Fatal infection with Mycobacterium fortuitum associated with oesophageal achalasia

Clinical Characteristics and Treatment Outcomes of Mycobacterium fortuitum Pulmonary Disease

We evaluated the clinical characteristics and treatment outcomes of 35 patients diagnosed with Mycobacterium fortuitum-pulmonary disease (M. fortuitum-PD). Prior to treatment, all isolates were sensitive to amikacin and 73% and 90% were sensitive to imipenem and moxifloxacin, respectively. Approximately two-thirds of the patients (24 of 35) remained stable without antibiotic treatment. Of 11 patients requiring antibiotic treatment, the majority (81%, 9 of 11) achieved a microbiological cure with susceptible antibiotics. IMPORTANCE Mycobacterium fortuitum (M. fortuitum) is a rapidly growing mycobacterium that causes M. fortuitum-pulmonary disease (PD). It is common among individuals with preexisting lung conditions. Limited data exist regarding treatment and prognosis. Our study examined patients with M. fortuitum-PD. Two-thirds of them remained stable without antibiotics. Among those requiring treatment, 81% achieved a microbiological cure with suitable antibiotics. In many cases, M. fortuitum-PD follows a stable course without antibiotics, and when necessary, a favorable treatment response can be achieved with the appropriate antibiotics.

[The Prevalence of Nontuberculous Mycobacterial Lung Disease with orwithout Reflux Esophagitis]

Background/Aims

Gastrointestinal reflux disease (GERD) is defined as 'a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications'. It is associated with various lung diseases, including bronchial asthma, chronic bronchitis, and bronchiectasis. GERD may also affect nontuberculous mycobacterial (NTM) lung disease. We presumed that the normal mucosal barrier of the bronchial epithelium is broken due to the aspiration of gastric juice and consequent chronic bronchial inflammation. This study investigated the prevalence of GERD in accordance with the presence or absence of NTM lung disease and analyzed the difference.

Methods

We screened patients with NTM lung disease in this hospital between January 2011 and December 2015. Among these patients, gastroscopic examinations as a health check-up were performed on 93 patients. We obtained the prevalence of Reflux esophagitis (RE) in patients with NTM and compared it with the prevalence of RE in the normal control subjects.

Results

Among 93 patients with NTM, patients without RE was 66.7% (62/93). RE-minimal change was diagnosed in 29.0% (27/93), and RE LA-A was diagnosed in 4.3% (4/93). Comparing the prevalence of RE minimal change, 29.0% (27/93) had NTM and 11.9% (3043/25536) did not have NTM. This was statistically significant.

Conclusions

We showed a greater prevalence of RE minimal change in patients with NTM than those without NTM with statistical significance.

Causative species of nontuberculous mycobacterial lung disease and comparative investigation on clinical features of Mycobacterium abscessus complex disease: A retrospective analysis for two major hospitals in a subtropical region of Japan

Nontuberculous mycobacteria (NTM) lung disease is increasing globally. Although the etiological epidemiology of NTM is different across regions, Mycobacterium avium complex (MAC) is the leading cause of NTM lung disease in most countries, including mainland Japan. Okinawa is located in the southernmost region of Japan and is the only prefecture categorized as a subtropical region in Japan, it is therefore likely the etiological epidemiology of NTM lung disease is different from mainland Japan. From 2009 to 2015, the medical records of patients, with respiratory specimens positive for NTMs, visiting or admitted to two Okinawan hospitals, were retrospectively analyzed. NTM lung disease cases were defined according to the American Thoracic Society criteria and patient epidemiology and clinical information were evaluated. Results indicate four hundred sixteen patients had bacterial cultures positive for NTM. The most common NTM was M. abscessus complex (MABC) (n = 127; 30.5%), followed by M. intracellulare (n = 85; 20.4%). NTM lung disease was diagnosed in 114 patients. Of these cases, MABC was most common (n = 41; 36.0%), followed by M. intracellulare (n = 31; 27.2%). Chronic obstructive pulmonary disease (COPD) and tracheostomy patients were more likely to develop MABC than MAC lung disease. Multivariate analysis showed a probable association between COPD and MABC lung disease. Chest computed tomography (CT) evaluation revealed bronchiectasis, nodules, and consolidation were less frequently observed in MABC patients compared with MAC patients. Our data suggests Okinawa may be one of the few places where MABC is the predominant pathogen causing NTM lung disease and our results add new insight to MABC lung disease, which is not yet well understood.

