Sarcopenia assessed using a questionnaire can predict in-hospital mortality in older patients with pulmonary tuberculosis

BACKGROUND & AIMS

Pulmonary tuberculosis is a severe disease with a high mortality rate. However, whether sarcopenia is a risk factor for in-hospital mortality remains unclear. The SARC-F (five items: strength, assistance in walking, rising from a chair, climbing stairs, and falls) is a questionnaire developed to screen for sarcopenia. This study aimed to determine whether the high risk of sarcopenia, assessed using the SARC-F questionnaire, affects in-hospital mortality in older patients with pulmonary tuberculosis.

METHODS

This was a retrospective, observational study. We included patients with active pulmonary tuberculosis aged ≥65 years who required inpatient treatment between 30 April 2021 and 30 November 2022. We assessed sarcopenia using SARC-F, and SARC-F ≥ 4 points at admission was defined as a high risk of sarcopenia. The primary outcome was all-cause mortality during hospitalisation. We extracted information on age, sex, body mass index, comorbidities, blood and biochemical tests, modified Glasgow Prognostic Score, calf circumference, geriatric nutritional risk index, physiotherapy, and length of hospital stay from medical records.

RESULTS

We included 147 patients (mean age: 83.0 ± 7.8 years; males: 61.9%). Ninety-three (63.3%) patients had a high risk of developing sarcopenia. Patients with a high risk of sarcopenia were significantly older (mean: 85.0 ± 7.1 years), had a lower body mass index (median: 18.1 kg/m2, range: 16.1-20.5 kg/m2), had a higher modified Glasgow Prognostic Score (median: 2, range: 2-2), and had a lower calf circumference (mean: 26.8 ± 3.6 cm), had a lower geriatric nutritional risk index (mean: 72.2 ± 12.9) than those without high-risk sarcopenia. More patients with a high risk of sarcopenia underwent physiotherapy (93.5%) than those without high-risk sarcopenia (P < 0.01, all). Kaplan-Meier survival curves showed that patients with a high risk of sarcopenia had significantly lower overall survival than those without high-risk sarcopenia (log-rank test, P = 0.001). Logistic regression analysis for in-hospital mortality showed that a high risk of sarcopenia significantly affected in-hospital mortality (odds ratio [OR]: 6.425, 95% confidence interval [CI]: 1.399-47.299). In addition, logistic regression analysis for each item of SARC-F showed that assistance in walking (OR: 3.931, 95% CI: 1.816-9.617) and rising from a chair (OR: 2.458, 95% CI: 1.235-5.330) significantly affected in-hospital mortality.

CONCLUSION

A high risk of sarcopenia, as assessed using SARC-F at admission, was a risk factor for in-hospital mortality in older patients with pulmonary tuberculosis. Among the SARC-F items, assistance in walking and rising from a chair were the risk factors for in-hospital mortality.

Nontuberculous Mycobacterial Pulmonary Disease in the Immunocompromised Host

The immunocompromised host is at an increased risk for pulmonary and extrapulmonary NTM infections. Where data are available in these specific populations, increased mortality is observed with NTM disease. Prior to starting therapy for NTM disease, providers should ensure diagnostic criteria are met as treatment is long and often associated with significant side effects and toxicities. Treatment should involve 2 to 4 agents and be guided by cultures and antimicrobial susceptibilities. Drug interactions are important to consider, especially in those with HIV or transplant recipients. Whenever possible, immunosuppression should be reduced or changed.

Whole-genome sequencing predicting phenotypic antitubercular drug resistance: meta-analysis

BACKGROUND

For simultaneous prediction of phenotypic drug susceptibility test (pDST) for multiple anti-tuberculosis drugs, the whole genome sequencing (WGS) data can be analyzed using either catalogue-based approach, wherein one causative mutation suggests resistance, (e.g., WHO catalog) or non-catalogue-based approach using complicated algorithm (e.g., TB-profiler, machine learning). The aim was to estimate the predictive ability of WGS-based tests with pDST as the reference, and to compare the two approaches.

METHODS

Following the systematic literature search, the diagnostic test accuracies for 14 drugs were pooled using a random-effect bivariate model.

