Nontuberculous mycobacterial infections in solid organ transplant candidates and recipients
- Aruna Subramanian, MD
Aruna Subramanian, MD
- Clinical Associate Professor of Medicine
- Stanford University School of Medicine
Nontuberculous mycobacteria (NTM) are ubiquitous in the environment, and more than 125 species have been identified . Solid organ transplant recipients have an increased risk for infection with NTM due to depressed cell-mediated immunity. Although NTM infection rates are low compared with other types of infection, when NTM infections occur in transplant recipients, they cause significant morbidity and mortality, due in part to difficulties in disease recognition, delayed diagnosis, and complex drug interactions [2-4].
This topic reviews NTM infections in solid organ transplant recipients. Tuberculosis and the evaluation, treatment, and prophylaxis of infection in solid organ transplant recipients, as well as bacterial, viral, and fungal infections in lung transplant recipients, are reviewed separately. (See "Tuberculosis in solid organ transplant candidates and recipients" and "Evaluation for infection before solid organ transplantation" and "Infection in the solid organ transplant recipient" and "Prophylaxis of infections in solid organ transplantation" and "Bacterial infections following lung transplantation" and "Clinical manifestations, diagnosis, and treatment of cytomegalovirus infection in lung transplant recipients" and "Prevention of cytomegalovirus infection in lung transplant recipients" and "Fungal infections following lung transplantation".)
Most nontuberculous mycobacterial (NTM) species have been found in soil and water and were thought not to be transmitted from animal to human or human to human . However, human-to-human spread of Mycobacterium abscessus among patients in cystic fibrosis centers and on a population level has been confirmed [6-8], and this mode of transmission may be more common than initially suspected [6-8]. In tuberculosis (TB)-nonendemic countries, NTM are more common etiologic agents of disease in solid organ transplant recipients than TB . Solid organ transplant recipients have an increased risk for infection with NTM due to depressed cell-mediated immunity, but NTM infections are nevertheless rare in this population
The slowly growing mycobacteria M. avium and M. intracellulare (together known as Mycobacterium avium complex [MAC]) are the most common NTM species to cause infection in the United States and are the most common species isolated after solid organ transplantation [5,9]. The other NTM species that are known to cause disease in solid organ transplant recipients include the slowly growing species M. kansasii, M. haemophilum, and M. marinum, along with the rapidly growing species M. fortuitum, M. chelonae, and M. abscessus (table 1) [2,4]. (See "Epidemiology of nontuberculous mycobacterial infections".)
In solid organ transplant recipients, the median onset of NTM infection is usually a year or more after transplantation [4,9,10]. Heart and lung transplant recipients have the highest rates of infection, ranging from 0.2 to 2.8 percent and 0.5 to 8.0 percent, respectively [4,9]. By contrast, rates of NTM infection in renal transplant recipients range from 0.16 to 0.38 percent, and, in one series of liver transplant recipients, the rate was 0.04 percent [2,4].
- Tortoli E. Impact of genotypic studies on mycobacterial taxonomy: the new mycobacteria of the 1990s. Clin Microbiol Rev 2003; 16:319.
- Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients. Clin Infect Dis 2004; 38:1428.
- Daley CL. Nontuberculous mycobacterial disease in transplant recipients: early diagnosis and treatment. Curr Opin Organ Transplant 2009; 14:619.
- Keating MR, Daly JS, AST Infectious Diseases Community of Practice. Nontuberculous mycobacterial infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:77.
- 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.
- Aitken ML, Limaye A, Pottinger P, et al. Respiratory outbreak of Mycobacterium abscessus subspecies massiliense in a lung transplant and cystic fibrosis center. Am J Respir Crit Care Med 2012; 185:231.
- Bryant JM, Grogono DM, Greaves D, et al. Whole-genome sequencing to identify transmission of Mycobacterium abscessus between patients with cystic fibrosis: a retrospective cohort study. Lancet 2013; 381:1551.
- Bryant JM, Grogono DM, Rodriguez-Rincon D, et al. Emergence and spread of a human-transmissible multidrug-resistant nontuberculous mycobacterium. Science 2016; 354:751.
- Malouf MA, Glanville AR. The spectrum of mycobacterial infection after lung transplantation. Am J Respir Crit Care Med 1999; 160:1611.
- Patel R, Roberts GD, Keating MR, Paya CV. Infections due to nontuberculous mycobacteria in kidney, heart, and liver transplant recipients. Clin Infect Dis 1994; 19:263.
- Longworth SA, Vinnard C, Lee I, et al. Risk factors for nontuberculous mycobacterial infections in solid organ transplant recipients: a case-control study. Transpl Infect Dis 2014; 16:76.
