Diagnosis of nontuberculous mycobacterial infections of the lungs in HIV-negative patients
- David E Griffith, MD
David E Griffith, MD
- Professor of Medicine
- University of Texas Health Center at Tyler
Nontuberculous mycobacterial (NTM) infections of the lungs often occur in the context of preexisting lung disease, especially chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumoconiosis, cystic fibrosis, and previous tuberculosis [1-4]. As a result, the clinical manifestations of NTM lung disease are often similar to those of the underlying disease. These include cough, fatigue, malaise, fever, weight loss, dyspnea, hemoptysis, and chest discomfort. These same symptoms are also present in patients with NTM lung disease who do not have preexisting pulmonary disease. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients".)
The possible presence of NTM lung disease often arises clinically when NTM are identified on sputum culture from a patient under evaluation for tuberculosis. The laboratory findings used to confirm the diagnosis of NTM infection in this setting will be reviewed here. The epidemiology, pathogenesis, and treatment of NTM are discussed separately. (See "Epidemiology of nontuberculous mycobacterial infections" and "Pathogenesis of nontuberculous mycobacterial infections" and "Treatment of nontuberculous mycobacterial infections of the lung in HIV-negative patients".)
The radiographic findings of nontuberculous mycobacterial (NTM) lung disease are variable, depending in part upon the species. Findings consistent with NTM pulmonary infection on chest radiograph or high-resolution computed tomography scan include infiltrates (usually nodular or reticulonodular), cavities, multifocal bronchiectasis, and/or multiple small nodules. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients".)
The radiographic pattern of disease can usually be separated into predominantly cavitary versus nodular/bronchiectatic. Some generalizations can be made:
- Cavitary disease in the upper lung zones, similar to pulmonary tuberculosis, is seen in approximately 90 percent of patients with M. kansasii infection and perhaps 50 percent of those with Mycobacterium avium complex (MAC) infection. The cavities caused by these organisms tend to have thinner walls and less surrounding parenchymal opacity than those caused by M. tuberculosis [5,6].
- At least 50 percent of patients with MAC lung disease have radiographic abnormalities characterized by nodules associated with bronchiectasis or nodular/bronchiectatic disease. The nodules and bronchiectasis are usually present within the same lobe and occur most frequently in the right middle lobe and lingula .
- Chapman JS. The Atypical Mycobacteria and Human Mycobacteriosis, 16th Ed, Plenum, New York 1977.
- Yeager H Jr, Raleigh JW. Pulmonary disease due to Mycobacterium intracellulare. Am Rev Respir Dis 1973; 108:547.
- Davidson PT. The diagnosis and management of disease caused by M. avium complex, M. kansasii, and other mycobacteria. Clin Chest Med 1989; 10:431.
- Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367.
- Woodring JH, Vandiviere HM. Pulmonary disease caused by nontuberculous mycobacteria. J Thorac Imaging 1990; 5:64.
- Christensen EE, Dietz GW, Ahn CH, et al. Initial roentgenographic manifestations of pulmonary Mycobacterium tuberculosis, M kansasii, and M intracellularis infections. Chest 1981; 80:132.
- Levin DL. Radiology of pulmonary Mycobacterium avium-intracellulare complex. Clin Chest Med 2002; 23:603.
- Swensen SJ, Hartman TE, Williams DE. Computed tomographic diagnosis of Mycobacterium avium-intracellulare complex in patients with bronchiectasis. Chest 1994; 105:49.
- Koh WJ, Lee KS, Kwon OJ, et al. Bilateral bronchiectasis and bronchiolitis at thin-section CT: diagnostic implications in nontuberculous mycobacterial pulmonary infection. Radiology 2005; 235:282.
- Edwards LB, Acquaviva FA, Livesay VT, et al. An atlas of sensitivity to tuberculin, PPD-B, and histoplasmin in the United States. Am Rev Respir Dis 1969; 99:Suppl:1.
- von Reyn CF, Green PA, McCormick D, et al. Dual skin testing with Mycobacterium avium sensitin and purified protein derivative: an open study of patients with M. avium complex infection or tuberculosis. Clin Infect Dis 1994; 19:15.
- Huebner RE, Schein MF, Cauthen GM, et al. Evaluation of the clinical usefulness of mycobacterial skin test antigens in adults with pulmonary mycobacterioses. Am Rev Respir Dis 1992; 145:1160.
- von Reyn CF, Williams DE, Horsburgh CR Jr, et al. Dual skin testing with Mycobacterium avium sensitin and purified protein derivative to discriminate pulmonary disease due to M. avium complex from pulmonary disease due to Mycobacterium tuberculosis. J Infect Dis 1998; 177:730.
- von Reyn CF, Horsburgh CR, Olivier KN, et al. Skin test reactions to Mycobacterium tuberculosis purified protein derivative and Mycobacterium avium sensitin among health care workers and medical students in the United States. Int J Tuberc Lung Dis 2001; 5:1122.
- Kitada S, Kobayashi K, Ichiyama S, et al. Serodiagnosis of Mycobacterium avium-complex pulmonary disease using an enzyme immunoassay kit. Am J Respir Crit Care Med 2008; 177:793.
- Kotilainen H, Valtonen V, Tukiainen P, et al. Prognostic value of American Thoracic Society criteria for non-tuberculous mycobacterial disease: a retrospective analysis of 120 cases with four years of follow-up. Scand J Infect Dis 2013; 45:194.