Impact of Aspergillus precipitating antibody test results on clinical outcomes of patients with Mycobacterium avium complex lung disease

Comprehensive Management Algorithm for Mycobacterium avium Complex Pulmonary Disease in the Real-World Setting

The management of Mycobacterium avium complex pulmonary disease (MAC-PD) is challenging because of limited efficacy and frequent adverse events associated with standard treatments. The 2020 guidelines from the American Thoracic Society, European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, and Infectious Diseases Society of America provide recommendations, but real-world adherence is often hindered by these issues, leading many patients to be unable to complete standard therapy. This review proposes a comprehensive management algorithm for MAC-PD, emphasizing multidisciplinary approaches and integrating nonantimicrobial management before, during, and after drug treatment to enhance patient outcomes. When a patient presents with chronic respiratory symptoms suggestive of nontuberculous mycobacteria, clinicians should follow a guideline-based approach to diagnosis, as diagnostic delays are common because of nonspecific symptoms. Proper evaluation should determine the disease phenotype (existence of cavitary lesions), as it influences treatment choices. Airway clearance, nutritional support, and management of underlying conditions are essential nonantimicrobial components. Regular outpatient monitoring helps detect disease progression and optimize treatment. Treatment strategies vary based on disease severity. For noncavitary nodular bronchiectatic disease, a thrice-weekly regimen is preferred because of better tolerability. Severe cases or those with cavitary forms may require daily treatment with additional aminoglycosides. Amikacin liposome inhalation suspension is recommended for patients not responding to standard regimens after 6 months. Recent research addresses drug intolerance, suggesting alternatives such as a two-drug regimen without rifamycin in certain cases. Consultation with nontuberculous mycobacteria specialists is advised for complex cases, particularly those with macrolide resistance or requiring surgical intervention. The algorithm emphasizes shared decision making, patient education, and family support to improve adherence and outcomes.

Prevalence of Chronic Pulmonary Aspergillosis in Patients With Mycobacterial and Non-Mycobacterial Tuberculosis Infection of the Lung: A Systematic Review and Meta-Analysis

BACKGROUND

Post-mycobacterial residual lung abnormality (PMLA) from prior tuberculous (PTLA) or non-tuberculous mycobacterial (PNTLA) lung infections predisposes to chronic pulmonary aspergillosis (CPA). However, the prevalence of CPA in patients with PMLA remains uncertain. We aimed to determine the prevalence of CPA in patients with PMLA.

METHODS

We performed a systematic search of PubMed and Embase databases up to January 31, 2025, to identify studies reporting CPA prevalence in patients with PTLA or PNTLA (excluding those with active tuberculosis). The pooled prevalence was calculated using frequentist meta-analysis (primary outcome), with Bayesian and trim-and-fill methods as sensitivity analyses. Study heterogeneity (I2) and publication bias were assessed. We performed multivariable meta-regression to evaluate factors affecting heterogeneity.

RESULTS

Thirty-one studies (4172 PTLA and 13,905 PNTLA) were included. Frequentist meta-analysis yielded a pooled CPA prevalence of 18% (95% confidence interval [CI], 11.6-25.4). Bayesian analysis with informative priors estimated prevalence of 7.1% (95% Credible Index, 4.5-10.4), and trim-and-fill adjustment for publication bias suggested prevalence to be 3.4% (95% CI, 0.69-7.7). On a multivariable analysis, we found CPA prevalence higher in hospital-based studies, high TB burden settings and studies with prospective or cross-sectional study designs; although CPA prevalence was higher in PTLA (23.1%) than in PNTLA (7%), it was not significantly different. We detected substantial heterogeneity (I2 = 98.8%) and publication bias.

CONCLUSION

There is a high prevalence of CPA in patients with PMLA, particularly in TB-endemic regions and hospital settings. Patients with PMLA should be routinely screened for CPA in high prevalence settings.

Development of allergic bronchopulmonary aspergillosis in a patient with nontuberculous mycobacterial-pulmonary disease successfully treated with dupilumab: A case report and literature review

Pulmonary manifestations in patients with allergic bronchopulmonary aspergillosis (ABPA) and nontuberculous mycobacterial-pulmonary disease (NTM-PD) include bronchiectasis and mucus plugging. A 68-year-old woman, treated with antibiotics and inhaled corticosteroids for NTM-PD and asthma, presented with fever and wheezing. ABPA was diagnosed based on laboratory findings (elevated peripheral blood eosinophil counts and serum total IgE levels and positive Aspergillus-specific IgE and IgG) and imaging observation of a high-attenuation mucus plug. Systemic prednisolone was avoided to prevent NTM-PD progression. Dupilumab, a monoclonal antibody that blocks IL-4/13, was introduced to improve the clinical findings. Herein, we discuss the pathophysiological mechanisms underlying this rare comorbidity.

A Systematic Review of Factors Associated with Mortality among Patients with Mycobacterium avium Complex Lung Disease

PURPOSE

As the number of patients with Mycobacterium avium complex lung disease is significantly increasing worldwide, several studies have focused on the prognostic factors associated with the disease. This systematic review investigated the factors associated with mortality among patients with Mycobacterium avium complex lung disease.

METHODS

Two investigators independently identified studies that were designed to determine risk factors for mortality in patients with Mycobacterium avium complex lung disease from PubMed, the Cochrane Register of Control Trial database, and EMBASE (accessed on 25 November 2022).

