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Wessell NM, Krieg B, Damioli L, Kleck CJ. Atypical Mycobacterial Infections of the Spine: Evaluation and Management. Orthopedics 2024; 47:e61-e66. [PMID: 38285551 DOI: 10.3928/01477447-20240122-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Atypical mycobacterial infections of the spine can be difficult to treat and represent a subset of the vertebral osteomyelitis and diskitis spectrum often requiring early and aggressive surgical intervention. The purpose of this review is to improve the understanding of and approach to disease management from the perspective of the spine surgeon. MATERIALS AND METHODS Debridement or excision of the affected levels may be necessary to decrease mycobacterial loads and restore biomechanics. A close relationship with the patient's internal medicine and infectious disease specialists should be maintained to ensure disease eradication or remission. Long-term suppressive antibiotic therapy may be required for infection control. RESULTS AND CONCLUSION Atypical mycobacterial spine infections are rare, complex, and difficult to eradicate. Our institution proposes a collaborative effort among the spine surgeon, infectious disease specialists, and internal medicine specialists to best approach the work-up, diagnosis, and treatment of these infections. [Orthopedics. 2024;47(2):e61-e66.].
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Husain FF, Nakamae T, Kamei N, Omori K, Maruyama T, Nakao K, Adachi N. Vertebral osteomyelitis due to Mycobacterium abscessus subsp. massiliense with paravertebral abscess: A case report and review. J Infect Chemother 2023:S1341-321X(23)00134-4. [PMID: 37244350 DOI: 10.1016/j.jiac.2023.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
The incidence of vertebral osteomyelitis (VO) caused by non-tuberculosis mycobacteria (NTM) without immunocompetence is extremely rare. Herein, we reported on a case of VO caused by NTM. A 38-year-old man was admitted to our hospital with persisting low back and leg pain which had lasted for a year. Before coming to our hospital, the patient was treated with antibiotics and iliopsoas muscle drainage. The biopsy confirmed the presence of a NTM, Mycobacterium abscessus subsp. massiliense. Several tests were conducted which showed the infection had progressively increased, such as vertebral endplate destruction on plain radiography, computed tomography scan, and epidural and paraspinal muscle abscesses on magnetic resonance imaging. The patient underwent radical debridement, anterior intervertebral fusion with bone graft, and posterior instrumentation with antibiotic administration. A year later, the patient's low back and leg pain was relieved without any analgetic. VO due to NTM is rare but can be treated with multimodal therapy.
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Affiliation(s)
- Fadlyansyah F Husain
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Department of Orthopaedic and Traumatology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Toshio Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshiaki Maruyama
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuto Nakao
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Cheng J, Zhang L, Huang Q, Li C, Yu J, Zhu M. Refractory Osteomyelitis Caused by Mycobacterium aubagnense and Its L-Form: Case Report and Review of the Literature. Infect Drug Resist 2022; 15:7317-7325. [DOI: 10.2147/idr.s388629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
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Sun X, Zhang T, Sun H, Sun X. Disseminated nontuberculous mycobacterial infection with cryptic immunodeficiency mimicking malignancy: a case report. BMC Pulm Med 2022; 22:452. [PMID: 36447235 PMCID: PMC9706953 DOI: 10.1186/s12890-022-02227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/05/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) usually invades vulnerable hosts. Disseminated NTM (dNTM) infection can affect nearly all organs and be easily misdiagnosed as metastatic carcinoma or other systemic diseases, especially in seemingly immunocompetent hosts. Identification of underlying immunodeficiency is critical for the diagnosis and treatment of dNTM. Adult-onset immunodeficiency (AOID) with anti-IFN-γ autoantibodies has recently been recognized as a crucial but frequently neglected risk factor for dNTM infection. Frequent relapses of infection are common in AOID patients despite appropriate anti-infective treatment and B-cell-depleting therapy has shown some promising results. Herein, we report a case of dNTM infection mimicking malignancy in an AOID patient who was successfully treated with rituximab. CASE PRESENTATION A middle-aged male presented with fever, productive cough, multifocal skin abscesses and multiple osteolytic lesions with pathological fractures. Chest CT revealed consolidation of the lingula while bronchoscopy showed a mass completely blocking the airway opening of the inferior lingual segment. Metagenomic next-generation sequencing and mycobacterial culture of skin pus and bronchoalveolar lavage fluid reported Mycobacterium Colombiense, confirming the diagnosis of dNTM infection. However, anti-NTM antibiotics alone failed to prevent disease relapse and progression. Further evaluation indicated undetectable serum IFN-γ concentration and high-titer autoantibodies against IFN-γ, suggesting that AOID was the underlying reason for dNTM. Rituximab was added to treatment and successfully controlled the infection without relapse at one-year follow-up. CONCLUSION We reported a rare case of disseminated Mycobacterium Colombiense infection manifested with pulmonary mass, pathological fracture and dermapostasis in a host with AOID. Our case demonstrated that AOID should be screened when patients get the episode of disseminated NTM infection particularly when other risk factors are excluded. Besides prolonged anti-NTM therapy, AOID-associated NTM infection should be treated with B-cell-depleting therapy to prevent recurrence.