- Lee Y, Song JW, Chae EJ, et al. CT findings of pulmonary non-tuberculous mycobacterial infection in non-AIDS immunocompromised patients: a case-controlled comparison with immunocompetent patients. Br J Radiol 2013; 86:20120209.
- Rawla MS, Kozak A, Hadley S, LeCates WW. Mycobacterium avium-intracellulare-associated acute interstitial nephritis: a rare cause of renal allograft dysfunction. Transpl Infect Dis 2009; 11:529.
- Singhal A, Gates C, Malhotra N, et al. Successful management of primary nontuberculous mycobacterial infection of hepatic allograft following orthotopic liver transplantation for hepatitis C. Transpl Infect Dis 2011; 13:47.
- Pandian TK, Deziel PJ, Otley CC, et al. Mycobacterium marinum infections in transplant recipients: case report and review of the literature. Transpl Infect Dis 2008; 10:358.
- Sanguinetti M, Ardito F, Fiscarelli E, et al. Fatal pulmonary infection due to multidrug-resistant Mycobacterium abscessus in a patient with cystic fibrosis. J Clin Microbiol 2001; 39:816.
- Fairhurst RM, Kubak BM, Shpiner RB, et al. Mycobacterium abscessus empyema in a lung transplant recipient. J Heart Lung Transplant 2002; 21:391.
- Taylor JL, Palmer SM. Mycobacterium abscessus chest wall and pulmonary infection in a cystic fibrosis lung transplant recipient. J Heart Lung Transplant 2006; 25:985.
- Chernenko SM, Humar A, Hutcheon M, et al. Mycobacterium abscessus infections in lung transplant recipients: the international experience. J Heart Lung Transplant 2006; 25:1447.
- Chalermskulrat W, Sood N, Neuringer IP, et al. Non-tuberculous mycobacteria in end stage cystic fibrosis: implications for lung transplantation. Thorax 2006; 61:507.
- Zaidi S, Elidemir O, Heinle JS, et al. Mycobacterium abscessus in cystic fibrosis lung transplant recipients: report of 2 cases and risk for recurrence. Transpl Infect Dis 2009; 11:243.
- Garrison AP, Morris MI, Doblecki Lewis S, et al. Mycobacterium abscessus infection in solid organ transplant recipients: report of three cases and review of the literature. Transpl Infect Dis 2009; 11:541.
- Silva JT, López-Medrano F, Fernández-Ruiz M, et al. Mycobacterium abscessus pulmonary infection complicated with vertebral osteomyelitis in a heart transplant recipient: case report and literature review. Transpl Infect Dis 2015; 17:418.
- Knoll BM, Kappagoda S, Gill RR, et al. Non-tuberculous mycobacterial infection among lung transplant recipients: a 15-year cohort study. Transpl Infect Dis 2012; 14:452.
- Abad CL, Razonable RR. Non-tuberculous mycobacterial infections in solid organ transplant recipients: An update. J Clin Tuberc Other Mycobact Dis 2016; 4:1.
- Kesten S, Chaparro C. Mycobacterial infections in lung transplant recipients. Chest 1999; 115:741.
- Woo MS, Downey S, Inderlied CB, et al. Pediatric transplant grand rounds. A case presentation: skin lesions in a post-lung transplant patient. Pediatr Transplant 1997; 1:163.
- Swetter SM, Kindel SE, Smoller BR. Cutaneous nodules of Mycobacterium chelonae in an immunosuppressed patient with preexisting pulmonary colonization. J Am Acad Dermatol 1993; 28:352.
- Baldi S, Rapellino M, Ruffini E, et al. Atypical mycobacteriosis in a lung transplant recipient. Eur Respir J 1997; 10:952.
- Torres F, Hodges T, Zamora MR. Mycobacterium marinum infection in a lung transplant recipient. J Heart Lung Transplant 2001; 20:486.
- Sádaba B, López de Ocáriz A, Azanza JR, et al. Concurrent clarithromycin and cyclosporin A treatment. J Antimicrob Chemother 1998; 42:393.
- Capone D, Palmiero G, Gentile A, et al. A pharmacokinetic interaction between clarithromycin and sirolimus in kidney transplant recipient. Curr Drug Metab 2007; 8:379.
- Lemoine M, Laurent C, Hanoy M, et al. Immune Reconstitution Inflammatory Syndrome Secondary to Mycobacterium kansasii Infection in a Kidney Transplant Recipient. Am J Transplant 2015; 15:3255.
- Huang HC, Weigt SS, Derhovanessian A, et al. Non-tuberculous mycobacterium infection after lung transplantation is associated with increased mortality. J Heart Lung Transplant 2011; 30:790.
- Longworth SA, Blumberg EA, Barton TD, Vinnard C. Non-tuberculous mycobacterial infections after solid organ transplantation: a survival analysis. Clin Microbiol Infect 2015; 21:43.