Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2013
ReviewNontuberculous mycobacteria in patients with cystic fibrosis.
As a result of their underlying lung disease, patients with cystic fibrosis (CF) have a higher risk of developing nontuberculous mycobacteria (NTM) infections compared with the general population. Although NTM may be present intermittently in low amounts in the airways of CF patients without an apparent clinical effect, progressive respiratory decline due to NTM disease may also occur. Identifying this latter group of patients can be challenging for clinicians because the usual symptoms exhibited by infected individuals without CF may be difficult to distinguish from the baseline respiratory dysfunction of a patient with CF. ⋯ For CF patients under evaluation for lung transplantation, NTM can play a critical role in determining overall outcomes, and treatment in the pre- and post-transplant period may be vital to success. A general approach to NTM in CF thus involves surveillance to detect NTM, careful monitoring for associated clinical decline, and consideration of treatment given for those with an otherwise unexplained deterioration. In this review, the epidemiology and clinical course of NTM in CF is described with an algorithm for management proposed.
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Semin Respir Crit Care Med · Feb 2013
ReviewUpdate on the epidemiology of pulmonary nontuberculous mycobacterial infections.
For decades, the incidence of pulmonary nontuberculous mycobacteria (NTM) has been reported to be increasing, yet formal epidemiological evaluation of this notion has been lacking until recently. Defining the epidemiology of NTM has been more challenging than with Mycobacterium tuberculosis (MTB). Unlike MTB, NTM are soil and water organisms, and infection is thought to be acquired from the environment rather than transmitted from person-to-person, with very rare exceptions. ⋯ Nonetheless, the prevalence of pulmonary NTM disease has increased dramatically in the United States and globally over the past 3 decades. Mycobacterium avium complex (MAC) accounts for the majority of NTM infections worldwide, but there is significant regional variability of various species. Additionally, novel species have been implicated in several countries in NTM pulmonary disease.
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The human immunodeficiency virus (HIV) pandemic has amplified the global burden of tuberculosis (TB), particularly in sub-Saharan Africa, where 82% of the world's TB/HIV coinfection exists. HIV infection significantly increases the risk of developing and dying from TB and was associated with 350,000 TB deaths in 2010. The diagnosis of HIV-associated TB is often challenging due to atypical clinical and radiographic manifestations, more frequent extrapulmonary disease, and higher rates of smear-negative pulmonary TB. ⋯ The comanagement of HIV and TB is challenging due to drug-drug interactions, overlapping drug toxicities, concerns about adherence, and the immune reconstitution inflammatory syndrome. However, the initiation of antiretroviral therapy (ART) during the course of TB treatment is necessary to improve survival, and the appropriate timing of ART is dependent on the level of immune suppression. Therefore, the management of TB must be well coordinated with HIV resources, prepared to rapidly diagnose HIV, assess immune status, and correctly treat both infections.
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Semin Respir Crit Care Med · Feb 2013
ReviewManagement of extrapulmonary nontuberculous mycobacterial infections.
Nontuberculous mycobacteria represent a vast group of environmental organisms that have the potential to cause disease in humans. Unlike tuberculosis, these organisms are not known to be transmitted from human to human. The most common clinical presentation is pulmonary disease. ⋯ Outbreaks have been reported due to inadequate disinfection of surgical equipment or contamination of injected solutions or medications. A high index of suspicion is required when patients present with subacute or chronic complaints of extrapulmonary infection. This review addresses the management of the common extrapulmonary nontuberculous infections.
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Semin Respir Crit Care Med · Feb 2013
ReviewUnderlying host risk factors for nontuberculous mycobacterial lung disease.
Nontuberculous mycobacteria (NTM) are environmental microbes that cause a variety of human diseases, particularly chronic lung infections. Despite the fact that NTM are widespread in the environment, relatively few people develop NTM lung disease, suggesting intrinsic vulnerability in some individuals. ⋯ Over the past several decades, NTM lung disease has been increasingly identified in postmenopausal women with slender body habitus. Thus we will also review the clinical and experimental evidence which supports the observation that such individuals are predisposed to NTM lung disease.