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Affiliation(s)
- Xiaochuan Sun
- grid.506261.60000 0001 0706 7839Department of Pulmonary and Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, 100730 Beijing, People’s Republic of China
| | - Ting Zhang
- grid.506261.60000 0001 0706 7839Department of Pulmonary and Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, 100730 Beijing, People’s Republic of China
| | - Hongli Sun
- grid.506261.60000 0001 0706 7839Department of Laboratory Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, People’s Republic of China
| | - Xuefeng Sun
- grid.506261.60000 0001 0706 7839Department of Pulmonary and Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, 100730 Beijing, People’s Republic of China
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Yu XJ, Lin YD, Hu P, Zee CS, Ji SJ, Zhou F. Imaging findings of vertebral osteomyelitis caused by nontuberculous mycobacterial organisms: Three case reports and literature review. Medicine (Baltimore) 2022; 101:e29395. [PMID: 35713445 PMCID: PMC9276087 DOI: 10.1097/md.0000000000029395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Prompt diagnosis of nontuberculous Mycobacterial (NTM) vertebral osteomyelitis is challenging, yet necessary to prevent serious morbidity and mortality. Here, we report 3 cases of vertebral osteomyelitis caused by NTM with imaging findings. PATIENT CONCERNS Case 1, a 58-year-old male patient, was admitted to our hospital because of the presence of a pulmonary mass for 6 months with cough and chest pain.Case 2, a 50-year-old male patient, had fever and cough for 3 years and was diagnosed with tuberculosis. Antituberculosis treatment was ineffective, accompanied by lymph node enlargement and osteosclerotic changes involving vertebral bodies.Case 3, a 66-year-old female patient, was admitted to our hospital with a mass on the top of her head for 1 month, which ruptured in the last 2 weeks. DIAGNOSES Case 1: Sputum culture revealed Mycobacterium (M.) avium.Case 2: The final culture results of the lymph node biopsy samples were M. intracellulare.Case 3: Culture results of the sputum and pus from the abscess were M. gordon.We found sclerosing lesions in the spine in all 3 NTM patients, which were easily misdiagnosed as metastatic tumors. In 2 cases, there was bone destruction in the ilium with limbic sclerosis, and there were abscesses near the ilium and in front of the sacrum in 1 case. INTERVENTIONS Case 1 was transferred to other specialist hospital.Case 3 received surgical treatment for cranial lesions and abscess drainage.Case 2 and case 3 received targeted treatment for nontuberculous mycobacteria in our hospital. OUTCOME The condition of case 1 was unknown.Recovery of case 2 was uneventful because of prolonged illness; however, inflammation gradually improved overall.Case 3 had no recurrence following surgical treatment. LESSONS In our 3 cases of NTM vertebral osteomyelitis, bone lesions were often misdiagnosed as bony metastases because of the presence of multiple sclerotic lesions. Diagnoses were challenging and delayed. It is important to consider osteomyelitis by NTM when disseminated osteosclerosis with or without osteolytic bone lesions is present in conjunction with continuous inflammatory symptoms and signs. Moreover, an open biopsy of the lesion should be performed for a definitive diagnosis.
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Affiliation(s)
- Xiao Jing Yu
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu Dong Lin
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Peng Hu
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Chi Shing Zee
- Department of Radiology, USC University Hospital, Los Angeles, CA
| | - Shu Juan Ji
- Department of Infectious Disease, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fei Zhou
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Mehkri Y, Felisma P, Panther E, Lucke-Wold B. Osteomyelitis of the spine: treatments and future directions. INFECTIOUS DISEASES RESEARCH 2022; 3:3. [PMID: 35211699 PMCID: PMC8865404 DOI: 10.53388/idr20220117003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteomyelitis of the spine is a serious condition that has been increasing with the intravenous drug pandemic and aging population. Multiple different organisms can cause osteomyelitis and mainstay of treatment is early recognition and antibiotics. The course can sometimes be indolent leading to delayed presentations. Once suspected, comprehensive workup and initiation of management should be employed. In rare circumstances, surgical evacuation or deformity correction is indicated. Continued antibiotic treatment should be considered post-operatively. METHODS Emerging treatment solutions are being developed to help target osteomyelitis in a more effective manner. In this review, we highlight the epidemiology and pathophysiology of spinal osteomyelitis. We overview the diagnostic workup and treatment options. Finally, we present new options that are currently being investigated and are on the near horizon. CONCLUSION This review offers a user friendly resource for clinicians and researchers regarding osteomyelitis of the spine and will serve as a catalyst for further discovery.
