• found in envirornment (examples: water, soil)
• transmission
  • no evidence of human human transmission
    • so, no need for special infection control precautions
• infections have been increasing (outnumber TB cases in US) and see nosocomial outbreaks and pseudo-outbreaks (where something in lab was contaminated)

• rapid growers (days in broth, less than wk in solid)
  • M abscessus
  • M chelonae
  • M fortuitum
• slow growers (1-2 wks in broth, 2-4 wks in solid)
  • MAC
  • M kansasii
  • M scrofulaceum
  • M ulcerans
  • M xenopi
  • M gordonae

• MAC
• M kansasii

• M abscessus
• M chelonae
• M fortuitum

• MAC
• M kansasii

must meet all three criteria

• compatible clinical syndrome w/no other etiology
  • cough
  • fever
  • fatigue
  • weight loss
• abnormal chest X ray or heart CT
  • infiltrates
  • cavitation
  • nodules
  • multifocal bronchiectasis
• bacteriologic critera
  • 2 positive cultures from sputum OR
  • positive culture from BAL
  • positive granuloma or AFB on biopsy and NTM from sputum

Colonization with NTM now considered less common.

• pulm. disease in elderly men with COPD
• pulm. disease in elderly non smoking women (lady windameir syndrome)
• pulm. disease in person with CF
• hypersensitivity pneumoitis (hot tub lung)
• disseminated disease in patients with AIDS
• lymphadenitis in children

• predom. in middle aged to elderly men with heavy smoking history
• more prevalent in southeat
• mimics TB: chronic, progressive
  • fibrocavitary disease
  • systemic symptoms
• frequent AFB smear positive
• surgery may be required despite modern therapy

• middle aged to elderly women with no prior lung disease (very thin body)
• dx
  • very slowly progressive with low grade symptoms
    • cough
    • weight loss
  • nodular bronchiectasis/interstitial disease (NOT cavitary)
  • may need high resolution CT to diagnose (cant see in X ray)
• thought to represent true disease, NOT colonization

• 20% of those colonized with MAC meet ATS criteria for NTM pulm. disease
• dx- difficult due to underlying lung disease
• tx- should be aggressive (both for dx and to achieve control of infection)

It is hard to tell who needs tx

• epidemiology
  • associated with indoor hot water
    • warm water aerosolizing MAC
  • patients tend to be young, immunocompetent
• dx- inflammatory, infectious process
  • subacute onset of dyspnea, cough, fever
  • CT/CXR show diffuse infiltrates, nodularity
  • culture positive for NTM (usually MAC)
• tx uncertain
  • steroids (seen as inflam. rxn)
  • antimycobact. drugs
  • observation only

• firmly establish dx (be certain the organism is causing clinical disease)
• empiric tx is not indicated (tx is commitment of 12+ months of difficult therapy)
• dx of NTM diesease does not mandate treatment
  • weigh impact of disease
  • the likelihood of cure and the ability to tolerate the therapy

• 3 or more active drugs
• obtain monthly sputum cultures
• tx until culture negative for 12 months (total duration: 18-24 mnths)
• failure if no clinical improvement for 6 mnths or culture positive at 12 mnths

• first line: aminoglycosides
• second line: rifabutin, rifampin, azithromycin
• third line: fluroquinolones

• epidemiology
  • usually in pateints with less than 50 CD4 cells
  • geographic widespread in US (uncommon in Africa)
  • unclear route of acquisition (GI?, resp?)
  • may have resp. colonization w/o pulm. or disseminated disease (pulm. disease rare in AIDS patients)

• clinical syndrome
  • fever, sweat
  • wt loss
  • anemia
  • abdominal pain
  • organomegaly
  • lymphadenopathy
• dx
  • blood cultures usually positive
  • bone marrow, liver, lymph node biopsy would be reasonable if blood cultures repeatedly negative

• pathogenesis
  • those with immmune restoration due to HAART, local MAC symptoms may worsen (they recognize bugs they didnt before)
  • usually 2-4 wks after therapy starts
• clinical signs
  • swollen lymph nodes
  • may have worsen fevers
  • lab abnormalities
  • local pain
• prognosis: patient improve over few weeks with no change in tx
• tx- symptom tx w/NSAIDS or if severe, steroids

• azithromycin or clarithromycin
• could use rifabutin as alternative

With CD4 below 50, you should be px. When your CD4 is above 100 for 3 months, you can stop.

• syndrome similar to TB
• epidemiology
  • more common in Midwest and South
• dx
  • frequent AFB smear positive
  • probe available for culture dx

In HIV patients, associated with CD4 less than 200 (both pulm. and disseminated)

• tx for 12 months after sputum conversion
• use traditional TB therapy (easier to treat than MAC)
  • INH
  • ETH
  • RIF (only drug where susceptible testing indicated)

• epidemiology
  • mainly in developing world
  • mostly in kids age 1-5
  • rare in adults
  • most common in head and neck areas (usually unilat. with few systemic symptoms)
  • MAC accounts for 80% in US (number two cause in M scrofulaceum)

• dx
  • must exclude TB
  • fine needle aspiration vs. excisional biopsy
• tx
  • surgical removal of involved nodes for both MAC and M scrofulaceum
  • uncommon relapse, but if do, repeat surgery or attempt chemotherapy

• epidemiology
  • associated with lake, bay, ocean, pool, aquarium
• pathogenesis- 1-2 mnths of incubation followed by granulomatous nodular ulcerative lesions (hand lesions common)
• dx- biopsy or culture w/ in vitro drug susceptibillity may be useful
• tx
  • responds to Clarithromycine and Ethambutol OR Rifampin and Ethambutol
  • tx 1-2 months after symptoms resolve, typically 3-4 months duration total

• skin/soft tissue infections (all three organisms)
  • trauma
  • post op wound infections
• pulmonary (more so M abscessus than M fortuitum)
  • indolent, progressive
    • cavitation uncommon
    • mild systemic symptoms

• rapid growers
  • M fortuitum
  • M abscessus

• health care outbreaks: surgical wound infections, prosthetic joints, prosthetic valves, lens implants, LASIK, central catheters
• pseudo outbreaks
  • usually due to water contamination (showers, ice machines, bronchoscopes, lab samples)

• 2-3 drugs for 4-12 months (shorter for skin and longer for lung)
• clarithromycin + cipro OR doxycycline OR sulfonamide
• if more severe, add amikacin, cefoxitin, imipenem

• M chelonae: two drugs 4-6 mnths
• M abscessus (very difficult to treat, you need IV antibiotics)

• remains common worldwide, esp. in tropical countries
• uncommon in US born individuals
• transmission unknown
• organisms M leprae cannot be cultured

• lepromatous
  • high bacillary lode
  • diffuse, extensive skin involvement
  • plaques, nodules
  • deformity of facial structures
  • anergy
• tuberculoid
  • few bacilli present
  • anesthesia present
  • react to M leprae skin tests
  • nerve involvement common
• mix

This is a highly treatable disease

• E nodosum: steroids, thalidomide
• reversal rxns- steroids