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Wang PH, Shu CC, Chen CY, Wei YF, Cheng SL. The role of treatment regimen and duration in treating patients with Mycobacterium avium complex lung disease: A real-world experience and case-control study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:164-174. [PMID: 38097480 DOI: 10.1016/j.jmii.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 02/12/2024]
Abstract
PURPOSE The treatment advantage of guideline-based therapy (GBT) in Mycobacterium avium complex lung disease (MAC-LD) is well-known. However, GBT is not always feasible. The aim of the study was to analyze the relationship of treatment regimens and duration with outcomes. MATERIALS AND METHODS This study screened patients with MAC-LD from Jan 2011 to Dec 2020 and enrolled those who received treatment. The treatment regimens were categorized to triple therapy (three active drugs) and non-triple therapy. The favorable outcomes included microbiological cure or clinical cure if no microbiologic persistence. RESULTS A total of 106 patients with MAC-LD were enrolled. Among them, 88 subjects (83 %) received triple therapy, 58 (54.7 %) had MAC treatment >12 months, and 66 (62.3 %) had favorable outcomes. Patients receiving triple therapy (90.9 % vs. 67.5 %, p = 0.008) and treatment >12 months (62.1 % vs. 42.5 %, p = 0.07) had higher proportion of favorable outcomes than unfavorable outcomes. Multivariable logistic regression analysis showed that age >65, comorbidities of COPD and prior tuberculosis, low hemoglobin, and high MAC burden were independent risk factors of unfavorable outcome. In contrast, triple therapy (OR: 0.018, 95 % CI: 0.04-0.78, p = 0.022) and treatment duration >12 months (OR: 0.20, 95 % CI: 0.055-0.69, p = 0.012) were protective factors against unfavorable outcome. CONCLUSIONS Triple therapy including GBT, and treatment more than 12 months achieved more favorable outcome. Maintenance of triple therapy, but not reducing the number of active drugs, might be an acceptable alternative of GBT.
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Affiliation(s)
- Ping-Huai Wang
- Division of Thoracic Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Chung Shu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chung-Yu Chen
- College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Yu-Feng Wei
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Lung Cheng
- Division of Thoracic Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Chemical Engineering and Materials Science, Yuan-Ze University, Taiwan
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Fujishima N, Komiya K, Yamasue M, Hiramatsu K, Kadota JI. A Systematic Review of Factors Associated with Mortality among Patients with Mycobacterium avium Complex Lung Disease. Pathogens 2023; 12:1331. [PMID: 38003795 PMCID: PMC10674274 DOI: 10.3390/pathogens12111331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
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.
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Affiliation(s)
- Nobuhiro Fujishima
- Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu 879-5593, Oita, Japan (M.Y.)
| | - Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu 879-5593, Oita, Japan (M.Y.)
| | - Mari Yamasue
- Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu 879-5593, Oita, Japan (M.Y.)
| | - Kazufumi Hiramatsu
- Medical Safety Management, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu 879-5593, Oita, Japan
| | - Jun-ichi Kadota
- Respiratory Medicine and Infectious Diseases, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu 879-5593, Oita, Japan (M.Y.)
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Luo X, Zheng X, Fang Y, Yu F, Cui H, Sun Q, Sha W. Risk factors for microbiological persistence after 6 months of treatment for Mycobacterium intracellulare and its impact on the drug-resistance profile. Microbiol Spectr 2023; 11:e0080523. [PMID: 37747243 PMCID: PMC10581050 DOI: 10.1128/spectrum.00805-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/04/2023] [Indexed: 09/26/2023] Open
Abstract
Patients with Mycobacterium intracellulare pulmonary disease are more likely to experience poor treatment outcomes if they have been observed with microbiological persistence after 6 months of treatment. This study aims to identify the risk factors for microbiological persistence and describe the changes in the minimum inhibitory concentration (MIC) during antimycobacterial treatment. This retrospective case-control study enrolled patients diagnosed with M. intracellulare pulmonary disease between April 2017 and September 2021 at Shanghai Pulmonary Hospital. Patients with positive cultures after 6 months of treatment (positive group) were matched by age and sex in a 1:1 ratio to patients with negative conversion (negative group). Totally, 46 pairs of patients were analyzed. Risk factors for microbiological persistence at month 6 were smoking, previous tuberculosis treatment, chronic lung diseases, a positive baseline acid-fast bacilli smear, and adverse drug reactions; the risk was reduced by a regimen containing ethambutol, ≥3 effective drugs, and a higher pre-treatment absolute lymphocyte count. Regarding the drug-resistance profile, the negative group had a higher proportion of susceptibility to clarithromycin (100.0% vs 84.8%, P = 0.012). Most isolates were susceptible or intermediate to amikacin in both groups (93.5% and 84.8%, respectively). Nine patients (16.4%, 9/55) had a change in the drug-resistance profile, including four who changed from clarithromycin susceptible to clarithromycin resistant, and the other three reversed. Two pairs of isolates had a change in resistance to amikacin. In conclusion, risk factors for microbiological persistence were identified, and the change in MIC values during antimycobacterial treatment indicated the need for monitoring to enable timely adjustment of the regimen.IMPORTANCENontuberculous mycobacteria pulmonary disease (NTM-PD) has been recognized as an important public health issue because of its increasing incidence globally, low cure rate, and high recurrence rate. NTM-PD has innate resistance to many first-line anti-tuberculous drugs, which limits the treatment options. Mycobacterium intracellulare is reportedly the most important pathogenic NTM and accounts for the highest proportion of NTM-PD in China. A previous study suggested that poor microbiological response after 6 months of treatment is predictive of treatment failure. The present study investigated the risk factors associated with persistent positive sputum cultures by treatment month 6 in patients with M. intracellulare pulmonary disease and the variation in minimum inhibitory concentration patterns in clinical settings. This information might help to identify patients at higher risk of treatment failure and enable the timely provision of necessary interventions.