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Affiliation(s)
- Yusuf Mehkri
- Department of Neurosurgery, University of Florida, Gainesville, Florida, the USA
| | - Patrick Felisma
- Department of Neurosurgery, University of Florida, Gainesville, Florida, the USA
| | - Eric Panther
- Department of Neurosurgery, University of Florida, Gainesville, Florida, the USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, the USA
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Omori K, Kitagawa H, Tadera K, Naka Y, Sakamoto S, Kamei N, Nomura T, Shigemoto N, Hattori N, Ohge H. Vertebral osteomyelitis caused by Mycobacteroides abscessus subsp. abscessus resulting in spinal cord injury due to vertebral body fractures. J Infect Chemother 2021; 28:290-294. [PMID: 34593323 DOI: 10.1016/j.jiac.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
Nontuberculous mycobacteria (NTM) rarely cause vertebral osteomyelitis; however, the clinical characteristics of vertebral osteomyelitis caused by NTM are poorly understood due to its rarity. A 74-year-old man with lung cancer was treated with prednisolone for immune checkpoint inhibitor-associated immune-related adverse events. He had been experiencing mild back pain without febrile episodes for five months, and was admitted to the hospital for worsening back pain and progressive paraplegia. Magnetic resonance imaging showed spinal cord compression at T4-5 due to fractures of the T5 and T7 vertebral bodies. The culture of a sample of pus from the T7 vertebral body obtained at the time of spinal fusion surgery yielded the Mycobacteroides abscessus (M. abscessus) complex. The patient was diagnosed with vertebral osteomyelitis caused by M. abscessus complex and treated with clarithromycin, amikacin, and imipenem; clarithromycin was later replaced by sitafloxacin because of inducible macrolide resistance. However, his neurologic deficits were irreversible, and he died due to a deteriorating general condition. The strain was identified up to subspecies level as M. abscessus subsp. abscessus by hsp65 and rpoB sequencing and nucleic acid chromatography. Although vertebral osteomyelitis due to NTM is rare, delayed diagnosis can lead to serious complications or poor outcomes. A prolonged clinical course, less frequent fever, vertebral destruction or spinal deformity, neurological deficits, or immunosuppressed conditions might be suggestive of NTM vertebral osteomyelitis.
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Affiliation(s)
- Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Hiroki Kitagawa
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kayoko Tadera
- Section of Clinical Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuhiko Naka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshihito Nomura
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Norifumi Shigemoto
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Translational Research Center, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
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Shahi PB, Panigrahi V, Adsul N, Kumar M, Acharya S, Kalra KL, Chahal RS. Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature. Surg Neurol Int 2020; 11:63. [PMID: 32363058 PMCID: PMC7193194 DOI: 10.25259/sni_50_2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 03/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background: The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4–L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management). Case Description: A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4–L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4–L5 level. This was treated with a L4–L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection. Conclusion: Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.
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Affiliation(s)
- Prem Bahadur Shahi
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | | | - Nitin Adsul
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Manoj Kumar
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Shankar Acharya
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - K L Kalra
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - R S Chahal
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, Delhi, India
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Davis MA, Antony S. T9-T10 Osteomyelitis, Epidural Abscess and Cord Compression Secondary to Mycobacterium abscessus: A Case Report. Infect Disord Drug Targets 2020; 21:289-293. [PMID: 32342821 DOI: 10.2174/1871526520666200428095022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND We report a case of spinal abscess/osteomyelitis at the T9-T10 levels in a non-immunocompromised patient who presented with lower extremity weakness secondary to a Mycobacterium abscessus infection. This patient was successfully treated with surgical debridement with amikacin-tigecycline-imipenem triple therapy before and after her debridement. Outcomes and treatment with this rare cause of epidural abscess/osteomyelitis are not well defined at this time. CASE REPORT Clinical Presentations with this species of mycobacterium are usually systemic with patients presenting with pulmonary and soft tissue infections. The primary presentation of spinal epidural abscess/osteomyelitis is unusual, especially when there is no primary focus such as a lung infection or concurrent bacteremia. CONCLUSION This paper presents a new case of spinal osteomyelitis without a primary source in addition to 10 previously reported M. abscessus cases. The treatment plans and outcomes suggest that surgical debridement along with a macrolide-based combination therapy should be considered a definitive treatment against Mycobacterium abscesses.
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Affiliation(s)
- Michelle A Davis
- Burrell College of Osteopathic Medicine, Las Cruces, New Mexico, United States
| | - Suresh Antony
- Burrell College of Osteopathic Medicine, Las Cruces, New Mexico, United States
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Shahi PB, Panigrahi V, Adsul N, Kumar M, Acharya S, Kalra KL, Chahal RS. Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature. Surg Neurol Int 2020. [DOI: 10.25259/sni_50_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background:
The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4–L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management).
Case Description:
A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4–L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4–L5 level. This was treated with a L4–L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection.
Conclusion:
Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.
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