Atypical Tuberculosis following surgery or laparoscopy. How to diagnose how to quantify and how to treat. This is a very important presentation for the discovery and management of atypical tuberculosis infection any surgery. this can happen after any laparoscopy or any interventional procedures.

1. Dr. Keyur Bhatt
MS, FAIS, MRCS (UK), FACS (USA)
ASIA BOOK & INDIA BOOK Record holder for “Grand Master of laparoscopic cholecystectomy”
LIMCA BOOK & INDIA BOOK Record holder “longest foreign body removal from stomach”

2. Greetings from our teaam

3. Management Atypical
Koch’s following Lap /
open Surgery
04.03.2020

4. Introduction
• The non-tuberculous mycobacteria (NTM) have emerged as important
opportunistic pathogens in the recent years especially in the era of
laparoscopy in developing countries leading to cases with
• Non-healing postoperative wounds or sinuses on abdominal wall
following general or gynecological surgeries.

5. Milestones in NTM research
AIDS, acquired immune deficiency syndrome; ATS, American Thoracic Society; HIV, human immunodeficiency virus; IDSA, Infectious Diseases Society of America; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial
lung disease.
1. Johnson MM, Odell JA. J Thorac Dis 2014; 6:210-20; 2. Aronson JD. The Journal of Infectious Diseases 1926; 39:315-20; 3. personal communication by scientific committee;
4. Buhler VB, Pollak A. Am J Clin Pathol 1953; 23:363-74; 5. Reich JM, Johnson RE. Chest 1992; 101:1605-9; 6. Horsburgh 1999 J Infect Dis 179 Suppl 3 S461-5; 7. Griffith ED, et al. Am J Respir Crit Care Med 2007; 175:367-416.
1880 1900 1920 1940 19801960 2000 20202010
Robert Koch discovers
Mycobacterium tuberculosis1
• “Atypical M. tuberculosis” identified in
birds, reptiles, fish and
the environment1-3
Sporadic case reports;
strains named Battey, Ryan, Mx etc.3
Buhler and Pollak isolate M.
kansasii from patients with
cavitary disease4
Nodular/bronchiectatic disease identified and
named “Lady Windermere syndrome”5
Disseminated M. avium disease
identified in HIV/AIDS patients6
5
ATS/IDSA guidelines: Definition of
NTM-LD, diagnosis and treatment
recommendations7

6. NOT assigned to either:1,2
• Mycobacterium tuberculosis complex
• Mycobacterium leprae
What are NTM?
HIV, human immunodeficiency virus; MOTT, mycobacteria other than tuberculosis; NTM, non-tuberculous mycobacteria.
1. McShane PJ, Glassroth J. Chest 2015; 148:1517-27; 2. Schönfeld N, et al. Pneumologie 2013; 67:605-33; 3. Faria S, et al. J Pathog 2015; 2015:809014;
4. Orme IM, Ordway DJ. Infect Immun 2014; 82:3516-22.
6
Recognition:
• Identified soon after M. tuberculosis, not initially
recognized as pathogenic2
• Suspected as potential cause of human
infections in the sanatorium era4
• 1950s: Direct evidence for causation of disease4
• Opportunistic infections in HIV patients led to
wider recognition & investigation4
Characteristics:
• Found in the environment1,2
• Opportunistic pathogens of humans & animals3
• As of 2015: > 172 different species with distinct
virulence features3
Also known as:
• Environmental mycobacteria
• Opportunistic mycobacteria
• Atypical mycobacteria
• Mycobacteria other than tuberculosis (MOTT)
NTM

7. NTM Mycobacterium tuberculosis
Not obligate pathogens – normally live free
in the environment1 Obligate pathogens: require host1
Low virulence: not usually pathogenic in the absence
of predisposing conditions2,3 Pathogenic3,6
Human-to-human transmission extremely rare, but
some evidence of this in the cystic fibrosis community4 Human-to-human transmission3
Infection rates increasing,
especially in developed countries5
Infection rates decreasing,
especially in developed countries5
Large heterogeneous group of species6 Mycobacterium tuberculosis complex contains
small group of closely related subspecies6,7
7
NTM vs. Mycobacterium tuberculosis: Key distinctions
NTM, non-tuberculous mycobacteria.
1. Primm TP, et al. Clin Microbiol Rev 2004; 17:98-106; 2. Tortoli E. Clin Microbiol Infect 2009; 15:906-10; 3. Tortoli E. FEMS Immunol Med Microbiol 2006; 48:159-78; 4. McShane PJ, Glassroth J. Chest 2015; 148:1517-27; 5. Brode SK, et al.
Int J Tuberc Lung Dis 2014; 18:1370-7; 6. Van Soolingen D. J Intern Med 2001; 249:1-26; 7. Cole ST. Microbiology 2002; 148:2919-28.
NTM and Mycobacterium tuberculosis differ in terms of pathogenicity, infection rates
and transmission routes