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Affiliation(s)
- Xuejiao Luo
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xubin Zheng
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yong Fang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fangyou Yu
- Department of Clinical Laboratory, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Haiyan Cui
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qin Sun
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Sha
- Department of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- Clinical and Research Center for Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Takayama Y, Yumen Y, Kitajima T, Honda N, Sakane N, Fukui M, Nagai N. Association of body size distortion with low body mass index in female patients with nontuberculous mycobacterial lung disease. PLoS One 2023; 18:e0290277. [PMID: 37607192 PMCID: PMC10443841 DOI: 10.1371/journal.pone.0290277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND We have previously reported that female patients with nontuberculous mycobacterial lung disease (NTM-LD) are thinner and eat less than healthy controls. Therefore, we hypothesized that their thinness is associated with body size misperception. The aim of this study was to clarify whether patients' body size perception (BSP) is associated with body mass index (BMI) independent of potential confounders. METHODS In this cross-sectional study, we assessed 81 outpatients for BSP using the Japanese version of Body Image Scale, body composition, dietary intake, and biochemical markers. As a control, we used BSP and self-reported anthropometric data from 111 healthy women collected via a web survey. First, BSP and BMI were compared between the patients and the controls. Second, patient data was compared between patients who overestimated their body size (OE, n = 31) and a control who did not (Non-OE, n = 50). Multiple regression analysis was performed to clarify the association between BSP (independent variable) and BMI (dependent variable), adjusting for potential confounders, such as age, disease duration, and nutritional factors. RESULTS There was a negative correlation between body size distortion and BMI in both patients and controls (p < 0.001, both). In interpatient comparisons, the OE group had significantly lower BMI and body fat percentage (p < 0.001, both), normalized energy (p = 0.037), and protein (p = 0.013) intakes, and significantly greater weight loss from age 20 (p = 0.003) than the Non-OE group. Multiple regression analysis revealed that overestimation of body size was associated with lower BMI independent of confounders, such as longer disease history, longitudinal weight loss, and nutritional factors. CONCLUSION These findings suggest that body size distortion is an etiological factor for lower BMI in female patients with NTM-LD. Thus, it may be important to understand the patient's body image when providing dietary advice.
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Affiliation(s)
- Yumi Takayama
- Department of Nutrition, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
- Laboratory of Nutritional Physiology, Graduate School of Human Science and Environment, University of Hyogo, Hyogo, Japan
| | - Yukina Yumen
- Laboratory of Nutritional Physiology, Graduate School of Human Science and Environment, University of Hyogo, Hyogo, Japan
| | - Takamasa Kitajima
- Respiratory Disease Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Noritsugu Honda
- Department of Rehabilitation, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute for Endocrine and Metabolic Disease, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Narumi Nagai
- Laboratory of Nutritional Physiology, Graduate School of Human Science and Environment, University of Hyogo, Hyogo, Japan
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Nonaka M, Matsuyama M, Sakai C, Matsumura S, Arai N, Nakajima M, Saito T, Hizawa N. Risk factors for clinical progression in patients with pulmonary Mycobacterium avium complex disease without culture-positive sputum: a single-center, retrospective study. Eur J Med Res 2023; 28:186. [PMID: 37291649 DOI: 10.1186/s40001-023-01152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVES Limited data are available on the progression of pulmonary Mycobacterium avium complex (MAC) disease without culture-positive sputum. The aim of this study was to identify the risk factors associated with clinical progression of pulmonary MAC disease diagnosed by bronchoscopy. METHODS A single-center, retrospective, observational study was conducted. Pulmonary MAC patients diagnosed by bronchoscopy without culture-positive sputum from January 1, 2013, to December 31, 2017 were analyzed. Clinical progression after diagnosis was defined as having culture-positive sputum at least once or initiation of guideline-based therapy. Then, clinical characteristics were compared between clinically progressed patients and stable patients. RESULTS Ninety-three pulmonary MAC patients diagnosed by bronchoscopy were included in the analysis. During the 4-year period after diagnosis, 38 patients (40.9%) started treatment, and 35 patients (37.6%) had new culture-positive sputum. Consequently, 52 patients (55.9%) were classified into the progressed group, and 41 patients (44.1%) were classified into the stable group. There were no significant differences between the progressed and the stable groups in age, body mass index, smoking status, comorbidities, symptoms, or species isolated from bronchoscopy. On multivariate analysis, male sex, monocyte to lymphocyte ratio (MLR) ≥ 0.17, and the presence of combined lesions in the middle (lingula) and lower lobes were risk factors for clinical progression. CONCLUSIONS Some patients with pulmonary MAC disease without culture-positive sputum progress within 4 years. Therefore, pulmonary MAC patients, especially male patients, having higher MLR or lesions in the middle (lingula) and lower lobes might need careful follow-up for a longer time.
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Affiliation(s)
- Mizu Nonaka
- Department of Respiratory Medicine, National Hospital Organization Ibarakihigashi National Hospital, Ibaraki, Japan
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masashi Matsuyama
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
- Department of Pulmonary Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Ibaraki, Tsukuba, 305-8575, Japan.
| | - Chio Sakai
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Sosuke Matsumura
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Arai
- Department of Respiratory Medicine, National Hospital Organization Ibarakihigashi National Hospital, Ibaraki, Japan
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masayuki Nakajima
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takefumi Saito
- Department of Respiratory Medicine, National Hospital Organization Ibarakihigashi National Hospital, Ibaraki, Japan
| | - Nobuyuki Hizawa
- Department of Respiratory Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Hwang H, Lee JK, Heo EY, Kim DK, Lee HW. The factors associated with mortality and progressive disease of nontuberculous mycobacterial lung disease: a systematic review and meta-analysis. Sci Rep 2023; 13:7348. [PMID: 37147519 PMCID: PMC10162985 DOI: 10.1038/s41598-023-34576-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 05/03/2023] [Indexed: 05/07/2023] Open
Abstract
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.
