Emergence of Refractory Otomastoiditis Due to Nontuberculous Mycobacteria: Institutional Experience and Review of the Literature

The role of vestibular function tests in nontuberculous mycobacterial otomastoiditis: A case report

BACKGROUND

Nontuberculous mycobacteria (NTM), an extremely rare pathogen causing cervicofacial infections, may result in permanent hearing impairment or intracranial complications. Due to the lack of specific manifestations during the initial onset of NTM otomastoiditis, physicians may misdiagnose it as cholesteatoma or other common bacterial infections.

PATIENT CONCERNS

A 44-year-old male who complained of left-sided aural fullness, otalgia, and dizziness for 2 months.

DIAGNOSIS

The initial diagnosis was hypothesized to be cholesteatoma based on a whitish mass with mucoid discharge filling the entire outer ear canal on otoscopy and left-sided mixed hearing loss. However, NTM was identified by microbial culture at the 2-month follow-up after surgery.

INTERVENTIONS

The patient underwent a left-sided exploratory tympanotomy. Because NTM otomastoiditis was diagnosed, 3 weeks of starting therapies were administered with azithromycin (500 mg/day, oral administration), cefoxitin (3 g/day, intravenous drip), and amikacin (750 mg/day, intravenous drip). The maintenance therapies were azithromycin (500 mg/day, oral administration) and doxycycline (200 mg/day, oral administration) for 7 months.

OUTCOMES

The patient's clinical condition improved initially after surgery, but the otomastoiditis gradually worsened, combined with subtle meningitis, 2 months after surgery. The external auditory canal became swollen and obstructed, making it difficult to monitor the treatment efficacy through otoscopy. Thus, we used regular vestibular function tests, including static posturography, cervical vestibular evoked myogenic potentials, and video Head Impulse Test, to assess recovery outcomes. After antibiotic treatment, the infectious symptoms subsided significantly, and there was no evidence of infection recurrence 7 months after treatment. Improvements in static posturography and cervical vestibular evoked myogenic potentials were compatible with the clinical manifestations, but video Head Impulse Test showed an unremarkable correlation.

LESSONS

The clinical condition of NTM otomastoiditis may be evaluated using vestibular tests if patients have symptoms of dizziness.

Antimicrobial therapy for nontuberculous mycobacterial pulmonary disease improved hearing loss and normalized myeloperoxidase-anti-neutrophil cytoplasmic antibody level: A case report

Several case reports have indicated that nontuberculous mycobacterial pulmonary disease is associated with anti-neutrophil cytoplasmic antibody-associated vasculitides. However, the effect of the treatment for nontuberculous mycobacterial pulmonary disease on anti-neutrophil cytoplasmic antibody-associated vasculitides remains unclear. An asymptomatic 80-year-old woman presented with nodular bronchiectasis. After 1 year, she developed a productive cough. Mycobacterial culture of the respiratory specimen revealed Mycobacterium avium. She was diagnosed with nontuberculous mycobacterial pulmonary disease based on the criteria proposed by the American Thoracic Society. Concurrently, she had hearing loss, tinnitus, and weight loss. A blood test showed an elevated level of myeloperoxidase-anti-neutrophil cytoplasmic antibody (107 IU/mL, normal level: <3.5 IU/mL). Bilateral otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitis was diagnosed based on the diagnostic criteria proposed by the Japan Otological Society. After starting antimicrobial agents for the nontuberculous mycobacterial pulmonary disease, her pulmonary symptoms and hearing loss improved, and the level of myeloperoxidase-anti-neutrophil cytoplasmic antibody normalized. No immunosuppressive treatment was administered. The present case suggests that nontuberculous mycobacterial pulmonary disease can cause otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitides, and antimicrobial treatment for the nontuberculous mycobacterial pulmonary disease may resolve otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitides.

Aural tuberculosis at the start of the 21st century. Literature review according to SWiM guidelines. Part 1: Clinical and diagnostic data

OBJECTIVES

Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century.

MATERIAL AND METHODS

Search of the Medline, Cochrane and Embase databases for the period 2000-2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data.

RESULTS

In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P=0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively.

CONCLUSION

Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.