RESULTS

Out of 779 articles, 44 articles with 16,821 specimens for meta-analysis and 13 articles not for meta-analysis were adopted. The areas under summary receiver operating characteristic curve suggested "excellent" (0.97-1.00) for 2 drugs (isoniazid 0.975, rifampicin 0.975), "very good" (0.93-0.97) for 8 drugs (pyrazinamide 0.946, streptomycin 0.952, amikacin 0.968, kanamycin 0.963, capreomycin 0.965, para-aminosalicylic acid 0.959, levofloxacin 0.960, ofloxacin 0.958), and "good" (0.75-0.93) for 4 drugs (ethambutol 0.926, moxifloxacin 0.896, ethionamide 0.878, prothionamide 0.908). The non-catalogue-based and catalogue-based approaches had similar ability for all drugs.

CONCLUSION

WGS accurately identifies isoniazid and rifampicin resistance. For most drugs, positive WGS results reliably predict pDST positive. The two approaches had similar ability.

Epidemiology of Mycobacterium abscessus

BACKGROUND

Nontuberculous mycobacteria (NTM) are highly abundant in soil, dust, and water sources, making human-pathogen contact frequent and recurrent. NTM represents over 200 species/subspecies; some are considered strict or opportunistic pathogens. Mycobacterium abscessus, often regarded as one of the most antibiotic-resistant mycobacteria, is the second most frequent NTM pulmonary disease pathogen.

OBJECTIVES

To describe the epidemiology of M. abscessus through a literature review focusing on clinical aspects.

SOURCES

We conducted searches on PubMed and Web of Knowledge for articles published from 2010 to the present using the keywords 'Mycobacterium abscessus', 'Nontuberculous mycobacteria', and 'epidemiology'. Our search prioritized original reports on the occurrence of NTM and M. abscessus infection/disease.

CONTENT

Advanced molecular and genetic diagnostic techniques have refined the M. abscessus complex (MABC) microbiological classification over the last few decades. MABC can adhere to surfaces and form a biofilm. This characteristic and its resistance to common disinfectants allow these microorganisms to persist in the water distribution systems, becoming a constant reservoir. The frequency and manifestation of NTM species vary geographically because of environmental conditions and population susceptibility differences. MABC lung disease, the most frequent site of NTM infection in humans, is often seen in patients with underlying lung diseases such as bronchiectasis, whereas MABC disseminated disease is related to immunosuppression. Skin and soft tissue infections are associated with surgical or injection procedures. Epidemiological evidence suggests an overall increase in MABC infection and disease in the last decade.

IMPLICATIONS

Establishing the burden of this disease is challenging because of varying measures of incidence and prevalence, referral bias, and differences in medical practices and reporting. Furthermore, environmental and structural determinants, infection routes, and MABC pulmonary disease mechanisms require additional investigation. This review contributes to a better understanding of the epidemiology of MABC, which could inform clinical practice and future research.

Type 2 Diabetes Mellitus- and Complication-Related Risk of Nontuberculous Mycobacterial Disease in a South Korean Cohort

We aimed to investigate whether type 2 diabetes mellitus (T2DM) and diabetes-related complications constitute significant risk factors for nontuberculous mycobacterial (NTM) disease. Data from the National Health Insurance Service-National Sample Cohort (which represents 2.2% of the total South Korean population) recorded between 2007 and 2019 were extracted to establish the NTM-naive T2DM cohort (n = 191,218) and the 1:1 age- and sex-matched NTM-naive matched cohort (n = 191,218). Intergroup comparisons were performed to determine differences in the NTM disease risk of the two cohorts during the follow-up period. During median follow-up of 9.46 and 9.25 years, the incidence of NTM disease was 43.58/100,000 and 32.98/100,000 person-years in the NTM-naive T2DM and NTM-naive matched cohorts, respectively. Multivariable analysis showed that T2DM alone did not confer a significant risk for incident NTM disease, although T2DM with ≥2 diabetes-related complications significantly increased NTM disease risk (adjusted hazard ratio [95% confidence interval], 1.12 [0.99 to 1.27] and 1.33 [1.03 to 1.17], respectively). In conclusion, the presence of T2DM with ≥2 diabetes-related complications significantly increases the risk for NTM disease. IMPORTANCE We assessed whether patients with T2DM are at higher risk for incident NTM disease through analysis of NTM-naive matched cohorts from the data of a national population-based cohort which represents 2.2% of the total South Korean population. Although T2DM alone is not a statistically significant risk factor for NTM disease, T2DM significantly increases the risk of NTM disease in those with ≥2 diabetes-related complications. This finding suggested that patients with T2DM with a larger number of complications should be considered a high-risk group for NTM disease.

