1. Atypical mycobacterial infections
Georgina Crowe DT204/2
(1)
Mycobacterial infections other than TB.differ from TB as not transferred from patient-patient.
Discovered 19th century after TB.
Not deemed pathogenic until mid 20th C
Found in natural soil and water environments & food.
Immunocompromised and competent hosts. Mostly HIV, AIDS and chronic lung disease patients effected.
Not very common ,increasing as AIDS and HIV are chronic lung disease increasing however.

2. Causes Mycobacterium avium-intracellulare Mycobacterium kansasii
Mycobacterium marinum
Mycobacterium ulcerans
Mycobacterium chelonae
>100 species of myco, these are the most common.
MAC and M.kansasii primarly cause lung disease like pumlonary TB .
M marnium,M.ulcerans and M.Chelonae cause skin infcetions .(2)

3. Genetic inheritance
Genetic predispositions to bronchiectasis and NTM disease
Clear association.
patients with cystic fibrosis often have pulmonary NTM disease.
Both conditions are associated with bronchiectasis. 
It is believed many NTM infections are acquired genetically but have not been fully proven yet
Bronchiectasis is destruction and widening of the large airways. If the condition is present at birth, it is called congenital bronchiectasis; If it develops later in life, it is called acquired bronchiectasis.

4. Clinical presentation
Infections: septic arthritis ,abscesses, skin and bone infection.
Commonly effected areas : lungs ,GIT, lymphatic system .
Symptoms: Fever
swollen lymph nodes
night sweats
extreme tiredness
Weight loss
diarrhoea
joint and bone pain
shortness of breath
paleness
skin lesions.
(2)
The clinical features of atypical mycobacterial infection depend on the infecting mycobacteria.

5. Lab ID Specimens: Gram stain(+/-) Blood culture
Sputum culture
Lymph node culture
Biopsy
Bone marrow culture
Stool culture
Diagnostic tests :
Gram stain(+/-)
Ziehl Neelson (acid fast/non acid fast)
Use of Light
fluorescent microscopy- Bright yellow rods against a black background(+)
Colony formation.
Growth on Lowenstein Jenson medium
Growth speed
Ppd skin test for TB (-/weak+)
Chest X-ray and CT scan
Specimens which the lab would receive for these infections would include.
Primary Tests done in the lab to diagnose these infections would include.
the laboratory must be informed of the clinician's suspicion of this diagnosis to take relevant precautions .
Runyon classification .rate and growth and production of yellow pigment and weather this pigment was produced in light or dark
Light 4 groups :photochromogens (slow growing, yellow pigment in rpesence of light.) ,scotochromogens(develop pigment in light or dark), non chromogens and rapid growers(no pigment)
Fluorescent microscopy: Auramine rhodamine dye, no heat ,decol with HcL&Ethanol , KMno4, false +
Solid, egg based agar 2-8 wks. growth, liquid broath 1-3wks , do both
NA amp- probes that id specific sequences of Nas and the ability to amplify (3)
How fast they grow: slow growing :MAC and kansassi, fast growing : chalonea
Colony formation: The different species of mycobacteria can be identified based on several factors, such as their appearance when grown in laboratory media. The larger, rough-looking colonies are M. chelonae, and the smaller, smooth colonies are M. avium. (4)

6. Newly developed tests
Gold standard for id of myco Molecular sequencing of genes rpoB and hsp65.
Nucleic acid probes .
Nucleic acid amplification techniques.
Bacilloscopy.
Multiplex PCR.
HPLC methods for NTM speciation
(5)
PCR ids tb from ntb
Bascilloscopy : sensitivity test of direct microscopy for detection of acid-fast bacilli in sputum 

7. (6) 
multiplex PCR of microbes from TBpatients.
bands 1,2,5 and 7 =TB;
Bands 3,4,6,8=NTM
bands 9 and 10= genomic DNA of TB
Band 11= -control;
Band m=size marker(ladder)  

8. Mycobacterium avium- intracellulare complex (M.A.C)
most common non TB.
HIV Pos AIDS.
Effects lungs.
Skin lesions are uncommon.
survives inside macrophage.
lymphadenitis and lung disease in healthy people.
Can spread to blood,lungs,spleen,liver and bone marrow and intestines in HIV patients
Rarely spreads in healthy patents.
Cure rate 30-85%
(1),(2), (4)
is inflammation of the lymph nodes and channels of the lymphatic system.
Lymphadentitis= inflammation of lymph nodes and channels of the lymphatic system.
Fig 3:hot tub lung. Diffuse consolidation of lung after being exposed to MAC in an indoor hot tub. Biopsy showed gramulomatas infection. Patient improved when ceased exposure to the hot tub (7).