Mycobacterium avium Complex Disease

Despite the ubiqitous nature of Mycobacterium avium complex (MAC) organisms in the environment, relatively few of those who are infected develop disease. Thus, some degree of susceptibility due to either underlying lung disease or immunosuppression is required. The frequency of pulmonary MAC disease is increasing in many areas, and the exact reasons are unknown. Isolation of MAC from a respiratory specimen does not necessarily mean that treatment is required, as the decision to treatment requires the synthesis of clinical, radiographic, and microbiologic information as well as a weighing of the risks and benefits for the individual patient. Successful treatment requires a multipronged approach that includes antibiotics, aggressive pulmonary hygiene, and sometimes resection of the diseased lung. A combination of azithromycin, rifampin, and ethambutol administered three times weekly is recommend for nodular bronchiectatic disease, whereas the same regimen may be used for cavitary disease but administered daily and often with inclusion of a parenteral aminoglycoside. Disseminated MAC (DMAC) is almost exclusively seen in patients with late-stage AIDS and can be treated with a macrolide in combination with ethambutol, with or without rifabutin: the most important intervention in this setting is to gain HIV control with the use of potent antiretroviral therapy. Treatment outcomes for many patients with MAC disease remain suboptimal, so new drugs and treatment regimens are greatly needed. Given the high rate of reinfection after cure, one of the greatest needs is a better understanding of where infection occurs and how this can be prevented.

Pulmonary resection for mycobacterium chelonae infection

Mycobacterium chelonae lung infection is rare and has long been recognized as an enigmatic infection resistant to medical therapy. Recently, we encountered a patient who underwent pulmonary resection for Mycobacterium chelonae infection. A 46-year-old man with no medical history was found to have an abnormal shadow in the left upper lung field on chest X-ray. Computed tomography showed a nodular shadow in the left upper lobe and disseminated shadows around it. Mycobacterium chelonae was detected from cultures of the sputum, bronchial washings, bronchoscopic biopsy specimens, and gastric fluid, and pulmonary infection with Mycobacterium chelonae was diagnosed. The shadow did not decrease in size despite antibiotic treatment. Since the lesion was confined to the left upper segment, we judged that a complete resection was possible, and performed left upper division segmentectomy. After surgery, no new foci of infection were observed in the lung. No effective therapy for Mycobacterium chelonae lung infection has been established to date, and reported cases of pulmonary resection for the treatment of Mycobacterium chelonae infection are extremely rare. However, surgery should be considered in patients in whom complete resection is deemed possible.

Mycobacterium chelonae empyema with bronchopleural fistula in an immunocompetent patient

Mycobacterium chelonae is one of the rapidly growing mycobacteria that rarely cause lung disease. M chelonae more commonly causes skin and soft tissue infections primarily in immunosuppressed individuals. Thoracic empyema caused by rapidly growing mycobacteria and complicated with bronchopleural fistula is rarely reported, especially in immunocompetent patients. In this article we report the first immunocompetent Arabian patient presented with M chelonae-related empyema with bronchopleural fistula which mimics, clinically and radiologically, empyema caused by Mycobacterium tuberculosis.

Prevalence of Gastroesophageal Reflux Disease in Patients With Nontuberculous Mycobacterial Lung Disease

BACKGROUND

Knowledge of the relationship between respiratory disorders and gastroesophageal reflux disease (GERD) is increasing. However, the association between GERD and pulmonary disease caused by nontuberculous mycobacteria (NTM) has not been studied in detail. We investigated the prevalence of GERD in patients with the nodular bronchiectatic form of NTM lung disease.

METHODS

Fifty-eight patients with the nodular bronchiectatic form of NTM lung disease underwent ambulatory 24-h esophageal pH monitoring. Of the 58 patients, 27 patients were identified as having Mycobacterium avium complex infection (15 with Mycobacterium intracellulare and 12 with M avium), and 31 patients had Mycobacterium abscessus pulmonary infection.

RESULTS

The prevalence of GERD in patients with the nodular bronchiectatic form of NTM lung disease was 26% (15 of 58 patients). Only 27% (4 of 15 patients) had typical GERD symptoms. No statistically significant differences were found between patients with GERD and those without GERD with regard to age, sex, body mass index, or pulmonary function test results. However, patients with GERD were more likely to have a sputum smear that was positive for acid-fast bacilli (12 of 15 patients, 80%), compared with patients without GERD (19 of 43 patients, 44%) [p = 0.033]. In addition, bronchiectasis and bronchiolitis were observed in more lobes in patients with GERD than in patients without GERD (p = 0.008 and p = 0.005, respectively).