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Affiliation(s)
- Hyeontaek Hwang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Eun Young Heo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea.
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Matsuyama M, Matsumura S, Nonaka M, Nakajima M, Sakai C, Arai N, Ueda K, Hizawa N. Pathophysiology of pulmonary nontuberculous mycobacterial (NTM) disease. Respir Investig 2023; 61:135-148. [PMID: 36640546 DOI: 10.1016/j.resinv.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/25/2022] [Accepted: 12/08/2022] [Indexed: 01/15/2023]
Abstract
In recent years, the incidence and prevalence of pulmonary nontuberculous mycobacterial (NTM) disease have increased worldwide. Although the reasons for this increase are unclear, dealing with this disease is essential. Pulmonary NTM disease is a chronic pulmonary infection caused by NTM bacteria, which are ubiquitous in various environments. In Japan, Mycobacterium avium-intracellulare complex (MAC) accounts for approximately 90% of the causative organisms of pulmonary NTM disease, which is also called pulmonary MAC disease or pulmonary MAI disease. It is important to elucidate the pathophysiology of this disease, which occurs frequently in postmenopausal women despite the absence of obvious immunodeficiency. The pathophysiology of this disease has not been fully elucidated; however, it can largely be divided into bacterial (environmental) and host-side problems. The host factors can be further divided into immune and airway problems. The authors suggest that the triangular relationship between bacteria, immunity, and the airway is important in the pathophysiology of this disease. The latest findings on the pathophysiology of pulmonary NTM disease are reviewed.
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Affiliation(s)
- Masashi Matsuyama
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan.
| | - Sosuke Matsumura
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Mizu Nonaka
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Masayuki Nakajima
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Chio Sakai
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Naoki Arai
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Kodai Ueda
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
| | - Nobuyuki Hizawa
- Department of Respiratory Medicine, Institute of Medicine, University of Tsukuba, Japan
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Takayama Y, Kitajima T, Honda N, Sakane N, Yumen Y, Fukui M, Nagai N. Nutritional status in female patients with nontuberculous mycobacterial lung disease and its association with disease severity. BMC Pulm Med 2022; 22:315. [PMID: 35971083 PMCID: PMC9380388 DOI: 10.1186/s12890-022-02109-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background In women, slender body habitus has been reported to be one of the predisposing factors underlying the development and poor prognosis of non-tuberculous mycobacterial lung disease (NTM-LD). Given the lack of nutritional data contributing to treatment strategies, we aimed to clarify the nutritional status of female patients with NTM-LD and its association with disease severity. Methods In this single-center observational study, we enrolled 81 female outpatients with NTM-LD. Data on healthy women of similar ages were selected from our previous survey data and categorized as controls. First, we compared anthropometric and dietary survey data between patients and controls. Second, after the patients were categorized into relatively mild (mild, n = 40) and relatively severe groups (severe, n = 41) based on pulmonary X-ray-image finding scores, body composition, nutritional intake, and biochemical markers were compared between the groups. To identify nutritional factors associated with disease severity, logistic regression analyses were performed. Results Compared with controls, patients with NTM-LD had significantly lower energy intake, body mass index, body fat, and skeletal muscle mass (all p < 0.001). Compared with the mild group, the severe group had significantly lower skeletal muscle mass (p = 0.037), albumin (p = 0.029), transthyretin (prealbumin) (p = 0.002), retinol-binding protein (p = 0.011), and hemoglobin (p = 0.001); however, no between-group differences were observed in energy or nutrient intake. Logistic analyses revealed that transthyretin (p = 0.025) and hemoglobin (p = 0.003) levels were independent factors associated with disease severity. Conclusions This is the first study to comprehensively report the association between NTM-LD severity and nutritional status, including body composition, nutrient intake, and biomarkers. The results suggest that initiating nutritional therapy from the mild stage of the disease to prevent undernutrition is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02109-5.
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Affiliation(s)
- Yumi Takayama
- Department of Nutrition, Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ogi-machi, Kita-ku, Osaka-city, Osaka, 530-8480, Japan.,Graduate School of Human Science and Environment, University of Hyogo, 1-1-12 Shinzaike-honcho, Himeji city, Hyogo, 670-0092, Japan
| | - Takamasa Kitajima
- Respiratory Disease Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ogi-machi, Kita-ku, Osaka-city, Osaka, 530-8480, Japan
| | - Noritsugu Honda
- Department of Rehabilitation, Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ogi-machi, Kita-ku, Osaka-city, Osaka, 530-8480, Japan
| | - Naoki Sakane
- Clinical Research Institute for Endocrine and Metabolic Disease, National Hospital Organization, Kyoto Medical Center, 1-1 Fukakusamukaihata-cho, Fushimi-ku, Kyoto-city, Kyoto, 612-8555, Japan
| | - Yukina Yumen
- Graduate School of Human Science and Environment, University of Hyogo, 1-1-12 Shinzaike-honcho, Himeji city, Hyogo, 670-0092, Japan
| | - Motonari Fukui
- Respiratory Disease Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, 2-4-20 Ogi-machi, Kita-ku, Osaka-city, Osaka, 530-8480, Japan
| | - Narumi Nagai
- Graduate School of Human Science and Environment, University of Hyogo, 1-1-12 Shinzaike-honcho, Himeji city, Hyogo, 670-0092, Japan.