Phage Therapy for Nontuberculous Mycobacteria: Challenges and Opportunities

Non-tuberculous mycobacterium (NTM) infections are often clinically challenging, with lengthy antibiotic regimens that fail to resolve the infections with few good outcomes remaining. Mycobacteriophages-viruses that infect Mycobacterium hosts-show promise as therapeutic agents for NTM infections and have been used in 20 compassionate use cases. Favorable outcomes were observed in many but not all cases, although the phages show exceptional safety profiles and no evidence of phage resistance was observed, even when only a single phage was administered. Phage-specific antibodies are commonly present following intravenous administration and are often neutralizing for the phage in vitro. However, phage neutralization does not consistently correlate with poor treatment outcomes and may not be a therapeutic limitation in all patients, even when immunocompetent. Currently, the therapeutic potential of phages is substantially limited by the great variation in phage susceptibility and a relatively small repertoire of therapeutically useful phages. As many as 45% of clinical isolates can have a smooth colony morphotype, and phages that both efficiently infect and kill these strains have yet to be described. In contrast, ~ 75% of rough strains are susceptible to and killed by one or more phages and therapeutic options can be considered on a compassionate use basis. Although therapies must currently be personalized, elucidating the determinants of phage host specificity, expanding the useful phage repertoire, and identifying the key determinants of clinical outcomes will reveal their full therapeutic potential.

Incidence of Nontuberculous Mycobacterial Pulmonary Infection, by Ethnic Group, Hawaii, USA, 2005-2019

To further clarify differences in the risk for nontuberculous mycobacterial pulmonary infection (NTM-PI) among ethnic populations in Hawaii, USA, we conducted a retrospective cohort study among beneficiaries of Kaiser Permanente Hawaii (KPH). We abstracted demographic, socioeconomic, clinical, and microbiological data from KPH electronic health records for 2005-2019. An NTM-PI case-patient was defined as a person from whom >1 NTM pulmonary isolate was obtained. We performed Cox proportional hazards regression to estimate incidence of NTM-PI while controlling for confounders. Across ethnic groups, risk for NTM-PI was higher among persons who were underweight (body mass index [BMI] <18.5 kg/m²). Among beneficiaries who self-identified as any Asian ethnicity, risk for incident NTM-PI was increased by 30%. Low BMI may increase susceptibility to NTM-PI, and risk may be higher for persons who self-identify as Asian, independent of BMI.

Cutaneous Mycobacterium massiliense Infection Caused by Skin Coining 'Gua Sha' in Korean Healthy Female

Nontuberculous mycobacteria are ubiquitous environmental organisms that are rare pathogens in immunocompetent individuals. However, cutaneous nontuberculous mycobacteria infections have been increasingly associated with invasive procedures, including surgery, liposuction, filler injection, intramuscular injection, mesotherapy, piercing, acupuncture, and cupping therapy. Herein, we report the first case of cutaneous nontuberculous mycobacteria infection caused by the East-Asian traditional treatment ‘Gua Sha’, also known as scraping, coining or spooning in English. A 35-year-old healthy female presented with widespread, painful skin nodules and pustules on her upper and lower extremities that had developed after Gua Sha treatment for body contouring. Histopathologic examination of the lesions revealed granulomatous inflammation in the dermis and the culture isolates were identified as Mycobacterium massiliense with molecular identification. The patient was successfully treated with intermittent incision and drainage of persistent nodules and oral clarithromycin based on antimicrobial susceptibility testing. We recommend implementation of a standard safety protocol for Gua Sha practitioners to minimize the risk of infection transmission.

Chronic recalcitrant erythema nodosum leprosum: therapeutic dilemma and role of mycobacterium indicus pranii vaccine

Erythema nodosum leprosum is a severe immune reaction that complicates the usual course of multibacillary leprosy. There is increased activation of T-cells in erythema nodosum leprosum. Treatment modalities available to date for the management are systemic steroids, thalidomide, methotrexate, cyclophosphamide, azathioprine, minocycline, and apremilast but none of them is promising and safe. Mycobacterium indicus pranii is an atypical mycobacterium possessing strong immunomodulatory properties. The vaccine for this mycobacterium has been shown to have both immunotherapeutic and immunoprophylactic effects in multibacillary leprosy patients. We report a case of chronic recalcitrant erythema nodosum Leprosum which responded to Mycobacterium indicus pranii vaccine without any adverse effects, thereby suggesting its role as a novel therapeutic option in this reaction.