CONCLUSIONS

Patients with the nodular bronchiectatic form of NTM lung disease have a high prevalence of increased esophageal acid exposure, usually without typical GERD symptoms.

Non-tuberculous mycobacteria masquerading as aspiration pneumonia in patients with gastrointestinal problems

The association between non-tuberculous mycobacterial pulmonary disease and achalasia, although previously documented in the respiratory literature, is not well recognised generally. We present a case of a female who presents with weight loss, cough and radiological findings of aspiration pneumonia and achalasia. A discussion of mechanisms for this association are presented.

Lung Disease Due to the More Common Nontuberculous Mycobacteria

As the prevalence of tuberculosis (TB) declines in the developed world, the proportion of mycobacterial lung disease due to nontuberculous mycobacteria (NTM) is increasing. It is not clear whether there is a real increase in prevalence or whether NTM disease is being recognized more often because of the introduction of more sensitive laboratory techniques, and that more specimens are being submitted for mycobacterial staining and culture as the result of a greater understanding of the role of NTM in conditions such as cystic fibrosis, posttransplantation and other forms of iatrogenic immunosuppression, immune reconstitution inflammatory syndrome, fibronodular bronchiectasis, and hypersensitivity pneumonitis. The introduction of BACTEC liquid culture systems (BD; Franklin Lakes, NJ) and the development of nucleic acid amplification and DNA probes allow more rapid diagnosis of mycobacterial disease and the quicker differentiation of NTM from TB isolates. High-performance liquid chromatography, polymerase chain reaction, and restriction fragment length polymorphism analysis have helped to identify new NTM species. Although treatment regimens that include the newer macrolides are more effective than the earlier regimens, failure rates are still too high and relapse may occur after apparently successful therapy. Moreover, treatment regimens are difficult to adhere to because of their long duration, adverse effects, and interactions with the other medications that these patients require. The purpose of this article is to review the common presentations of NTM lung disease, the conditions associated with NTM lung disease, and the clinical features and treatment of the NTM that most commonly cause lung disease.

Exogenous lipoid pneumonia superinfected with acid-fast bacilli in infants: a report of nine cases

Super-infection of an exogenous lipoid pneumonia by nontuberculous mycobacteria has been described in the literature. It produces a distinctive histologic picture with suppurative, noncaseating granulomas surrounding lipid vacuoles containing acid-fast bacilli. Mainly isolated cases have been found, but seldom in children. We describe a series of 9 children with similar histological findings. All our patients were under 1 year of age, malnourished, and with chronic respiratory symptoms. The diagnosis, based on the characteristic histology with acid-fast rods, was established at autopsy in 4 cases, on lobectomy specimens in 4 and by open lung biopsy in 1. Mycobacterium fortuitum-chelonei was cultured in 1 case. Gastro-esophageal reflux was documented in all 4 cases in which it was explored. Aspiration of lipid gastric contents or of oil given as medication can result in exogenous lipoid pneumonia, which in turn becomes super-infected with mycobacteria. Recognition of the distinctive histology permits the diagnosis of this complication.

False-Positive PET Scan in a Patient With Lipoid Pneumonia Simulating Lung Cancer

PURPOSE

Lipoid pneumonia usually presents with alveolar infiltrates or as a nonresolving process. We report a case of lipoid pneumonia that presented as a solitary pulmonary nodule and had a high standard uptake value on PET scan, thereby mimicking a malignant process. This case highlights the presence of false-positive PET imaging in a patient with lipoid pneumonia and Mycobacterium chelonae infection.

MATERIALS AND METHODS

The patient was examined using CT scanning. The nodule was further investigated with a PET scan using F-18 FDG and the standard uptake value was determined.

RESULTS

Histopathology following removal of the nodule confirmed the diagnosis of lipoid pneumonia, and the bronchoalveolar lavage (BAL) was reported as M. chelonae, a rapidly growing mycobacterium (RGM).

CONCLUSION

Lipoid pneumonia can present as a PET-positive lung nodule and should be considered in the differential diagnosis and workup of a solitary pulmonary nodule.

Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria

The history, taxonomy, geographic distribution, clinical disease, and therapy of the pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria (RGM) are reviewed. Community-acquired disease and health care-associated disease are highlighted for each species. The latter grouping includes health care-associated outbreaks and pseudo-outbreaks as well as sporadic disease cases. Treatment recommendations for each species and type of disease are also described. Special emphasis is on the Mycobacterium fortuitum group, including M. fortuitum, M. peregrinum, and the unnamed third biovariant complex with its recent taxonomic changes and newly recognized species (including M. septicum, M. mageritense, and proposed species M. houstonense and M. bonickei). The clinical and taxonomic status of M. chelonae, M. abscessus, and M. mucogenicum is also detailed, along with that of the closely related new species, M. immunogenum. Additionally, newly recognized species, M. wolinskyi and M. goodii, as well as M. smegmatis sensu stricto, are included in a discussion of the M. smegmatis group. Laboratory diagnosis of RGM using phenotypic methods such as biochemical testing and high-performance liquid chromatography and molecular methods of diagnosis are also discussed. The latter includes PCR-restriction fragment length polymorphism analysis, hybridization, ribotyping, and sequence analysis. Susceptibility testing and antibiotic susceptibility patterns of the RGM are also annotated, along with the current recommendations from the National Committee for Clinical Laboratory Standards (NCCLS) for mycobacterial susceptibility testing.

Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria

The history, taxonomy, geographic distribution, clinical disease, and therapy of the pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria (RGM) are reviewed. Community-acquired disease and health care-associated disease are highlighted for each species. The latter grouping includes health care-associated outbreaks and pseudo-outbreaks as well as sporadic disease cases. Treatment recommendations for each species and type of disease are also described. Special emphasis is on the Mycobacterium fortuitum group, including M. fortuitum, M. peregrinum, and the unnamed third biovariant complex with its recent taxonomic changes and newly recognized species (including M. septicum, M. mageritense, and proposed species M. houstonense and M. bonickei). The clinical and taxonomic status of M. chelonae, M. abscessus, and M. mucogenicum is also detailed, along with that of the closely related new species, M. immunogenum. Additionally, newly recognized species, M. wolinskyi and M. goodii, as well as M. smegmatis sensu stricto, are included in a discussion of the M. smegmatis group. Laboratory diagnosis of RGM using phenotypic methods such as biochemical testing and high-performance liquid chromatography and molecular methods of diagnosis are also discussed. The latter includes PCR-restriction fragment length polymorphism analysis, hybridization, ribotyping, and sequence analysis. Susceptibility testing and antibiotic susceptibility patterns of the RGM are also annotated, along with the current recommendations from the National Committee for Clinical Laboratory Standards (NCCLS) for mycobacterial susceptibility testing.

Imaging of Non-tuberculous (Atypical) Mycobacterial Pulmonary Infection

Pulmonary infections due to mycobacterial organisms are increasing in incidence. Non-tuberculous (atypical) mycobacteria (NTM) represent a significant proportion of mycobacterial infections and may prove difficult to diagnose due to their non-specific clinical and radiographic presentations. An increasing volume of radiological data is now available for the more common non-tuberculous mycobacterial infections, and we have summarized the imaging features found in such cases, identifying radiographic features that would favour the diagnosis of a non-tuberculous mycobacterium and that, in some cases, suggest a specific organism.

Rapidly growing mycobacterial lung infection in association with esophageal disorders

Esophageal or other swallowing disorders complicated by lipoid pneumonia are reported to be associated with pulmonary infections caused by rapidly growing mycobacteria. Herein we describe a 63-year-old woman with achalasia of the esophagus complicated by lung infection with Mycobacterium chelonae and a 47-year-old man in whom long-term ingestion of mineral oil was complicated by lipoid pneumonia and M. fortuitum lung infection. A MEDLINE search of English language publications from 1966 to 1997 revealed 18 cases of lung infections caused by rapidly growing mycobacteria in patients with esophageal disorders. Of these 18 patients and our 2 patients, 11 were men and 9 were women (mean age, 50 years). Achalasia was present in 11 patients, and 6 had lipoid pneumonia without evidence of esophageal disorders. Three patients had lipoid pneumonia caused by lipoid ingestion in the setting of achalasia or another swallowing disorder. In 14 patients, lung infection was caused by M. fortuitum; in 5, M. chelonae; and in 1, a non-M. fortuitum rapidly growing mycobacterial infection. The most common clinical feature was fever, and the most common roentgenologic abnormality was the presence of unilateral or bilateral and patchy or dense infiltrates. The sputum was the most common source of isolation of rapidly growing mycobacteria. Achalasia and lipoid pneumonia are important risk factors for the development of lung infections caused by rapidly growing mycobacteria. Treatment of the esophageal disease might prevent occurrence of and facilitate recovery from these infections.