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Cheng LP, Chen SH, Lou H, Gui XW, Shen XN, Cao J, Sha W, Sun Q. Factors Associated with Treatment Outcome in Patients with Nontuberculous Mycobacterial Pulmonary Disease: A Large Population-Based Retrospective Cohort Study in Shanghai. Trop Med Infect Dis 2022; 7:tropicalmed7020027. [PMID: 35202222 PMCID: PMC8876156 DOI: 10.3390/tropicalmed7020027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 02/06/2023] Open
Abstract
Infectious diseases caused by nontuberculous mycobacteria (NTM) are increasingly common. This retrospective cohort study examined factors associated with outcomes in patients from Shanghai who had NTM pulmonary disease (NTMPD) from January 2014 to December 2018. The causative bacterial species, drug susceptibility test results, treatment outcomes, sputum culture conversion rate, and risk factors associated with treatment failure were determined. The most common species were Mycobacterium avium complex (MAC) (50%), M. abscessus (28%), and M. kansasii (15%). Over five years, the proportions of M. kansasii and M. abscessus increased, and that of MAC decreased. The treatment success rate was significantly greater for patients infected with M. kansasii (89.9%) than MAC (65.0%, p < 0.001) and M. abscessus (36.1%, p < 0.001). Multivariate analysis indicated the risk factors for treatment failure were pathogenic NTM species (M. abscessus: aOR = 9.355, p < 0.001; MAC: aOR = 2.970, p < 0.001), elevated ESR (>60 mm/h: aOR = 2.658, p < 0.001), receipt of retreatment (aOR = 2.074, p < 0.001), and being middle-aged or elderly (>60 years-old: aOR = 1.739, p = 0.021; 45-60 years-old: aOR = 1.661, p = 0.034). The main bacterial species responsible for NTMPD were MAC, M. abscessus, and M. kansasii. Patients who were infected by M. abscessus or MAC, with elevated ESR, received retreatment, and were middle-aged or elderly had an increased risk of treatment failure.
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Affiliation(s)
| | | | | | | | | | | | - Wei Sha
- Correspondence: (W.S.); (Q.S.)
| | - Qin Sun
- Correspondence: (W.S.); (Q.S.)
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Im Y, Hwang NY, Kim K, Kim H, Kwon OJ, Jhun BW. Impact of time between diagnosis and treatment for nontuberculous mycobacterial pulmonary disease on culture conversion and all-cause mortality. Chest 2021; 161:1192-1200. [PMID: 34793759 DOI: 10.1016/j.chest.2021.10.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/15/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Limited data are available regarding when to start treatment following a diagnosis of nontuberculous mycobacteria-pulmonary disease (NTM-PD) or regarding how achieving culture conversion affects NTM-PD outcomes. RESEARCH QUESTION Does the time between diagnosis and antibiotic initiation influence culture conversion or all-cause mortality in NTM-PD, and is there any association between achieving culture conversion after antibiotics and reduced all-cause mortality? STUDY DESIGN AND METHODS We evaluated 712 patients who received antibiotics for ≥ 6 months after diagnosis of NTM-PD between July 1997 and December 2013. Data on the waiting period, defined as the time interval between diagnosis and treatment initiation, and on outcomes such as culture conversion by six months or death were collected. Factors associated with outcomes were analyzed after adjusting for disease severity using the body mass index, age, cavity, erythrocyte sedimentation rate and sex (BACES) system. RESULTS Thirty-eight percent of study patients had mild disease, 48% had moderate disease, and 14% had severe disease. The median waiting period without antibiotics among all patients was 4.8 (interquartile range 1.3-20.8) months. After treatment initiation, 479 (67%) patients achieved culture conversion within six months, whereas 135 (19%) patients died. In univariate and multivariate models adjusted for BACES severity, no association between the waiting period and 6-month culture conversion or death was identified. However, 6-month culture conversion demonstrated a significant negative correlation with death (crude hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.33-0.65; adjusted HR 0.51, 95% 0.35-0.74). In the sub-group treated for ≥ 12 months, 12-month culture conversion was also associated with reduced death (adjusted HR 0.51, 95% CI 0.33-0.78). INTERPRETATION It may be reasonable to start antibiotics according to the 'watchful waiting' strategy for NTM-PD, but given the survival benefits, achieving culture conversion is an important goal for patients in need of treatment.
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Affiliation(s)
- Yunjoo Im
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Na Young Hwang
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - O Jung Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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11
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Tanaka G, Jo T, Tamiya H, Sakamoto Y, Hasegawa W, Matsui H, Fushimi K, Yasunaga H, Nagase T. Factors affecting in-hospital mortality of non-tuberculous mycobacterial pulmonary disease. BMC Infect Dis 2021; 21:698. [PMID: 34284734 PMCID: PMC8293483 DOI: 10.1186/s12879-021-06395-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/14/2021] [Indexed: 12/04/2022] Open
Abstract
Background The incidence and prevalence of non-tuberculous mycobacterial pulmonary disease (NTM-PD) are reportedly increasing in many parts of the world. However, there are few published data on NTM-PD-related death. Using data from a national inpatient database in Japan, we aimed in this study to identify the characteristics of patients with NTM-PD and clinical deterioration and to identify risk factors for in-hospital mortality. Methods We examined data from the Diagnosis Procedure Combination (DPC) database in Japan from July 2010 to March 2014. We extracted data for HIV-negative NTM-PD patients who required unscheduled hospitalization. We evaluated these patients’ characteristics and performed multivariable logistic regression analysis to identify risk factors for all-cause in-hospital mortality. Results A total of 16,192 patients (median age: 78 years; women: 61.2%) were identified. The median body mass index (BMI) was 17.5 kg/m2 (IQR 15.4–20.0). All cause In-hospital death occurred in 3166 patients (19.6%). The median BMI of the patients who had died was 16.0 kg/m2 (IQR 14.2–18.4). Multivariable analysis revealed that increased mortality was associated with male sex, lower BMI, lower activities of daily living scores on the Barthel index, hemoptysis, and comorbidities, including pulmonary infection other than NTM, interstitial lung disease, pneumothorax, and malignant disease. Conclusions We found associations between being underweight and having several comorbidities and increased in-hospital mortality in patients with NTM-PD. Preventing weight loss and management of comorbidities may have a crucial role in improving this disease’s prognosis.
