontuberculous mycobacterial lung disease. A process in evolution

Assessing the impact of the diagnosis if NTM lung disease on the patient and choosing appropriate therapy are separate considerations. Health care professionals have progressed from an era when patients had unrecognized, progressive, and untreated NTM disease to an era when NTM disease is diagnosed frequently but therapy is either unnecessary or possibly worse than the disease. Perhaps the 1990 ATS statement was correct. The problem is not diagnosing patients with NTM lung disease, the problem is deciding what to do with them after they are diagnosed.

Disseminated mycobacterium avium complex infection presenting as osteomyelitis in a normal host

Disseminated Mycobacterium avium complex (MAC) infection presenting as a painful lytic femur lesion with associated fever, night sweats and weight loss occurred in a 45-y-old woman with apparent normal immune function. Surgical drainage and 24 months of medical therapy resulted in a cure.

Mediastinal lymphadenopathy caused by Mycobacterium avium-intracellulare complex in a child with normal immunity: successful treatment with anti-mycobacterial drugs and laser bronchoscopy

We report on the case of a 9-month-old Caucasian girl referred to our institution with a history of fever of unknown origin and wheezing, unresponsive to bronchodilator and anti-inflammatory therapy. Subsequent investigation led to a diagnosis of mediastinal lymphadenopathy caused by Mycobacterium avium-intracellulare (MAI). The infected lymph tissue infiltrated and obstructed the right bronchus and significantly compressed the left bronchus to the point of near closure. Given the high degree of morbidity and potential mortality from thoracic surgery in this patient, we treated her with a combination of anti-mycobacterial drugs (rifabutin, clarithromycin, ciprofloxacin, clofazimine, amikacin, ethambutol) and glucocorticoids to relieve airway compression. The endobronchial granulation tissue was resected by laser bronchoscopy. This combined approach led to eventual normalization of radiologic and endoscopic findings, and the anti-mycobacterial chemotherapy was discontinued 12 months after the first bronchoalveolar lavage culture was negative for MAI. The patient remains asymptomatic 1 year after completion of this course of therapy. We suggest that mediastinal lymphadenopathy with bronchial infiltration and extrinsic airway compression caused by MAI in otherwise healthy children can be successfully treated with aggressive chemotherapy, glucocorticoids, and laser bronchoscopy.

Pneumonectomy secondary to Mycobacterium fortuitum in infancy

Severe necrotic lung disease as a result of infection with a rapidly growing mycobacteria occurred in a 4-month-old infant. Successful treatment required a pneumonectomy.

Synovial involvement by Mycobacterium marinum. A histopathological study of 25 culture-proven cases

The present culture-proven cases are contrary to the generally held view that infection with Mycobacterium marinum is habitually a superficial infection without potentially serious consequence. A wide spectrum of pathological lesions may be seen in the synovium and adjacent tissues in patients infected by M. marinum. Variations in the morphology of the inflammatory reaction occurs both between cases and, to a lesser extent, in different areas of individual cases. The inflammation ranges from the common non-specific diffuse form, to lesser areas of focal non-caseating lesions, to rarer focal caseating types of granulomatous reaction, and can include an acute inflammatory cell component. Fibrinous exudate on the synovial surface is a recurrent feature and is often the site harbouring most acid-fast bacilli. The variation of inflammatory reaction with time and the possible effects of local steroid injection are discussed.

Ankylosing spondylitis lung disease and Mycobacterium scrofulaceum

The development of apical pulmonary fibrosis and bullous disease is a rare but well recognized extra-articular manifestation of ankylosing spondylitis (AS). The fibrobullous disease is usually asymptomatic and diagnosed at an incidental radiological examination. When symptoms do develop, they are usually due to superimposed colonization or infection by bacteria, fungi or mycobacteria. Only six cases of non-tuberculous mycobacterial superinfection in AS have been reported. We report a patient with AS and progressive apical fibrobullous disease in whom Mycobacterium scrofulaceum was repeatedly cultured over a 12-year period.