The master of masquerade: A case series of unusual presentations of cutaneous tuberculosis in the immunocompromised host

Cutaneous tuberculosis is known for its varied presentations, especially in the setting of immunosuppression. Clinical manifestations can be modified by the site of involvement as well as the type of cutaneous tuberculosis in a particular patient. Although cutaneous tuberculosis only accounts for a small percentage (1-2%) of extrapulmonary cases, it is encountered fairly frequently in dermatology practice in an endemic country like India. These cases are being presented to highlight unusual presentations of well-known forms of cutaneous TB (TB gumma and erythema induratum of Bazin) and rare morphologies (panniculitis) in immunosuppressed individuals, thereby emphasizing the need for the dermatologist in a TB-endemic country to be constantly vigilant.

Multicenter Study of the Accuracy of the BD MAX Multidrug-resistant Tuberculosis Assay for Detection of Mycobacterium tuberculosis Complex and Mutations Associated With Resistance to Rifampin and Isoniazid

BACKGROUND

Tuberculosis (TB) control is hindered by absence of rapid tests to identify Mycobacterium tuberculosis (MTB) and detect isoniazid (INH) and rifampin (RIF) resistance. We evaluated the accuracy of the BD MAX multidrug-resistant (MDR)-TB assay (BD MAX) in South Africa, Uganda, India, and Peru.

METHODS

Outpatient adults with signs/symptoms of pulmonary TB were prospectively enrolled. Sputum smear microscopy and BD MAX were performed on a single raw sputum, which was then processed for culture and phenotypic drug susceptibility testing (DST), BD MAX, and Xpert MTB/RIF (Xpert).

RESULTS

1053 participants with presumptive TB were enrolled (47% female; 32% with human immunodeficiency virus). In patients with confirmed TB, BD MAX sensitivity was 93% (262/282 [95% CI, 89-95%]); specificity was 97% (593/610 [96-98%]) among participants with negative cultures on raw sputa. BD MAX sensitivity was 100% (175/175 [98-100%]) for smear-positive samples (fluorescence microscopy), and 81% (87/107 [73-88%]) in smear-negative samples. Among participants with both BD MAX and Xpert, sensitivity was 91% (249/274 [87-94%]) for BD MAX and 90% (246/274 [86-93%]) for Xpert on processed sputa. Sensitivity and specificity for RIF resistance compared with phenotypic DST were 90% (9/10 [60-98%]) and 95% (211/222 [91-97%]), respectively. Sensitivity and specificity for detection of INH resistance were 82% (22/27 [63-92%]) and 100% (205/205 [98-100%]), respectively.

CONCLUSIONS

The BD MAX MDR-TB assay had high sensitivity and specificity for detection of MTB and RIF and INH drug resistance and may be an important tool for rapid detection of TB and MDR-TB globally.

Biobank for multidrug-resistant tuberculosis research: importance of sequential samples

Since 2013, Masan National Tuberculosis Hospital has collected standardized specimens from its tuberculosis patients, which include a large number of multidrug-resistant strains. The repository collects matched participants and their bacilli samples, compiling sequential samples from the beginning of treatment. The repository aims to provide resources for in-depth international research.

Opportunistic infections in pediatrics: when to suspect and how to approach

OBJECTIVES

To describe the characteristics of opportunistic infections in pediatrics regarding their clinical aspects, as well as the diagnostic strategy and treatment.

SOURCE OF DATA

Non-systematic review of literature studies in the PubMed database.

SYNTHESIS OF DATA

Opportunistic infections caused by non-tuberculous mycobacteria, fungi, Herpesvirae, and infections affecting individuals using immunobiological agents are analyzed. Because these are severe diseases with a rapid evolution, diagnostic suspicion should be early, associated with the patient's clinical assessment and history pointing to opportunistic infections. Whenever possible, samples of secretions, blood, and other fluids and tissues should be collected, with early therapy implementation.

CONCLUSIONS

Despite the improved diagnosis of opportunistic infections in recent years, they remain a challenge for pediatricians who are not used to these infections. They should raise the suspicion and start treating the case, but should also resort to specialists in the management of these infections to provide a better outcome for these patients, who still have high mortality.