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Affiliation(s)
- Goh Tanaka
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Taisuke Jo
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.,Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Tamiya
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yukiyo Sakamoto
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Wakae Hasegawa
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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12
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Furuuchi K, Fujiwara K, Uesgi F, Shimoda M, Seto S, Tanaka Y, Yoshiyama T, Yoshimori K, Kurashima A, Ohta K, Morimoto K. Posttreatment Lymphopenia Is Associated With an Increased Risk of Redeveloping Nontuberculous Lung Disease in Patients With Mycobacterium avium Complex Lung Disease. Clin Infect Dis 2021; 73:e152-e157. [PMID: 32507892 DOI: 10.1093/cid/ciaa729] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Lymphopenia has been reported as a risk factor for poor prognosis in various infectious diseases, including Mycobacterium avium complex lung disease (MAC-LD), and recurrence in several infectious diseases. However, the association between lymphopenia and the risk of redeveloping nontuberculous lung disease (NTM-LD) after completed treatment for MAC-LD is unknown. METHODS We performed a retrospective cohort study with 147 patients with MAC-LD who successfully completed guideline-based therapy. Lymphopenia was defined as an absolute lymphocyte count (ALC) <1000 cells/μL based on commonly accepted reference values. RESULTS During the median follow-up period of 41.9 months after treatment completion, 59 (40.1%) patients redeveloped NTM-LD. Patients with NTM-LD redevelopment had significantly lower posttreatment ALCs (median, 1260 vs 1420 cells/μL) than those without, and the univariate Cox proportional hazard analysis identified posttreatment ALC as a predictive factor for redevelopment (hazard ratio, .94 [95% confidence interval, .89-.99] for every increase of 100 cells/μL; P = .04). In the multivariate analysis, posttreatment ALC and the extent of bronchiectasis were independently associated with NTM-LD redevelopment. The cumulative rate of NTM-LD redevelopment was significantly higher in patients with posttreatment lymphopenia than in those without (P = .008). CONCLUSIONS Posttreatment lymphopenia could predict an increased risk of NTM-LD redevelopment after completed treatment for MAC-LD.
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Affiliation(s)
- Koji Furuuchi
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Department of Pathophysiology and Host Defense, the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Department of Basic Mycobacteriosis, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Keiji Fujiwara
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Ibaraki, Japan
| | - Fumiko Uesgi
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Masafumi Shimoda
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Shintaro Seto
- Department of Pathophysiology and Host Defense, the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Yoshiaki Tanaka
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Takashi Yoshiyama
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Kozo Yoshimori
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Atsuyuki Kurashima
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Ken Ohta
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Kozo Morimoto
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Division of Clinical Research, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Tokyo, Japan
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13
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Kim HJ, Kwak N, Hong H, Kang N, Im Y, Jhun BW, Yim JJ. BACES Score for Predicting Mortality in Nontuberculous Mycobacterial Pulmonary Disease. Am J Respir Crit Care Med 2021; 203:230-236. [PMID: 32721164 DOI: 10.1164/rccm.202004-1418oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Because the prognosis of nontuberculous mycobacterial pulmonary disease varies, a scoring system predicting mortality is needed.Objectives: We aimed to develop a novel scoring system to predict mortality among patients with nontuberculous mycobacterial pulmonary disease.Methods: We included patients age ≥20 years with newly diagnosed nontuberculous mycobacterial pulmonary disease, with Mycobacterium avium, M. intracellulare, M. abscessus subsp. abscessus, or M. abscessus subsp. massiliense. Cox proportional hazards models were used to identify predictors of mortality in a derivation cohort, and a scoring system was developed. It was validated in an independent prospective cohort.Measurements and Main Results: A total 1,181 and 377 patients were included in the derivation and validation cohorts, respectively. In the final model, body mass index <18.5 kg/m2 (1 point), age ≥65 years (1 point), presence of cavity (1 point), elevated erythrocyte sedimentation rate (1 point), and male sex (1 point) were selected as predictors for mortality. We named this novel scoring system BACES (body mass index, age, cavity, erythrocyte sedimentation rate, and sex). Harrell's C-index for the BACES score was 0.812 (95% confidence interval, 0.786-0.837) in the derivation cohort and 0.854 (95% confidence interval, 0.797-0.911) in the validation cohort, indicating excellent discrimination performance. The estimated 5-year risk of mortality was 1.2% with BACES score 0 and 82.9% with BACES score 5.Conclusions: We developed the BACES score, which could accurately predict mortality among patients with nontuberculous mycobacterial pulmonary disease caused by M. avium, M. intracellulare, M. abscessus subsp. abscessus, or M. abscessus subsp. massiliense.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; and
| | - Hyunsook Hong
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Noeul Kang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yunjoo Im
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; and
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14
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Aksamit TR. One Step Closer: Nontuberculous Mycobacterial Pulmonary Disease and Predicted Mortality-The BACES Score. Am J Respir Crit Care Med 2021; 203:163-164. [PMID: 32835508 PMCID: PMC7874411 DOI: 10.1164/rccm.202008-3051ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Timothy R Aksamit
- Pulmonary Disease and Critical Care Medicine Mayo Clinic Rochester, Minnesota
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15
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Mortality in rheumatoid arthritis patients with pulmonary nontuberculous mycobacterial disease: A retrospective cohort study. PLoS One 2020; 15:e0243110. [PMID: 33264361 PMCID: PMC7710034 DOI: 10.1371/journal.pone.0243110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022] Open
Abstract
Objective The aim of this study was to compare long-term mortality following diagnosis of pulmonary nontuberculous mycobacterial (NTM) disease between patients with and without rheumatoid arthritis (RA) and to evaluate predictive factors for death outcomes. Methods We reviewed the electronic medical records of all patients who were newly diagnosed with pulmonary NTM disease at participating institutions between August 2009 and December 2018. Patients were followed until death, loss to follow-up, or the end of the study. Taking into consideration the presence of competing risks, we used the cumulative incidence function with Gray’s test and Fine-Gray regression analysis for survival analysis. Results A total of 225 patients (34 RA patients and 191 non-RA controls) were followed, with a mean time of 47.5 months. Death occurred in 35.3% of RA patients and 25.7% of non-RA patients. An exacerbation of pulmonary NTM disease represented the major cause of death. The estimated cumulative incidence of all-cause death at 5 years was 24% for RA patients and 23% for non-RA patients. For NTM-related death, the 5-year cumulative incidence rate was estimated to be 11% for RA patients and 18% for non-RA patients. Gray’s test revealed that long-term mortality estimates were not significantly different between patient groups. Fine-Gray regression analysis showed that the predictive factors for NTM-related death were advanced age (adjusted hazards ratio 7.28 [95% confidence interval 2.91–18.20] for ≥80 years and 3.68 [1.46–9.26] for 70–80 years vs. <70 years), male sex (2.40 [1.29–4.45]), Mycobacterium abscessus complex (4.30 [1.46–12.69] vs. M. avium), and cavitary disease (4.08 [1.70–9.80]). Conclusions RA patients with pulmonary NTM disease were not at greater risk of long-term mortality compared with non-RA patients. Rather, advanced age, male sex, causative NTM species, and cavitary NTM disease should be considered when predicting the outcomes of RA patients with pulmonary NTM disease.