9. Mycobacterium kansasii
Cure rate 100%
chronic infection of the lungs similar to pulmonary TB
Second most common non-tuberculosis mycobacterial infection associated with AIDS
Symptoms include fever, swollen lymph nodes and lung crackles and wheezing
Skin lesions may occur either alone or as part of a more widespread disease
Aerosol formation from water sources
Fig 1: M.Kansassii infection on a patients knee. Hiv.va.gov (8)

10. Mycobacterium marinum
Fish tank granulomas.
Uncommon .
Weakened immune systems, fish handlers, swimmers.
Fresh and salt water.
Dormant for 2-6mts.
single lump or pustule where a cut was that breaks down to form a crusty sore or abscess.
Mostly affects elbows, knees, feet, knuckles or fingers.
Multiple lesions and widespread disease in immunocompromised patients.
Sometimes red, swollen and tender joints.
Optimal low Temp.
Rarely cause lung disease.
(1),(2) ,(5)
Fig 2.Patient with Mycobacterium marnium. wheelessonline.com (9)

11. Mycobacterium chelonae
Worldwide distribution.
found in tap water and other water sources.
lung disease, joint infection, eye disease and other organ infections.
May result in non-healing wound, subcutaneous nodule or abscess.
Immunosuppression may cause disseminated lesions throughout the body
Rapid grower on medium.
Increasing in patients with CF
(5)

12. Mycobacterium ulcerans
Buruli ulcer.
most common in Central and West Africa around areas of lush vegetation and swamps.
Tropical areas.
Painless lesion, grows slowly, itchy.
Toxins.
nodule of 1-2 cm develops 7-14 days after infection through broken skin.
After 1-2months the nodule breaks down to form a shallow ulcer, spreads rapidly and may involve up to 15% of skin surface.
Severe infections may destroy blood vessels, nerves, and invade bone
If untreated can destroy massive amounts of skin and bone  deformities
WHO began its Global Buruli Ulcer Initiative in 1998
(1),(2).
Fig.1.Large ulcerated mycobacterium ulcerans lesion effecting the entire lower limb. An Bras Dermatol (10)
Bruli ulcer after region in Uganda where it was first discovered.
Toxin damages the skin and underlying tissue.

13. Treatment depends on organism and the severity of the infection.
course of antibiotics.
Rifampicin, Ethambutol, Isoniazid, Minocycline, Ciprofloxacin Clarithromycinn Azithromycin and Cotrimoxazole.
Usually combination.
MAC=clarithromycin and ethambutol, sometimes ciprofloxacin or rifabutin also (18-24mts) .
M. marinum treat for at least two months.
M. kansasii  treat for at least 18 months.clarithromycin and rifampin
M. chelonae .clarithromycin in combination with another drug, Sometimes surgical excision needed
Antibiotics are usually ineffective for M.ulcerans. Rifampicin may promote healing of pre-ulcerative lesions. wound care and removal of the necrotic tissue common.
Surgical removal of infected lymph nodes and skin lesions sometimes necessary.
In severe cases, skin grafts may be necessary to repair the surgical wound
Treatment for mycobacterial infections depends on the type of bacterium, the location and severity of the infection, and the status of the person's immune system.
up to six medications may be used at once. Surgery, sometimes along with medications, is the most effective way to treat lymph node infections and skin lesions.(2)
MAC =improves with third drug . Improvement seen within 6 mts, respiratory function,fever,stamina, appetite, weight gain
M.ulcerans :antibiotics commonly ineffective in treating large skin lesions. . Most lesions eventually spontaneously heal after 6-9 months but may leave behind extensive scarring and disfigurement
AIDS patients on HIV protease inhibitor drugs cannot be treated with rifampicin because rifampicin significantly increases the breakdown of these drugs. Rifabutin is a suitable alternative
Will therapy be more debilitating than the disease, especially for elderly patients with minimal symptoms? If pulmonary NTM disease has caused localized lung destruction (e.g. of a single lung lobe), would a combined medical/surgical approach be worth considering?(5)

