Non-tuberculous mycobacteria (NTM) include all mycobacterial species except those in the Mycobacterium tuberculosis complex which cause tuberculosis. There are over 150 identified NTM species, some of which can cause disease in humans, especially in immunosuppressed individuals. NTM are commonly found in the environment including water and soil. Common diseases caused by NTM include pulmonary disease, lymphadenitis, and skin and soft tissue infections. Treatment involves a combination of antimicrobials and is based on the species isolated and results of drug susceptibility testing.

4.  All mycobacterial species except those
that cause tuberculosis (TB)
 Mycobacterium tuberculosis complex
includes M. tuberculosis
 including M. tuberculosis subsp canetti
 M.bovis
 M. bovis BCG strain
 M. africanum
 M. caprae
 M. microti
 M. pinnipedii
 Leprosy (M. leprae).

7.  1954 Runyon first NTM classification
 >100 NTM species(150)
 Other names
 Mycobacteria other than tuberculosis (MOTT)
 Atypical
 Environmental
 Opportunistic
 Variable pathogenicity and geographic
regions
 40% cause diseases in human
 Immunosupp host; more virulent lesions

8.  Water(fresh/salt) soil, food and animals:
 NOT person to person
 cigarette; paper, tobacco, filter
 Does not spread from person to another
 Relatively resistant to chlorination and
ozonization
 Outbreak and Pseudo-outbreak in the hospita
 HIV and dialysis patients
 Improve laboratory methods  reporting
 MAC 40%,rapidly growing 10%,15%
unknown,25% M.gordonae,2.5%
M.kansasii(MW USA and UK) and 1% M.xenopi
(Ontario)

9.  Rapid Growers
 Days in broth
 < 1 week in solid
media
 M.abscessus
 M.chelonae
 M.fortutum
 M smegmatis
 Slow Growers
 1-2 weeks in broth
2-4 weeks in solid
media
 M.avium
 M.kansasii
 M.scrofulaceum
 M.ulcerans
 M.xenopi
 M.gordonae

10.  M.leprae cannot be cultured
 M.marinum lower temperature required
 M.haemophilum lower temperature & Fe
 M.ulcerans lower temperature required
 M.genavense very slow growth in broth
 DNA probes for MAC, M. kansasii and M.
gordonae available
 Identification and sensitivity needed

11.  Highly Virulent Low virulence
 Person-person Environment
contact
PPD + PPD-
S to ATT not typical ATT

12.  Risk factors
 Immunosuppression ( HIV, Medications )
 Aging esp western population esp MAC
 BCG vaccination rates
 Cystic fibrosis
 Fibronodular bronchiectasis
 Decrease incidence of TB in North America:
relative more incidence of NTM

13.  Common clinical syndromes:
1. Lymphadenopathy
2. Chronic pulmonary disease
3. Skin and soft tissue infections (often
associated with trauma or a foreign body)
sometimes with extension to bone and joint
4. Disseminated disease.

15.  Pulmonary disease: 70-75% isolates of
NTM
 Definition
 Usually adults
 Symptoms of cough, sputum production,
weight loss
 Two or more sputum isolates or one isolate
from, BAL, Bx, sterile site
 Distribution of isolates varies regionally
 MAC, rapid growers, M kansassi & M xenopi

16.  Pulmonary disease
 Common etiological agents
 M. avium complex(MAC)
 M. kansasii: one + sample diagnostic
 M. abscessus
 M. xenopi

20.  Elderly men with COPD
 Middle aged to elderly Non- smoking women
 CF patients
 Hypersensitivity pneumonitis

21.  M.Kansasii
 Similar to TB
 US midwest and
south
 AFB positive
 Probe positive
 HIV CD4 <200
pulmonary and
disseminated
 M..xenopi
 UK, Northern
Europe and
Canada, less
common in US
 Rural /farm area
 Very good outcome

22.  Pulmonary disease
 Treatment
 Treatment with combined antimicrobials
 Resection if localized

23.  Lymph node disease
 Definition
 Usually <5 years age; well; no h/o contact
 Unilateral submandibular site commonest
 Sub-mental, preauricular
 Onset of symptoms subacute
 Skin induration inflamation,suppuration &
sinus tract formation
 R/O TB
 MAC (80%) is the most common followed
by M. scrofulaceum
 Dx Fine needle or excisional Bx

24.  Lymph node
disease
 Common
etiological agents
 MAC
 M. kansasii
 M. malmoense
 M. haemophilum
 Uncommon
etiological agents
 M. scrofulaceum
 M.fortuitum/
peregrinum
 M.abscessus/
chelonae