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16
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Griffith DE, Aksamit TR. Managing Mycobacterium avium Complex Lung Disease With a Little Help From My Friend. Chest 2020; 159:1372-1381. [PMID: 33080299 DOI: 10.1016/j.chest.2020.10.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/13/2020] [Accepted: 10/16/2020] [Indexed: 12/26/2022] Open
Abstract
Management of Mycobacterium avium complex (MAC) lung disease is complicated, frequently unsuccessful, and frustrating to patients and clinicians. The initial treatment effort may not be directed solely at MAC infection, rather it is often initiating airway clearance measures for bronchiectasis. The next important steps are deciding who to treat and when to initiate therapy. Definitive or unambiguous guidance for these decisions is often elusive. The evidence supporting the current macrolide-based regimen for treating MAC lung disease is compelling. This regimen has been recommended in consensus nontuberculous mycobacterial treatment guidelines from 1997, 2007, and 2020, although clinician compliance with these recommendations is inconsistent. Understanding the idiosyncrasies of MAC antibiotic resistance is crucial for optimal antibiotic management. As a corollary, the importance of avoiding development of macrolide resistance due to inadequate therapy cannot be overstated. An inhaled liposome amikacin preparation is now approved for treating refractory MAC lung disease and holds promise for an even broader role in MAC therapy. Surgery is also an important therapeutic adjunct for selected patients. Microbiologic recurrences due either to new infection or treatment relapse/failure are common and require the same level of rigorous assessment and clinical judgment for determining their significance as initial MAC isolates. In summary, treatment of patients with MAC lung disease is rarely straight forward and requires familiarity with multiple factors directly and indirectly related to MAC lung disease. The many nuances of MAC lung disease therapy defy simple treatment algorithms; however, with patience, attention to detail, and perseverance, the outcome for most patients is favorable.
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Affiliation(s)
| | - Timothy R Aksamit
- Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, MN
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17
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Hachisu Y, Murata K, Takei K, Tsuchiya T, Tsurumaki H, Koga Y, Horie T, Takise A, Hisada T. Prognostic nutritional index as a predictor of mortality in nontuberculous mycobacterial lung disease. J Thorac Dis 2020; 12:3101-3109. [PMID: 32642232 PMCID: PMC7330762 DOI: 10.21037/jtd-20-803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Although the association between nontuberculous mycobacterial lung disease (NTM-LD) and malnutrition is known, there are a few reports on the association between the nutritional score and death in patients with NTM-LD. This study investigated the association between the nutrition data at the time of NTM-LD diagnosis and death. Methods A retrospective study was conducted for patients with NTM-LD who visited the Maebashi Red Cross Hospital from January 2014 to December 2018. The patients were divided into the survival and death groups and analyzed statistically. Results The diagnostic criteria for NTM-LD were met by 150 patients. The median age was 70 years (range, 20–94 years). There were 51 (34.0%) men and 99 (66.0%) women. In the death group, the body mass index was significantly low, and there were significantly more patients with asthma. Further, computed tomography at the first visit revealed significantly fewer cases of the nodular bronchiectasis type. In the hematologic examination at the time of NTM-LD diagnosis, the white blood cell, neutrophil, and platelet counts and C-reactive protein and serum calcium levels were significantly higher in the death group, while the serum albumin level was significantly lower. In the death group, the prognostic nutritional index (PNI), calculated from the hematologic findings, was significantly lower, while the Glasgow Prognostic Score (GPS) was significantly higher. A logistic regression analysis was performed on items with significant differences, and the PNI and platelet count were independent factors predicting death. Conclusions PNI might be effective as a prognostic factor for NTM-LD.