14. Antibiotic resistance
Clarithromycin susceptibility testing for M.Avium complex.
Rifampin susceptibility for M.Kansasii
M. marinum is often resistant to isoniazid. Treatment with other antibiotics
MIC determinations using the broth microdilution method ,susceptibility testing of rapidly growing mycobacteria.
(5)
How susceptibility testing is done.
 ‘S’ (susceptible), ‘R’ (resistant) or ‘I’ (intermediate) format.
Most NTM naturally resistant to lots of common Antibiotics.
Often use some abs that are used for TB.
Overcoming resistance requires many abs at one time.
Side effects common ,nb monitor.
Treatment up to 2 yrs.
Rifampin susp NB for M.Kansasii as it’s the main ab to treat it.
M.Kansasii easier to treat, often needs only 3 anti-TB drugs..
M.avium & M.Cholanea much harder to kill.3-5 drugs needed .depending how localised, could need surgery also (11).
MIC(minimum inhibitory conc).smallest amount of antibiotic that will stop the growth of the microorganism.
rapidly growing mycobacteria (i.e. M. abscessus, M. chelonae and M. fortuitum).

15. Current clinical trials
Satta et al.” treatment only based on expert opinion ,case series and few clinical trial.”
ELISA simple, fast ,high sensitivity and specificity. Current large scaled multicentre study.
OPC67683 Anti-TB drug.
west Africa trial on M.ulcerans , combination of rifampin and streptomycin daily for 8 wks.
optimal drug combinations and dosing intervals for treatment of pulmonary NTM.
Satta et al want new studies which reassess the medical management of NTM infections particularly MAC and M.Abscessus.,
Want more practical measures for clinical assessments and research trials which would include more info about the patient i.e. their experience and reported outcome. This will make for better clinical management decisions and realistic treatments specific for each patient.
Most treatments nowadays are prolonged use on multiple drugs which have some serious side effects including impairments of hearing, vision and kidney function. (12)
Diagnosis of MAC pulmonary disease and its differentiation from pulmonary TB often difficult. New serological test serological test by enzyme immunoassay which detects serum Abs to glycopeptidolipid antigen.AB levels show severity.
Okada et al explained in a recent article how Dr.Makoto matsumoto discovered a new anti-tb drug called OPC which is made from nitroimidazole compounds. Inhibiting mycolic acid synthesis and has strong antimicrobial ability. is a derivative of nitroimidazole compounds. Multidrug therapy including OPC could can shorten the course of chemo for TB patients. Most promising new NTM drug being developed(13)
M.ulcerans trail with these drugs can kill the M.Ulcerans bacilli ,arrest the disease and promote healing without relapse .improved treatment options are the focus of the research.(14)
Cooke et all, oxford journal can ab dosing be down on less than a daily or thrice weekly and still have good treatment outcomes for pulmonary NTMM infections???(5)
A lot more room for clinical trials in this areas especially in genetic risk factors, earlier diagnosis, optimal treatment and drug discovery. (5)

16. Stem cell therapies
2012 Disseminated M .Marnium infection in hematopoietic stem cell transplant recipient.
Stem cell therapies doesn't seem to be a big thing for NTM infections. However….
Jacobs et al, reported in 2012 a case of disseminated M.Marnium in hematopoietic stem cell transplant recipient . Several cases of M.Marnium in immunocompromised, solid organ transplant recipients, none in patients with stem cell therapies
Jacobs et al believed that this was the first reported disseminated M.Marnium infection in SCT recipient who continued to develop new skin lesions even months post therapy.
(15)