Mycobacterium chelonei tenosynovitis of the hand: a case report

We report an unusual organism, Mycobacterium chelonei, which causes digital tenosynovitis. Atypical mycobacterial infections of the hand are uncommon. The diagnosis should be suspected when there is persistent swelling or tenosynovitis, inconsistent with other inflammatory processes such as rheumatoid arthritis. Synovial biopsy specimen and appropriate cultures are necessary to confirm the diagnosis.

Culture of Vibrio extorquens from severe, chronic skin ulcers in a Puerto Rican woman

A 48-year-old Puerto Rican woman developed extensive ulcers on her buttocks, right arm, and thighs over a 3 1/2-year period. The lesions began as small, subcutaneous nodules which subsequently ulcerated and expanded up to 19 cm in diameter. Biopsy of both ulcerated and nonulcerated lesions showed acid-fast bacilli. Culture of both types of lesions grew Vibrio extorquens, a partially acid-fast methanolophilic organism not previously associated with disease in humans. The patient developed agglutinating antibody, titer 1:80, to this organism. The disease responded to treatment with antibiotics to which the organism was sensitive in vitro.

Mycobacterial lymphadenitis

The plan for cervical lymph node biopsy should include special maneuvers for recognition of patients with lymphadenitis due to atypical mycobacteria, since these children need extensive operations. The diagnosis should be suspected in children less than 3 yr old with lymphadenopathy present for several months and no exposure to cats (or with negative cat scratch skin tests). Wide local excision of all visibly involved nodes is recommended; acid-fast touch preparations should be done and interpreted during operation in any suspicious case. Limited operations should be avoided in children with mycobacterial lymphadenitis. The illness may be more common than previously suspected.

Disseminated nongranulomatous Mycobacterium avium osteomyelitis

A 17 month old black girl had multiple, rapidly progressive osteolytic lesions, cervical lymphadenopathy, fever, and weight loss clinically compatible with disseminated malignant disease. Histologically the bone lesions were characteristic of acute nongranulomatous osteomyelitis with a few acid fast organisms. Mycobacterium avium was cultured. Immunologic evaluation showed an intact response to the infection. Disseminated Mycobacterium avium infection may occur in immunologically intact children, clinically simulate malignant disease, and produce an acute nonspecific inflammatory lesion.

Pulmonary mycobacterial infections due to Mycobacterium intracellulare-avium complex. Clinical features and course in 100 consecutive cases

One hundred consecutive cases of pulmonary infection due to Mycobacterium intracellulare-avium seen during a 3 1/2-year period qualified for review on the basis of a compatible chest x-ray film, repeated isolations from cultures of sputum, and follow-up of three to eight years. Infections with M intracellulare-avium represented 27 percent of all mycobacterial infections seen during this period, including those due to M tuberculosis. The cases of disease due to M intracellulare-avium were predominantly in men with preexisting pulmonary disease, with a peak incidence in the sixth decade, but nearly one-third of the cases were in younger persons free of coexisting disease. The disease was chronic and indolent in most cases, and only a few showed a progressive course. A stable course was frequently observed despite prolonged persistently positive cultures of sputum. A favorable prognosis was most often found in those with previously treated tuberculosis. Poor prognosis was often due to a serious associated disease, such as cancer, rather than to advancing mycobacterial infection itself. Age, sex, or race was unrelated to prognosis. Conversion to negative status on culture was attained in one-half of the cases. Those with extensive radiographic involvement or cavitation were more likely to have treatment fail bacteriologically. No combination of chemotherapy appeared to be particularly effective, including the use of five or more drugs in eight cases demonstrating progressive disease. Surgery, too, was ultimately disappointing in that recurrence appeared in six of 18 carefully selected cases.

Suppurative cervical adenitis caused by opportunist mycobacterium

Of 45 consecutive submandibular abscesses treated by external drainage in a district oral surgery unit, four cases, representing nearly 9% of the sample, were caused by opportunist Mycobacterium avian-intracellulare, an organism known to give a poor response to all known antimycobacterial chemotherapeutic agents. Treatment by excision of the diseased tissue is indicated in these cases. The diagnosis and management of these conditions is discussed.