Prescribing Patterns for Treatment of Mycobacterium avium Complex and M. xenopi Pulmonary Disease in Ontario, Canada, 2001-2013

Surveys suggest that clinicians diverge from guidelines when treating Mycobacterium avium complex (MAC) pulmonary disease (PD). To determine prescribing patterns, we conducted a cohort study of adults >66 years of age in Ontario, Canada, with MAC or Mycobacterium xenopi PD during 2001-2013. Using linked laboratory and health administrative databases, we studied the first treatment episode (>60 continuous days of >1 of a macrolide, ethambutol, rifamycin, fluoroquinolone, linezolid, inhaled amikacin, or, for M. xenopi, isoniazid). Treatment was prescribed for 24% MAC and 15% of M. xenopi PD patients. Most commonly prescribed was the recommended combination of macrolide, ethambutol, and rifamycin, for 47% of MAC and 36% of M. xenopi PD patients. Among MAC PD patients, 20% received macrolide monotherapy and 33% received regimens associated with emergent macrolide resistance. Although the most commonly prescribed regimen was guidelines-recommended, many regimens prescribed for MAC PD were associated with emergent macrolide resistance.

[Clinical characteristics and drug susceptibility test of nontuberculous mycobacterial lung disease]

Objective: To investigate the clinical characteristics and drug susceptibility test (DST) of patients infected with different nontuberculous mycobacteria (NTM). Methods: The patients with nontuberculous mycobacterial lung disease (NMLD) in Shanghai Pulmonary Hospital from March 2014 to March 2015 were studied retrospectively by analyzing the clinical characteristics, radiological features and DST results. A total of 201 NMLD patients [male 108, age(58±15) yrs] were enrolled into this study including 48 cases of M. Kansasii [male 13, age (52±16) yrs],46 cases of M. Abscess[male 46, age (57±16) yrs], 92 cases of M. Intracellulare [male 43, age (61±13) yrs], and 15 cases of M. Avium [male 6, age (67±10) yrs]. Clinical data were collected when the diagnosis was made and Chi-square test was used to compare the differences among 4 groups of patients. Bonferroni method was used for further pairwise comparisons. Results: There were significant differences among the 4 groups in the age(χ(2)=6.42, P<0.001) and the gender(χ(2)=49.18, P<0.001) of the patients. The history of bronchiectasis in the groups of M. Kansasii, M. Abscess, M. Intracellulare and M. Avium were 2/48, 31/46, 39/92 and 4/15 cases respectively(χ(2)=41.84, P<0.001). For the Gamma-interferon release assays (ELISA) (IGRA), the positive rate of IGRA in the groups of M. Kansasii, M. Abscess, M. Intracellulare and M. Avium were 83%(40/48), 30%(14/46), 23%(21/92) and 33% (5/15) respectively(χ(2)=50.96, P<0.001). The radiological features were significantly different in tree-in-bud(8/48, 35/46, 36/92 and 4/15 cases respectively, χ(2)=36.48, P<0.001), pleural thickness or mild effusion (21/48, 36/46, 69/92 and 7/15 cases, χ(2)=19.54, P<0.001), bronchiectasis (20/48, 39/46, 78/92 and 10/15 cases, P<0.001) and cavities (38/48, 21/46, 63/92 and 10/15 cases, χ(2)=12.38, P<0.001) among the 4 groups(M. Kansasii, M. Abscess, M. Intracellulare and M. Avium). The drug resistance rates of M. Kansasii to rifampin, ethambutanol and ofloxacin were 10%(5/48), 8%(4/48) and 15%(7/48) respectively; the resistance rates of M.Intracellulare to ethambutanol was 45%(41/92), and the resistance rates of M.Abscess were all over 80% to all anti-TB drugs. The results of pairwise comparisons showed that the male proportion(46/48) and IGRAs positive rate(40/48) of patients with M. Kansasii were higher than those of other groups, and the incidence of bronchiectasis(20/48) and pleural changes(21/48) was lower than those of other groups. The female ratio(33/46), history of bronchiectasis (31/46) and tree-in-bud sign of patients(35/46) with M. Abscess were higher than those of other groups. Conclusions: There were differences in the clinical manifestations and imaging features of 4 common NMLD diseases, which were helpful for clinical differentiation. The patients with M. Kansasii infection were mainly male, with a high IGRA positive rate and fewer lesions of bronchiectasis or pleural changes. Most of the patients with M. Abscess were female, with a previous history of bronchiectasis, and with most of the lesions showing tree-in-bud signs. The NTM species had a high rate of resistance to anti-TB drugs except M. Kansasii.

