Seminars in respiratory and critical care medicine
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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.
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Semin Respir Crit Care Med · Feb 2013
Management of nontuberculous mycobacterial (NTM) lung disease.
Nontuberculous mycobacterial (NTM) lung diseases present formidable obstacles to successful management, especially when compared with tuberculosis, beginning with diagnosis and extending through treatment. Factors peculiar to NTM disease such as extensive microbial resistance mechanisms and difficult to interpret, even misleading, in vitro drug susceptibility patterns are just two of the multiple and frustrating clinical management challenges. ⋯ In spite of these difficulties, the majority of NTM lung disease patients are still treated successfully. Because the prevalence of NTM is rising, it is increasingly necessary for clinicians to understand those unique aspects of NTM lung disease diagnosis and treatment that differ from tuberculosis and that contribute to limited treatment options.