26.  Lymph node disease
 Treatment
 Surgical resection is usually curative

27.  Skin/soft tissue/bone/joint and tendons
 Definition
 History of trauma: injection, pedicure,
aucupuncture, surgery, cosmetic surgery
involving implants
 or superficial laceration
 Presence of a foreign body
 May grow in ‘sterilized water’, presence of
chlorine, glutaraldehyde, formaldehyde.
Cause post op infection

28.  Skin/soft
tissue/bone/joint
and tendons
 Common etiological
agents
 M. marinum
 M.
fortuitum/peregrinu
m
 M.
abscessus/chelonae
 M. ulcerans
 Uncommon
etiological agents
 MAC
 M. kansasii
 M. terrae
 M. haemophilum

29.  Water ,fish
 Lake, bay,ocean,pool,aquarium
 1-2 month IP  granulomatous nodular –
ulcerative lesions (hands)
 Bx for diagnosis

30. Fish tank granuloma/ M.marinum

31. Buruli ulcer /M.ulcerans
 Chronic cutanous
ulcer
 Africa mostly
 Debridment

32.  Skin/soft tissue/bone/joint and tendons
 Treatment
 Debridement plus combined drug therapy

34.  C/E Blood ; TLC, DLC
 AB: anti-neutrophil cytoplasmic/ perinuclear
anti neutrophil cytoplasmic AB
 ESR
 Angiotensin converting enzyme
 X-RAY: chest, CAT thorax
 Culture: sputum, BAL
 PPD
 Pulmonary function tests
 Lung biopsy

41.  Disseminated
 Definition
 HIV or other immunosuppressive disease
 Symptoms: fever, weight loss, diarrhea
 Any site possible
 No trauma necessary

42.  Disseminated
 Prevention & treatment
 Prevention of MAC in HIV by prophylaxis
 Treat positive blood culture aggressively

43.  Disseminated
 Common etiological agents
 MAC
 M. genavense
 M. abscessus/chelonae
 M. haemophilum
 Any mycobacterium may cause disease in
association with significant
immunosuppression HIV CD4 < 50), and
any localized lesion may disseminate.

44.  M.fortutum
 M.abscessus
 M.chelonae
 Skin and soft tissue infection after trauma ,
post-op, cardiac, mammoplasty and cosmetic
 Pulmonary M.abscessus > M.fortutum
 Indolent, progressive
 Cavitary uncommon
 Mild systemic symptoms

45.  Worldwide –esp in tropical countries
 Transmission rout unknown
 Can not be cultured
 Syndromes
 Lepromatous
 Tuberculoid
 Mixed
 Treatment 6-months to 2 years
 Dapsone + Rif +/- clofazimine

49.  Principles of Treatment of NTM Disease
 1. Patients evaluated to determine the
significance of an NTM isolate.
 Presence in sterile site
 repeatedly from airway secretions in
association with a compatible clinical and
radiologic picture confirms the diagnosis.
 2. Treatment of rapidly growing
mycobacteria should be guided by in vitro
susceptibilities.
 Other drug susceptibility testing is not
standardized.

50.  3. Treatment should usually combine at least
two drugs of proven efficacy.
 4. Contact follow-up is not necessary since
NTM are not transmitted from person to
person.
 5. Duration of therapy has not been
determined; in general, 6-12 months is
required following negative cultures.

51.  6. In soft tissue infections:
 rapidly growing mycobacteria, a
combination of debridement and treatment
with antimicrobials is recommended.
 For selection of antimicrobial agents,
consultation with the laboratory should be
undertaken regarding the reliability of in
vitro testing.

52.  MAC Clarithromycin or azithromycin +
ethambutol+Rifampin (CARE)
 M. xenopi Rifampin+Ethambiotol +INH
 M. kansasii Rifampin + Ethambutol
 M. malmoense Rifampin or Ethambutol
 M. marinum Rifampin or Clari +
Ethambutol 2-3 months
 Rapid growers doxycycline, amikacin,
imipenem, quinolones, sulfonamides,
cefoxitin, clarithromycin

53.  M. haemophilum Clarithromycin,
Rifampin Cipro or Amikacin
 M. genavense Clarithromycin,
Rifabutin or AmikacinEthambutol
 M. ulcerans Clarithromycin,
Rifampin, Ethambutol or PAS (
Paraaminosalicylic acid)
 MAC prophylaxis Azithromycin ,
Clarithromycin or Rifabutin 300 if CD4
<50x 106/L