[The clinical analysis of chronic obstructive pulmonary disease patients complicated with nontuberculous mycobacterial pulmonary disease]

Objectives: Long-term use of inhaled corticosteroids (ICS) was reported as a risk factor for patients with chronic obstructive pulmonary disease (COPD) complicated with nontuberculous mycobacterial lung disease (NTM-LD). But it was not reported often in China. Methods: We conducted a retrospective analysis of patients who were diagnosed with COPD and NTM-LD in our department from January 1(st) 2017 to December 31(th) 2018. Results: This study consisted of 10 male and 5 female patients with a mean age of (66±7) years. The detailed clinical data and radiological images were reviewed systemically. There were 4 current smokers (26.7%) and 6 past smokers (40%). All cases were current ICS users, with a mean duration of (27.3±9.7) months, ranging from 3 months to 61 months. Among them, 8 cases (53.3%) used inhaled fluticasone and 7 cases (46.7%) used inhaled budesonide. Aggravated coughing (15 cases, 100%), expectoration (15 cases, 100%) and dyspnea (10 cases, 66.7%) were the common clinical manifestations, although fever was only reported in 4 cases (26.7%). All cases showed normal white blood cell count and lymphocyte count, and some of them (7 cases, 46.7%) showed elevated erythrocyte sedimentation rate and C-reactive protein. Most of them (14 cases, 93.3%) had normal TB-SPOT results. Multiple focal bronchiectasis (9 cases, 60%) and significant emphysema (12 cases, 80%) were the common manifestations of basic high-resolution CT (HRCT) prior NTM infection. The occurrence of bronchiectasis (15 cases, 100%), "tree in bud" sign (12 cases, 80%) and tiny cavities (8 cases, 53.3%) were the common HRCT abnormalities for the NTM-LD cases. According to the 2007's NTM-LD diagnosis criteria, most of them (13 cases, 86.7%) were diagnosed with positive sputum samples at least twice, and 2 cases were diagnosed with positive CT-directed bronchial alveolar lavage fluid. NTM-PCR analysis was performed routinely for the isolated NTM samples to identify the NTM species. Mycobacterium avium complex (MAC) was the most common NTM species (8 cases, 53.3%). After treatment with proposed anti-NTM strategies, most cases improved (9 cases, 60%), and some of them (4 cases, 26.7%) were cured and a few cases (2 cases, 13.3%) relapsed. Conclusions: When COPD patients treated with ICS showed aggravated cough, expectation and/or dyspnea, and new occurrence of bronchiectasis and/or "tree in bud" sign in the recent HRCT, the differential diagnosis of NTM-LD should be considered. Respiratory samples should be arranged for NTM cultures and PCR analysis as soon as possible. Earlier antimicrobial strategies according to the identified NTM species would improve the clinical outcomes.

[Prevalence and risk factors associated to tuberculosis and non-tuberculous mycobacterial infections in HIV-positive patients in Bogotá]

INTRODUCTION

Tuberculosis is one of the most widely distributed infectious diseases worldwide. It is the most common cause of mortality among AIDS patients. In Colombia, 12,918 tuberculosis cases were notified, and 926 deaths were reported in 2015.

OBJECTIVE

To determine the prevalence and risk factors associated to mycobacterial infections in HIVpositive patients in two public hospitals from Bogotá.

MATERIALS AND METHODS

A prospective and descriptive study was carried out by an active search for tuberculosis cases and non-tuberculous mycobacterial infections in HIV-positive patients. We considered demographic, social, clinical, and personal habits as variables. Statistical analyses were done using Stata 13™ software.

RESULTS

Three hundred and fifty six patients were included, 81.2% were men and 18.8% were women; the mean age was 36.5 years. Tuberculosis infection had a frequency of 19.9% (95% CI: 15.9-24.5%) and non-tuberculous mycobacterial infection had a 3.9% frequency (95% CI: 2.16-6.5%). Bivariate analysis showed a statistically significant association between tuberculosis infection and CD4+ T cell counts (p=0.003), viral load (p=0.008), antiretroviral therapy (p=0.014), and body mass index (BMI) <18 kg/m2 (p=0.000). In non-tuberculous mycobacterial infections there was a statistically significantassociation with BMI (p=0.027) and CD4+ T cell counts (p=0.045).