8. NTM classification
NTM, non-tuberculous mycobacteria.
1. Fedrizzi T, et al. Sci Rep 2017; 7:45258; 2. Thomson 2009 Respirology 14 (1), 12-26. Figure adapted from Fedrizzi T, et al. Sci Rep 2017; 7:45258
8
triplexthermores.
gordonae
Rapid
(usually 7-10 days2)
Slow
(usually 1-3 weeks, sometimes
up to
8 weeks2)
Growth rate

9. Classification

11. NTM are found throughout the environment
NTM, non-tuberculous mycobacteria.
Falkinham JO, 3rd. J Appl Microbiol 2009; 107:356-67; pictures taken from https://pixabay.com/.
11
NTM habitats are intimately shared with those of humans
Potting soils
Acidic, brown-
water swamps
Hot tubs and
spas
Metal removal
fluid systems
Natural water
sources
Drinking water
distribution
systems (biofilm
formation)
Boreal forest
soils and peats

12. Likely routes of
infection
Transmission of NTM
CF, cystic fibrosis; NTM, non-tuberculous mycobacteria; NTM-LD, non-tuberculous mycobacterial lung disease
1. Falkinham JO, 3rd. J Appl Microbiol 2009; 107:356-67; 2. Johnson MM, Odell JA. J Thorac Dis 2014; 6:210-20; 3. McShane PJ, Glassroth J. Chest 2015; 148:1517-27.
12
Inhalation
of NTM-laden
aerosols or dust1
Ingestion of
soil or water1
Person-to-person
transmission
extremely rare,
but some
evidence of this in
the CF
community3
Contamination of
hospital water
supplies and
medical
equipment2
Gastroesophageal reflux
disease has been indicated as a
mediator of NTM-LD1
• Swallowing of NTM followed
by gastric reflux leading to
aspiration into the lung

13. The hydrophobic outer membrane supports NTM
survival and distribution
NTM, non-tuberculous mycobacteria.
Falkinham JO, 3rd. J Appl Microbiol 2009; 107:356-67.
13
• Promotes surface attachment and biofilm
formation
• Prevents wash-out
• Protects against antimicrobial agents, including
antibiotics and disinfectants
• Concentrates bacteria at air/water interface
• Aids aerosol distribution and transmission
from water distribution systems by inhalation
Biofilm formation and hydrophobic characteristics allow colonisation
of unfavourable habitats and easy spread
Mycobacterium
Cell wall
Mycolic acid
Peptidoglycan/ar
abinan layer
Plasma membrane
Lipopolysaccharide
Protein

14. 50% 75% 100%0% 25%
(% of patients who met diagnostic criteria, per species)
Not all NTM are equal
NTM, non-tuberculous mycobacteria.
1. van Ingen J, et al. Thorax 2009; 64:502-6; 2. van Ingen J, et al. Infect Genet Evol 2012; 12:832-7; 3. Zweijpfenning S, et al. Respir Med 2017; 131:220-4.
Clinical relevance is different for each NTM species1–3
14

15. 15
NTM disease: 4 main manifestations
HIV, human immunodeficiency virus; NTM, non-tuberculous mycobacteria.
1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Tortoli E. Clin Microbiol Infect 2009; 15:906-10; 3. Johnson MM, Odell JA. J Thorac Dis 2014; 6:210-20;
4. McShane PJ, Glassroth J. Chest 2015; 148:1517-27.
Pulmonary disease1,2 Lymphatic disease1,2
Skin/soft tissue disease1,2
Disseminated disease1,2
Typically an infantile disease
affecting cervical lymph nodes2
Also in adults with HIV infection1
Predisposing lung conditions1,3
Predisposing genetic factors4
Situational (hypersensitivity pneumonitis)2,3
The lung is by far the most frequent disease site1
Most commonly seen in association with profound
immunosuppression, e.g. HIV infection2,3
The most common sources include:
• contact with contaminated water or
infected fish2
• traumas and surgical wounds2
Nosocomial infections have been
described3
Both host factors and organism characteristics influence the
susceptibility and manifestations of NTM disease3