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Affiliation(s)
- Yoshimasa Hachisu
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Keisuke Murata
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Kousuke Takei
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Takuma Tsuchiya
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Hiroaki Tsurumaki
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yasuhiko Koga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takeo Horie
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Atsushi Takise
- Department of Respiratory Medicine, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, Maebashi, Japan
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18
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Impact of Aspergillus precipitating antibody test results on clinical outcomes of patients with Mycobacterium avium complex lung disease. Respir Med 2020; 166:105955. [DOI: 10.1016/j.rmed.2020.105955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/17/2020] [Accepted: 03/31/2020] [Indexed: 01/19/2023]
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19
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Ratnatunga CN, Lutzky VP, Kupz A, Doolan DL, Reid DW, Field M, Bell SC, Thomson RM, Miles JJ. The Rise of Non-Tuberculosis Mycobacterial Lung Disease. Front Immunol 2020; 11:303. [PMID: 32194556 PMCID: PMC7062685 DOI: 10.3389/fimmu.2020.00303] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/06/2020] [Indexed: 12/21/2022] Open
Abstract
The incidence and number of deaths from non-tuberculous mycobacterial (NTM) disease have been steadily increasing globally. These lesser known “cousins” of Mycobacterium tuberculosis (TB) were once thought to be harmless environmental saprophytics and only dangerous to individuals with defective lung structure or the immunosuppressed. However, NTM are now commonly infecting seemingly immune competent children and adults at increasing rates through pulmonary infection. This is of concern as the pathology of NTM is difficult to treat. Indeed, NTM have become extremely antibiotic resistant, and now have been found to be internationally dispersed through person-to-person contact. The reasons behind this NTM increase are only beginning to be elucidated. Solutions to the problem are needed given NTM disease is more common in the tropics. Importantly, 40% of the world's population live in the tropics and due to climate change, the Tropics are expanding which will increase NTM infection regions. This review catalogs the global and economic disease burden, at risk populations, treatment options, host-bacterial interaction, immune dynamics, recent developments and research priorities for NTM disease.
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Affiliation(s)
- Champa N. Ratnatunga
- The Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Immunology Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- *Correspondence: Champa N. Ratnatunga
| | - Viviana P. Lutzky
- Immunology Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Andreas Kupz
- The Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, Australia
| | - Denise L. Doolan
- The Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, Australia
| | - David W. Reid
- Immunology Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Matthew Field
- The Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, Australia
| | - Scott C. Bell
- Immunology Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Rachel M. Thomson
- Immunology Department, Gallipoli Medical Research Institute, Brisbane, QLD, Australia
| | - John J. Miles
- The Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, Australia
- John J. Miles
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20
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Oshitani Y, Kitada S, Edahiro R, Tsujino K, Kagawa H, Yoshimura K, Miki K, Miki M, Kida H. Characteristic chest CT findings for progressive cavities in Mycobacterium avium complex pulmonary disease: a retrospective cohort study. Respir Res 2020; 21:10. [PMID: 31915013 PMCID: PMC6950929 DOI: 10.1186/s12931-020-1273-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although cavities are an important finding in Mycobacterium avium complex pulmonary disease (MAC-PD), there is little information regarding the types of cavities that indicate disease progression. This study was performed to identify cavity characteristics that were associated with disease progression in patients with MAC-PD. METHODS This retrospective cohort study included 97 patients presenting with MAC-PD with cavities between December 2006 and June 2016. We compared initial and final computed tomography (CT) findings, classified 52 and 45 patients in the progressive and non-progressive cavity groups, respectively, and examined the progression-related imaging features in initial CT images. A progressive cavity was defined by more than two-fold increase in internal diameter or emergence of a new cavity around the initial cavity. RESULTS Patients in the progressive group were older (p < 0.001), had a lower body mass index (p = 0.043), and showed higher diabetes complication rates (p = 0.005). The initial CT in the progressive group showed a longer maximum internal diameter of the cavity (p < 0.001) and higher rates of cavities close to the chest wall (p < 0.001), multiple cavities (p = 0.023), consolidation around the cavity (p < 0.001), atelectasis (p = 0.011), and pleural thickening (p < 0.001). Multivariable logistic regression analysis revealed that the maximum internal diameter of the cavity (odds ratio [OR]: 1.11, 95% confidence interval [CI]: 1.02-1.21; p=0.012) and consolidation around the cavity (OR: 16.15, 95% CI: 4.05-64.46; p < 0.001) were significantly associated with progressive cavities. In cavities with a maximum internal diameter of ≥10 mm and simultaneous consolidation, the probability of progression was as high as 96.2%. The 10-year mortality rates in the progressive and non-progressive cavity groups were 46.7 and 9.8% (p < 0.001), respectively, while the 10-year respiratory failure rates were 28.1 and 0%, respectively (p < 0.001). CONCLUSIONS Large cavity size and consolidation on CT showed strong relationships with disease progression, which led to respiratory failure and high mortality rate.
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Affiliation(s)
- Yohei Oshitani
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan.
| | - Seigo Kitada
- Department of Respiratory Medicine, Yao Tokushukai General Hospital, Osaka, Japan
| | - Ryuya Edahiro
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuyuki Tsujino
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
| | - Hiroyuki Kagawa
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
| | - Kenji Yoshimura
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
| | - Keisuke Miki
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
| | - Mari Miki
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
| | - Hiroshi Kida
- Department of Respiratory Medicine, National Hospital Organization, Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka-shi, Osaka, 560-8552, Japan
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21
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Cowman S, van Ingen J, Griffith DE, Loebinger MR. Non-tuberculous mycobacterial pulmonary disease. Eur Respir J 2019; 54:13993003.00250-2019. [PMID: 31221809 DOI: 10.1183/13993003.00250-2019] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/31/2019] [Indexed: 02/03/2023]
Abstract
Nontuberculous mycobacterial pulmonary disease (NTM-PD) is a challenging infection which is becoming increasingly prevalent, particularly in the elderly, for reasons which are unknown. While underlying lung disease is a well-established risk factor for NTM-PD, it may also occur in apparently healthy individuals. No single common genetic or immunological defect has been identified in this group, and it is likely that multiple pathways contribute towards host susceptibility to NTM-PD which further interact with environmental and microbiological factors leading to the development of disease.The diagnosis of NTM-PD relies on the integration of clinical, radiological and microbiological results. The clinical course of NTM-PD is heterogeneous, with some patients remaining stable without the need for treatment and others developing refractory disease associated with considerable mortality and morbidity. Treatment regimens are based on the identity of the isolated species, drug sensitivity testing (for some agents) and the severity of disease. Multiple antibiotics are typically required for prolonged periods of time and treatment is frequently poorly tolerated. Surgery may be beneficial in selected cases. In some circumstances cure may not be attainable and there is a pressing need for better regimens to treat refractory and drug-resistant NTM-PD.This review summarises current knowledge on the epidemiology, aetiology and diagnosis of NTM-PD and discusses the treatment of two of the most clinically significant species, the M. avium and M. abscessus complexes, with a focus on refractory disease and novel therapies.