Spectrum of mycobacterial pathogens responsible for head and neck tuberculosis-like presentation

Tuberculosis (TB) of the head and neck can be contained in the lymph nodes, larynx, oropharynx, salivary glands, nose and paranasal sinuses, ear, skin and skull. Head and neck TB presentations are varied in nature and thus difficult to diagnose. The clinical features, radiological findings, microbiological diagnostic modalities, surgical and medical management and outcomes of nine cases of head and neck TB are discussed in detail here, together with a thorough review of the literature. Patients presented with atypical symptoms such as discharging sinus, ear lobule swelling, otitis media, vision loss and facial weakness, long refractory otorrhoea and granulation tissue in the ear canal. We diagnosed tubercular skull base osteomyelitis (one case) and laryngeal tuberculosis (two cases), mastoid tuberculosis (one case) and non-tubercular mycobacterial infection involving the temporal bone (two cases), sino-nasal region (one case), maxilla (one cases) and ear lobule (one case) over a period of 8 months. All patients were managed successfully with a combination of surgery and a well-planned treatment regimen for non-tuberculous mycobacteria (NTM) or anti-tubercular drugs for TB. All had successful outcomes except one patient with tubercular skull base osteomyelitis who expired before the initiation of anti-tubercular therapy (ATT). High clinical suspicion followed by thorough diagnostic work-up for both TB and NTM would enable early diagnosis and complete treatment.

Clinical characteristics and an evaluation of predictors for a favorable outcome of Mycobacterium abscessus otomastoiditis: a systematic review and meta-analysis of individual participant data

BACKGROUND

Otomastoiditis caused by Mycobacterium abscessus is rare, but its incidence has increased over the last decades and its optimal treatment remains unknown. This study aims to summarise clinical and therapeutic features and to find characteristics associated with favourable treatment outcomes of patients with M. abscessus otomastoiditis.

METHODS

We searched MEDLINE, EMBASE and Web of Science to identify studies including patients with M. abscessus otomastoiditis. A one-stage individual patient data (IPD) meta-analysis was conducted. A two-level mixed-effects linear regression model was provided for antimycobacterial treatment duration.

RESULTS

Twenty-three studies reported a total of 85 patients. Children presented with an unique clinical profile of a history of ear infections, tympanostomy tube placement and antibiotic treatment. Antimycobacterial treatment was administered for 26 (Inter Quartile Range (IQR): 15-35) weeks. Macrolides were prescribed in 98.8%. Surgery was performed in 80.5%, of which 47.1% required revision surgery. Otalgia was a significant predictor (β = 9.3; p = .049) of antimycobacterial treatment duration.

CONCLUSIONS

Mastoid surgery (regularly requiring revision) and a multidrug regimen for a minimum of six months including a minimum of three active agents are most often needed to attain cure. The presence of otalgia significantly extends the treatment duration of M. abscessus otomastoiditis.

Three cases of otitis media caused by Mycobacterium abscessus subsp. abscessus: Importance of medical treatment and efficacy of surgery

This study aimed to assess the clinical presentation, antibiotic therapy, surgery, and outcomes in patients with otitis media caused by Mycobacterium abscessus subsp. abscessus and discuss the efficacy of surgery. This is a retrospective case review of three patients diagnosed with otomastoiditis caused by M. abscessus subsp. abscessus. All patients had refractory otorrhea. One patient had granulation tissue in the tympanic membrane. They received medical treatment and underwent surgery. Otorrhea was resolved several months after the initiation of long-term multiantibiotic therapy in all cases. The timing of surgery varied among patients. Before initiating antibiotic therapy, mastoidectomy was performed to achieve definitive diagnosis in two patients, and wound dehiscence developed in these patients. Two patients underwent debridement after the initiation of multiantibiotic therapy. After antibiotic administration, tympanoplasty was performed to improve hearing in one patient. All patients achieved culture negativity after treatment, and no recurrences have been noted. From three cases, it is suggested that the mainstay of treatment for M. abscessus subsp. abscessus is long-term multiantibiotic therapy, and surgery itself may have little effect on achieving ear dryness. Thus, in most patients, drug therapy should be prioritized. Considering postoperative complications, surgery before achieving ear dryness should be avoided, except in emergency cases. In addition, if the diagnosis is not confirmed by repeated bacteriological tests, mastoidectomy should be performed to collect specimens. Tympanoplasty for hearing loss or eardrum perforation is recommended after discontinuation of medications.

Bipolar Distribution of Minimum Inhibitory Concentration of Q203 Across Mycobacterial Species