RESULTS

Of the 1133 titles and abstracts screened, 54 full texts were selected for review, and 15 studies were finally included in this systematic review. The most commonly studied risk factors were advanced age and low body mass index (11 studies for each), followed by male sex (8 studies), hypoalbuminemia (5 studies), and cavity (5 studies). In each study, these factors were mostly associated with increased all-cause mortality among patients with Mycobacterium avium complex lung disease as confirmed via multivariate analysis.

CONCLUSIONS

Advanced age, male sex, low body mass index, hypoalbuminemia, and cavity are likely to be the common risk factors for all-cause mortality among patients with Mycobacterium avium complex lung disease, suggesting that patients with these factors need to be carefully monitored.

The factors associated with mortality and progressive disease of nontuberculous mycobacterial lung disease: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to comprehensively evaluate the factors associated with mortality and progressive disease in NTM-LD patients. We conducted a literature search to identify the eligible studies, dated between January 1, 2007, and April 12, 2021. Forty-one studies with total 10,452 patients were included. The overall all-cause mortality rate was 20% (95% CI 17-24%). The overall rates of clinical and radiographic progressive disease were 46% (95% CI 39-53%) and 43% (95% CI 31-55%), respectively. Older age, male sex, history of TB, diabetes, chronic heart disease, malignancy, systemic immunosuppression, chronic liver disease, presence of cavity, consolidative radiologic features, acid-fast bacillus (AFB) smear positivity, hypoalbuminemia, anemia, increasing platelet count, high CRP, and high ESR were significantly associated with increased all-cause mortality, whereas increasing body mass index (BMI), hemoptysis, and treatment with rifamycin regimen (in M. xenopi) were significantly associated with decreased all-cause mortality in multivariable analysis. History of TB, Aspergillus co-infection, cough, increased sputum, weight loss, presence of cavity, and AFB smear positivity were significantly associated with increased clinical progression with treatment, while older age and low BMI were significantly associated with decreased clinical progression in multivariable analysis. Older age, interstitial lung disease, presence of cavity, consolidative radiologic feature, anemia, high CRP, and leukocytosis were significantly associated with increased radiographic progression after adjusting for covariates. Older age, history of tuberculosis, presence of cavity, consolidative radiologic features, AFB smear positivity, anemia, and high C-reactive protein were common significant factors associated with the all-cause mortality and clinical or radiographic progressive disease of NTM-LD. These factors are thought to directly affect NTM-LD related mortality. The future prediction models for the prognosis of NTM-LD should be established considering these factors.

Aspergillus isolation in nontuberculous mycobacterial pulmonary disease: Associated with antimycobacterial treatment initiation but not response

PURPOSE

Chronic pulmonary aspergillosis is a serious complication of nontuberculous mycobacterial pulmonary disease (NTM-PD), and diagnosis remains challenging. The present study examined associations between the respiratory isolation of Aspergillus and the clinical characteristics and treatment outcomes of patients with NTM-PD.

METHODS

All patients meeting NTM-PD criteria as defined by the ATS/IDSA statement, with at least one respiratory sample cultured for fungi, were included in this retrospective cohort analysis. Patients with at least one respiratory sample isolating Aspergillus were compared to patients who did not isolate Aspergillus. The primary outcomes were culture conversion and radiologic evolution 12 months after NTM-PD treatment initiation.

RESULTS

During a 12 year period, 497 patients meeting the inclusion criteria were seen in our tertiary care center, of whom 130 grew Aspergillus. Median follow up after NTM-PD diagnosis was 46 months. Inhaled corticosteroid use, a nodular-bronchiectatic CT pattern and NTM-PD treatment initiation were more frequent in patients who isolated Aspergillus compared to those who did not (p-value respectively 0.01, 0.03 and < 0.001). Rates of culture conversion (63.0% vs. 62.2%, respectively; p-value 1) and radiologic evolution (improvement or stability in 69.7% vs. 77.2%, respectively; p-value 0.25) were not significantly different between treatment groups. Likewise, culture reversion rate and 5-year mortality were not significantly different. Additionally, A. fumigatus and repeated detection of Aspergillus were not associated with treatment outcomes.

CONCLUSION

There was no association between respiratory isolation of Aspergillus and NTM-PD treatment outcomes in this cohort. However, treatment for NTM-PD was initiated more frequently in patients who isolated Aspergillus.

Chronic Pulmonary Aspergillosis Following Nontuberculous Mycobacterial Infections: An Emerging Disease

Chronic pulmonary aspergillosis (CPA) following nontuberculous mycobacterial (NTM) lung disease is being increasingly recognized, especially in countries where tuberculosis is not endemic, with an incidence rate of 3.9–16.7%. NTM lung disease has been identified as a predictor of mortality in CPA patients. The major risk factors for NTM-associated CPA include fibrocavitary NTM lung disease, the presence of pulmonary emphysema, and high-dose corticosteroid use. The onset of CPA is 1.5–7 years following the diagnosis of NTM lung disease. The diagnosis can be made using standard criteria; however, serological diagnosis using Aspergillus precipitin has demonstrated a higher sensitivity and specificity when compared with fungal culture from respiratory specimens. Treatment is challenging since rifampicin and oral triazoles should not be used concomitantly. The prognosis is poor, and the factors associated with worse prognosis are corticosteroid use and high C-reactive protein level.