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Affiliation(s)
- Steven Cowman
- Host Defence Unit, Royal Brompton Hospital, London, UK.,Imperial College, London, UK
| | - Jakko van Ingen
- Dept of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David E Griffith
- Dept of Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Michael R Loebinger
- Host Defence Unit, Royal Brompton Hospital, London, UK .,Imperial College, London, UK
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22
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Kwon BS, Lee JH, Koh Y, Kim WS, Song JW, Oh YM, Lee SD, Lee SW, Lee JS, Lim CM, Choi CM, Huh JW, Hong SB, Shim TS, Jo KW. The natural history of non-cavitary nodular bronchiectatic Mycobacterium avium complex lung disease. Respir Med 2019; 150:45-50. [PMID: 30961950 DOI: 10.1016/j.rmed.2019.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 12/28/2018] [Accepted: 02/03/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to investigate the natural history of non-cavitary nodular bronchiectatic (NC-NB) Mycobacterium avium complex (MAC) lung disease (LD). METHODS Among all patients diagnosed with NC-NB MAC LD between March 2000 and December 2013, 551 patients who were followed until December 2017 were enrolled at a tertiary referral center in South Korea. Patients were subdivided into progressive and stationary groups, depending on whether treatment was initiated within 3 years after diagnosis. We investigated the proportion of patients not receiving anti-MAC treatment within 3 years after the diagnosis. The rate for spontaneous sputum conversion in the untreated group was also calculated. RESULTS The mean age of 551 patients was 61.1 years. During the median 5.8 years of follow-up, 323 (58.6%) patients received treatment within 3 years (progressive group), whereas the remaining 228 (41.4%) patients did not (stationary group). Multivariate analysis revealed that age ≤ 60 years, a positive sputum smear, the presence of systemic symptoms, body mass index >18.5 kg/m2, and the involvement of ≥ 4 lobes were predictors of receiving treatment. Additionally, during the median of 5.0 years follow-up, spontaneous sputum conversion occurred in 52.2% of patients who did not receive treatment. CONCLUSIONS Among patients diagnosed with NC-NB MAC LD, approximately 40% did not receive antibiotic treatment within 3 years of diagnosis. Moreover, about 50% of untreated patients experienced spontaneous sputum conversion.
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Affiliation(s)
- Byoung Soo Kwon
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Jun Hee Lee
- University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Younsuck Koh
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Woo-Sung Kim
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Jin-Woo Song
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Yeon-Mok Oh
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Sang-Do Lee
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Sei Won Lee
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Jae-Seung Lee
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Chae-Man Lim
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Chang-Min Choi
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Jin-Won Huh
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Sang-Bum Hong
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea
| | - Kyung-Wook Jo
- Division of Pulmonology and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Centre, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, South Korea.
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23
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Diel R, Lipman M, Hoefsloot W. High mortality in patients with Mycobacterium avium complex lung disease: a systematic review. BMC Infect Dis 2018; 18:206. [PMID: 29724184 PMCID: PMC5934808 DOI: 10.1186/s12879-018-3113-x] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/25/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The incidence of nontuberculous mycobacterial (NTM) pulmonary disease caused by Mycobacterium avium complex (MAC) in apparently immune-competent people is increasing worldwide. We performed a systematic review of the published literature on five-year all-cause mortality in patients with MAC lung disease, and pooled the mortality rates to give an overall estimate of five-year mortality from these studies. METHODS We systematically reviewed the literature up to 1st August 2017 using PubMed® and ProQuest Dialog™ to search Medline® and Embase® databases, respectively. Eligible studies contained > 10 patients with MAC, and numerical five-year mortality data or a treatment evaluation for this patient group. Mortality data were extracted and analysed to determine a pooled estimate of all-cause mortality. RESULTS Fourteen of 1035 identified studies, comprising 17 data sets with data from a total of 9035 patients, were eligible. The pooled estimate of five-year all-cause mortality was 27% (95% CI 21.3-37.8%). A high degree of heterogeneity was observed (I2 = 96%). The mortality in the data sets varied between 10 and 48%. Studies predominantly including patients with cavitary disease or greater comorbidity reported a higher risk of death. Patients in Asian studies tended to have a lower mortality risk. Predictors of mortality consistent across studies included male sex, presence of comorbidities and advanced patient age. CONCLUSIONS Despite high heterogeneity, most studies in patients with MAC pulmonary disease document a five-year all-cause mortality exceeding 25%, indicating poor prognosis. These findings emphasise the need for more effective management and additional prospective mortality data collection.
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Affiliation(s)
- Roland Diel
- LungenClinic Grosshansdorf, Wöhrendamm 80, 22927, Großhansdorf, Germany.,Institute for Epidemiology, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Marc Lipman
- Division of Medicine, UCL Respiratory, University College London & Royal Free Hospital London NHS Foundation Trust, London, NW3 2QG, UK
| | - Wouter Hoefsloot
- Department of pulmonary diseases, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
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24
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Furuuchi K, Ito A, Hashimoto T, Kumagai S, Ishida T. Clinical significance of Aspergillus species isolated from respiratory specimens in patients with Mycobacterium avium complex lung disease. Eur J Clin Microbiol Infect Dis 2017; 37:91-98. [DOI: 10.1007/s10096-017-3105-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/07/2017] [Indexed: 11/28/2022]
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