Chest
Volume 133, Issue 1, January 2008, Pages 243-251
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Recent Advances in Chest Medicine
Pulmonary Disease Due to Nontuberculous Mycobacteria

https://doi.org/10.1378/chest.07-0358Get rights and content

Nontuberculous mycobacteria (NTM) are increasingly associated with pulmonary disease. This is a worldwide phenomenon and one that is not related just to better diagnostic techniques or HIV infection. The mode of transmission of NTM is not well defined, but environmental exposure may be the major factor. While most exposed and infected individuals never acquire NTM disease, some ostensibly immunocompetent persons will. Although our understanding of the pathogenesis of NTM disease is incomplete, we believe that both host and mycobacterial factors are involved. Among the former, interferon-γ“trafficking” may well play a central role. When disease occurs, it is likely to present in one of three prototypical forms: a tuberculosis-like pattern often affecting older male smokers with COPD; nodular bronchiectasis classically occurring in middle-aged or older women who never smoked and present with cough; and hypersensitivity pneumonitis following environmental exposure. While Mycobacterium avium complex has been described with all three forms, many other NTM can produce one or another of them; variants of these prototypes also exist. Diagnosis of NTM disease relies on microbiology and chest CT scanning, and criteria to aid diagnosis are available. Treatment of disease depends on the species involved, extent and form of disease, and overall condition of the patient. Surgery for localized disease may be useful for those species expected to be refractory to medical therapy. Observation without treatment may be appropriate for some patients with slowly progressive disease that is expected to be particularly difficult to treat.

Section snippets

Epidemiology and Pathogenesis

NTM are commonly occurring organisms and have been recovered in many parts of the world and from a variety of environmental reservoirs including fresh and salt water, soil, and biofilms.2 The mode(s) of transmission of NTM to humans has not been defined, although person-to-person transmission is thought not to occur or to be very uncommon, at least in immune-competent hosts. Isolation techniques used for limiting the spread of M tuberculosis are, therefore, not applied to NTM. Because NTM are

Clinical Presentation

Based largely on experience with several species, particularly MAC, in immunocompetent persons, NTM disease in the chest most commonly presents in one of three “prototypical” forms21: a tuberculosis-like pattern classically involving the upper lobes of older men with substantial smoking histories and COPD22; nodular bronchiectasis, often occurring in slender older women nonsmokers including some with skeletal deformities23 and typically presenting with cough2425; and hypersensitivity

Diagnosis

Whereas upper lobe, cavitary tuberculosis-like NTM disease generally presents little diagnostic difficulty other than excluding tuberculosis, nodular bronchiectatic disease is more subtle. Indeed, NTM have often been considered as colonizing areas of slowly progressive disease. Histologic evidence of NTM tissue invasion and reaction, however, suggest “benign” colonization is less likely than previously thought.3536 Because skin test antigens specific for NTM species are not readily available

Treatment

Some years ago, a practical classification presented by Bailey55 discussed grouping mycobacteria as either easy or hard to treat; M kansasii typified the former group, and MAC described the latter. Intervening years and, particularly, the availability of newer macrolides/azilides have changed the situation, but in relative terms it is still correct that some NTM are relatively straightforward in their treatment, while others are extremely difficult to cure. Some general principles also bear

ACKNOWLEDGMENT

The author wishes to acknowledge and thank Meredith Ryan for assistance in the preparation of this article.

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