Clinical and radiological features of pulmonary disease caused by rapidly growing mycobacteria in cancer patients

The role of rapidly growing mycobacteria in the pathogenesis of pulmonary disease is being increasingly recognized; however, the clinical significance of these mycobacteria in patients with underlying malignancy has not been well studied. Over a 6-year period, 37 cancer patients with rapidly growing mycobacteria isolated from respiratory specimens were identified at our center. Mycobacterium chelonae group was isolated in 24 cases and Mycobacterium fortuitum in 13 cases. Of the 24 cases with cultures yielding Mycobacterium chelonae group, eight met the study criteria for infection and were determined to be clinically significant, whereas only one of the Mycobacterium fortuitum isolates was determined to represent infection. An average of two antimicrobial agents were used for treatment, most commonly clarithromycin, ciprofloxacin, and trimethoprim/sulfamethoxazole. Although the isolation of rapidly growing mycobacteria represents colonization in most cases, these bacteria, especially the Mycobacterium chelonae group, may cause pulmonary disease in cancer patients. The clinical and radiological findings are usually non-specific in this population, and patients with respiratory cultures yielding rapidly growing mycobacteria should be assessed carefully to distinguish infection from colonization. Effective therapy can be provided with oral regimens that include at least two antibiotics to which the organism is susceptible.

Determination of the in vitro susceptibility of 220 Mycobacterium fortuitum isolates to ten antimicrobial agents

The authors investigated the in vitro susceptibility to antimicrobial agents of 220 Mycobacterium fortuitum isolates originating from clinical samples (14) of patients attending the Hospital Universitario de Canarias and Hospital del Tórax, and from environmental sources (206): 3 from sea water, 10 from the water supply and 193 from sewage. The Minimum Inhibitory Concentration (MIC) was calculated using the broth microdilution method with Mueller-Hinton Broth without supplement. Amikacin was the most efficacious antimicrobial agent against all the isolates of M. fortuitum with an MIC which was considerably lower than its critical concentration. The good results achieved with amikacin in vitro are confirmed by those obtained in vivo, with patients infected with M. fortuitum. No significant difference was found in the efficacy of amikacin and ofloxacin against all the isolates assayed.

Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients

The role of rapidly growing mycobacteria (RGM) as pulmonary pathogens has been unclear. We identified 154 cases of lung disease caused by RGM using the microbiologic and radiographic criteria of the American Thoracic Society (ATS) and availability of the causative organism for study. More than one third of patients had positive lung biopsy cultures. Patients were predominantly white (83%), female (65%) nonsmokers (66%), and they had prolonged periods from onset of symptoms to diagnosis of their disease. Cough was an almost universal presenting symptom, whereas constitutional symptoms became more important with progression of disease. Upper lobe infiltrates were most common (88%), with 77% of patients developing bilateral disease. Cavitation was present in only 16% of the patients. Specific underlying diseases were infrequent, but they included previously treated mycobacterial disease (18%), coexistent Mycobacterium avium complex (8%), cystic fibrosis (6%), and gastroesophageal disorders with chronic vomiting (6%). The majority of isolates (82%) were M. abscessus (formerly M. chelonae subsp. abscessus). Effective treatment for M. fortuitum long disease was accomplished with drug therapy, whereas surgical resection of localized disease was the only effective long-term therapy for M. abscessus. Although the disease was generally slowly progressive, 21 of 154 (14%) patients died as a consequence of progressive RGM lung disease and respiratory failure. RGM should be recognized as a cause of chronic mycobacterial lung disease, and respiratory isolates should be assessed carefully.

Soft tissue abscess caused by Mycobacterium fortuitum

Mycobacterium fortuitum is an environmental organism which rarely causes disease. We report the case of a young man in whom this organism caused a soft tissue abscess. The laboratory findings and subsequent management of the case are described.

Fatal pulmonary infection with Mycobacterium fortuitum

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