17. Animal based research
M.Ulcerans-skeletal muscle contracture and atrophy.
Male mice
Injected near Right bicep muscle
“The combination of BCG and HVJ-liposome/HSP65 DNA+IL-12 DNA by a prime-booster procedure could lead to an overall effect of 100% survival in infected monkeys”. 
(13)
M.ulceran can cause skeletal muscle contraction and atrophy (dec in functon)
In this study, male mice were injected subcutaneously with M.Ulcerans near their right biceps . No contact was made between agent and muscle.
Histological, morphological and functional properties of the muscles were assessed post injection.
Day 42 post injection: contraction force was reduced by 31% and cross sectional area by 29% in the effected muscles compared to the control muscles.
Also on day 42 the necrotic areas on infection had spread to 7% of total body area. (16)
A study by Okada and Kobayashi from 2007 showed that the combination of BCG and HVJ-liposome/HSP65 DNA+IL-12 DNA
The results from this animal trial are so good it is now being proposed for human trials.(13)

18. Prevalence
50yrs ago, older males, nowadays 80% middle aged or elderly females.(5)
Ireland=0.0004% in 2000 (17)
MAC =most common in all regions.
M.Kansassi= Central and southern states of America, England and Wales. Second most common type of NTM (11)
M.Marnea= Gulf of Mexico, Atlantic ocean ,<1 in 1000.
M.Ulcerans=tropical and subtropical regions Africa, central America, south east Asia ,Australia.
 regional differences in environmental conditions may favour difference in the most predominant NTM in the water and soil in the different areas of the world.

19. References
(1)HumanIlness.com ;mycobacterial infections,Atypical .n.d , (acessed 17 April 2014) .
(2) Atypical mycobacterial infections , (Accessed 14/4/14)
(3)Gentry.C, Pharmacotherapy self assessment programme :infectious diseases, 5th ed, Kansas city : American college of clinical pharmacy ;2005
(4) Schraufnagel.D. Nontuberculous (Environmental) Mycobacterial Disease. In: Kell.B (eds.)Breathing in America, diseases progress and hope. 1st ed. America: American Thoracic society; p121-9
(5) Cook.J, Nontuberculous mycobacteria: opportunistic environmental pathogens for predisposed hosts. Oxford journals 2010 ; 96(1) : 45-59
(6) Lima.S, Duarte.R, Montenegro.L, et al.: Rapid detection and differentiation of mycobacterial species using a multiplex PCR system. Rev Soc Bras Med Trop.2013 ;46(4):447-52
(6) figure 3 .
(7) . Johnson.M,Odell.J. Nontuberculous mycobacterial pulmonary infections. Journal of thoracic disease (3)23-32.

20. References continued.
(8) Volberding.P .dermatological manifestations of HIV.
(9) Clifford R,Wheeless. Mycobacterium Marnium. ,(accessed 17 April 2014).
(10) fBoleira.M, Lupi.O, Lehman.L ,Et al. Buruli ulcer:An Bras Dermatol. 2010;85(3):
(11) Huitt.D, Nontuberculous Mycobacteria (NTM):Treatment (Accessed 22nd April 2014).
(12) G.Satta, T.McHugh, Mountford.J, Et al. Managing pulmonary nontuberculous mycobacterial infection,time for a patient-centered approach Ann Am Thorac Soc. 2014 Jan;11(1):
(13) Okada.M,Kobayashi.K, Recent progress in mycobacteriology. Kekkaku 2007 ;82(10):
;300(3):724-32
(14) P.Converse,E.Nuermberger,D.Almeida .Et al, Treating Mycobacterium ulcerans disease (Buruli ulcer): from surgery to antibiotics, is the pill mightier than the knife?. Future Microbiol. 2011 ;6(10):
(15) Jacobs.S, George.A, Papanicolaou.G,Et al, Disseminated Mycobacterium marinum infection in a hematopoietic stem cell transplant recipient. Transpl Infect Dis. 2012;14(4):410-4

21. References cotinued
(16) Houngbédji.G, Bouchard.P,Frenette.J. Mycobacterium ulcerans infections cause progressive muscle atrophy and dysfunction, and mycolactone impairs satellite cell proliferation. Am J Physiol Regul Integr Comp Physiol. 2011
(17) Kennedy.M, O’Connor.T, Ryan.C, et al: Non tuberculosis mycobacteria incidence in south-west Ireland from respir med.2003;97(3):257-6