16. 16
Diagnosis and management of NTM is
challenging
NTM-LD, non-tuberculous mycobacterial lung disease.
1. Griffith DE, et al. Am J Respir Crit Care Med 2007; 175:367-416; 2. Thomson RM, Yew WW. Respirology 2009; 14:12-26; 3. van Ingen J, et al. Drug Resist Updat 2012; 15:149-61; 4. Adjemian J, et al. Ann Am Thorac Soc 2014; 11:9-16; 5.
Griffith DE, Aksamit TR. Curr Opin Infect Dis 2012; 25:218-27; 6. Haworth CS, et al. Thorax 2017; 72:ii1-ii64; 7. Ryu YJ, et al. Tuberc Respir Dis (Seoul) 2016; 79:74-84.
Late diagnosis
Non-specific symptoms
Symptoms may overlap with
underlying lung disease
Therapeutic challenge
Multi-drug regimens
Treatment for 1–2 years
Risk of side effects
Poor adherence to evidence-based
treatment guidelines
Promotes antibiotic resistance
Refractory disease
Little data on efficacy of other drugs or
interventions
Cases should be referred to
NTM experts
A multidisciplinary approach is required to adequately diagnose and
manage patients with

17. • The NTM infections usually are not the cause of mortality but they
can definitely increase the morbidity significantly, especially when
they are not diagnosed and treated on time.

18. When to suspect
• NTM infections in post-operative wound though rare should be
suspected in all post-operative wound infections which occurs later or
when they don’t heal with routine post-operative antibiotic
treatments.
• Usually all the wounds heals initially and than later patient will
develop the sinus/ induration discharging watery pus approximately
4 to 6 weeks following surgery.

19. Diagnosis
• Typically patients don’t have pain, they are afebrile with no other
systemic illness.
• Usually it’s a chronic non- healing wound or sometimes not even at
the site of wound but may be in nearby skin, after surgery
• One should think of NMT and must investigate in that manner.

20. Culture
• The optimal culture for NTM isolation should be performed at
multiple temperatures 25°C, 37°C, and 42°C to ensure that the
cultures grow all possible pathogens.
• The development of DNA fingerprinting technology, especially pulsed-
field gel electrophoresis, has been suggested as a diagnostic tool.
• Polymerase chain reaction (PCR) has been used to aid in diagnosing
these conditions

21. Stages

22. Sites

23. Treatment
• Infections with NTM can be treated with a variety of antibiotics and
their combinations. The recommended treatment of NTM causing SSI
is usually drugs from macrolide, fluoroquinolone, Linezolid, Sulpha
and aminoglycoside groups.
• The specific drugs which have shown efficacy against NTM are
Clarithromycin, Azithromycin, Ciprofloxacin, Levofloxacin, Amikacin
and Tobramycin .

24. Does ATT work
NO

25. Studies

27. Usual susceptibility

28. Our data of 25 Patients
M:F 13:12
TYPE OF SURGERY
LAP 18
OPEN 5
I & d 2
Average duration of patient when we received them 8.02 months
Number of time they underwent I & D before landing 1.88 times
Number of culture positive patients 6 out of 25
Average duration it took to heal 3.72 months
Average duration of treatment 8.32 months
4 Patients received full
Course of Standard 4 Drug
ATT without any response

29. Our Rx protocol
• We treated all our patients including who are culture negative with
• Clarithromycin/Azythromycin,
• Ciprofloxacin / Levofloxacin, Amikacin (one patient),
• Co-trimoxazol / Rifampicin
• Doxycycline
• The treatment continued for 3 to 6 months after cessation of discharge
from site

31. Complications
• Chronic sinus discharging pus
• Infected Mesh / wound
• Re appearing sinus
• Invasive NTM Disease (usually very rare, only happens in
immunocompromised individual, elderly patient, COPD with steroid,
AIDS)

32. Prevention

33. THANKS

35. Video