In this study, we conducted an experimental study to evaluate in vitro susceptibility of Q203 against Mycobacterium tuberculosis, as well as the major pathogenic nontuberculous mycobacterial species. A total of 344 nonduplicate mycobacterium isolates were randomly selected for in vitro susceptibility testing. Overall, Q203 exhibited excellent activity against multidrug-resistant (MDR-) and extensively drug-resistant tuberculosis (XDR-TB) isolates, whereas it showed high minimum inhibitory concentration (MIC) values for all nontuberculous mycobacteria (NTM) isolates tested. The MIC₅₀ and MIC₉₀ values were both 0.008 mg/L for MDR- and XDR-TB isolates, respectively. In contrast, the MIC₅₀ and MIC₉₀ values of four NTM species were all >16 mg/L. QcrB of M. tuberculosis, a component of the CytBC1 complex of the respiratory chain targeted by Q230, shared 89.7% amino acid sequence identity with Mycobacterium avium QcrB, 87.9% with that of Mycobacterium intracellulare, and 84.0% with that of Mycobacterium fortuitum, whereas with low sequence identity observed in QcrB sequence of Mycobacterium abscessus. Notably, the QcrBs of M. avium and M. intracellulare contained a 10-amino acid insertion in the linker between the eighth and ninth helical region. In conclusion, our data demonstrate the bipolar distribution of Q203 MICs across mycobacterial species. Compared with the high MICs in four clinically relevant mycobacterial species, MDR- and XDR-TB isolates have extremely low MICs, indicating that Q203 is a particularly promising candidate for TB treatment. In addition, the 10-amino acid insertion within QcrBs of M. avium and M. intracellulare may be a plausible explanation for the natural resistance to Q203 among these two species.

Nontuberculous mycobacterial infection in a tertiary care center in Mexico, 2001-2017

INTRODUCTION

Nontuberculous mycobacteria (NTM) comprise several pathogens with a complex profile of virulence, diverse epidemiological and clinical patterns as well as host specificity. Recently, an increase in the number of NTM infections has been observed; therefore, the objective of this study was to evaluate the clinical characteristics and outcomes of these infections.

METHODS

We included patients with NTM infections between 2001-2017 and obtained risk factors, clinical features and outcomes; finally, we compared this data between slowly growing (SGM) and rapidly growing mycobacteria (RGM).

RESULTS

A total of 230 patients were evaluated, 158 (69%) infected and 72 (31%) colonized/pseudoinfected. The average annual incidence in the first 11 years of the study was 0.5 cases per 1000 admissions and increased to 2.0 cases per 1000 admissions later on. The distribution of NTM infections was as follows: bloodstream and disseminated disease 72 (45%), lung infection 67 (42%), skin and soft tissue infection 19 (12%). Mycobacterium avium complex was the most common isolate within SGM infections, and HIV-infected patients were the most affected. Within RGM infections, M. fortuitum was the most common isolate from patients with underlying conditions such as cancer, type-2 diabetes mellitus, presence of invasive devices, and use of immunosuppressive therapy. We did not find significant differences in deaths and persistent infections between disseminated SGM infection when compared to disseminated RGM infection (42% vs. 24%, p=0.22). However, disseminated SGM infection required a longer duration of therapy than disseminated RGM infection (median, 210 vs. 42 days, p=0.01). NTM lung disease showed no significant differences in outcomes among treated versus non-treated patients (p=0.27).

CONCLUSIONS

Our results show a significant increase in the number of Non-tuberculosis-mycobacteria infections in our setting. Patients with slow-growing-mycobacteria infections were mainly persons living with human immunodeficiency virus . Older patients with chronic diseases were common among those with rapidly-growing-mycobacteria infections. For non-tuberculosis-mycobacteria lung infection, antibiotic therapy should be carefully individualized.

Esophageal Mycobacterium avium-intracellulare infection in a bone marrow transplant patient: Case report and literature review

Mycobacterium avium-intracellulare complex (MAC) is the most common cause of nontuberculous mycobacterial (NTM) disease in humans. We report a case of esophageal MAC disease in a patient who had allogeneic bone marrow transplant for acute lymphoblastic leukemia. Although pulmonary MAC in immunocompromised host is not uncommon, there are only a few cases of NTM-associated esophageal mass reported. Our report and literature review highlight the importance of considering MAC in the differential diagnosis of dysphagia or odynophagia.

Clinical Challenges in the Diagnosis and Treatment of Temporal Bone Osteomyelitis

Temporal bone osteomyelitis is a serious life-threatening condition—a quick and proper diagnosis is needed to start treatment and reduce morbidity and mortality. Changing trends of the disease make a differential diagnosis difficult. To emphasize the importance of a clinical suspicion of this dangerous condition, our experience with three difficult cases is presented. The diagnosis was based on clinical symptoms, otoscopic findings, and findings on computed tomography or magnetic resonance imaging. Neoplasm and granulomatous inflammation were excluded by multiple biopsies. The disease can develop in nondiabetic patients. The disorder might be related to the initial inflammatory process in the middle ear with further direct spreading of infection through defects in the bony walls to deep temporal bone structures. Imaging should be performed early to detect osteolytic lesions of the skull base. Surgery was used for the presence of bone sequestra and infratemporal abscess.