CONCLUSION

Factors associated with an impaired immune system caused by HIV infection are an important risk factor for developing tuberculosis. The lack of antiretroviral therapy and the BMI were also important risk factors for tuberculosis.

Dermatology ECHO - an innovative solution to address limited access to dermatology expertise

INTRODUCTION

The present maldistribution of dermatologists in the USA may make it difficult for patients to access timely and quality care. Access to specialty care may be even more challenging for rural and underserved patients due to geographical limitations and other socioeconomic hardships. With over one-third of primary care patients seeking care for at least one skin problem, it is important to follow the American Academy of Dermatology Special Positioning Workgroup\'s core areas of impact regarding treatment of conditions that affect millions of patients by using a team-based approach and telemedicine technologies. The objective of this study was to demonstrate the Dermatology Extension for Community Healthcare Outcomes (ECHO) project approach in multidisciplinary telementoring and education of primary care providers (PCPs) in treatment and management of complex, costly, and common skin diseases via live interactive video technologies.

METHODS

Dermatology ECHO is a distance education telementoring platform that uses a multidisciplinary case-based approach in a non-judgemental environment. A team of specialists, including general dermatologists, pediatric dermatologists, a dermatopathologist, a clinical psychologist, and a nurse practitioner, meets via video with a number of PCPs from isolated, rural, or underserved areas to discuss de-identified patient cases and present dermatology-specific continuing medical education (CME)-approved didactic presentations. The University of Missouri, Department of Dermatology, leads the first Dermatology ECHO in the USA. They partner with various primary care clinics across Missouri to provide mentoring in the treatment of skin conditions. Missouri Telehealth Network provides operational support through the Show-Me ECHO project. The network also assists with provider recruitment activities.

RESULTS

The authors describe a patient case to illustrate the effect of ECHO on provider distance learning and patient outcomes. A 69-year-old woman from rural Missouri was spurred by a rooster. She presented to her primary care clinic six times over a 2-month period. She was prescribed several different medications and underwent tests and one procedure, including vaccination. After the patient\'s case was presented during the Dermatology ECHO session, she was correctly diagnosed with a Mycobacterium skin infection, and new recommendations were made. The patient improved significantly within 2 weeks.

CONCLUSIONS

As specialty medical evidence-based recommendations continue to increase, providers practicing in isolated rural and underserved areas may find it challenging to keep up with the new knowledge. Dermatology ECHO creates a community of practice that allows participating providers to discuss complex cases, receive specific guidance and mentoring, and participate in CME presentations. The case presented here supports the authors\' observations that Dermatology ECHO is an appropriate platform for learning evidence-based medical knowledge via videoconferencing technology.

The outcomes of anatomical lung resection for nontuberculous mycobacterial lung disease

Background

The number of cases of nontuberculous mycobacterial (NTM) lung disease has been increasing in recent years, and the efficacy of surgical treatment has been recognized. We investigated the clinical characteristics and behavior of NTM lung disease and analyzed the outcomes of surgery.

Methods

The data of 25 patients who underwent anatomical resection for NTM lung disease in our institution between January 2004 and December 2014 were retrospectively examined.

Results

The patients included 10 men and 15 women (mean age, 63.1 years). Twenty patients had Mycobacterium avium, and 5 had Mycobacterium intracellular. The indications for lung resection in 20 definitively diagnosed patients included a remaining or worsening lesion despite medical treatment (n=16), massive hemoptysis or bloody sputum (n=5), and prolonged smear positivity (n=1); multiple reasons were allowed. In five cases without a definitive diagnosis, surgery was performed due to the suspicion of lung cancer. The surgical procedures included pneumonectomy, n=4; lobectomy, n=13; and segmentectomy, n=8. Complete resection was achieved in 10 cases (40.0%). Video-assisted thoracoscopic surgery (VATS) was performed in 17 cases (68.0%), especially in 6 of 8 cases (75.0%) that underwent segmentectomy and in 10 of 11 cases (90.9%) that received simple lobectomy. There was one case of hospital mortality. Among the 22 patients who were followed at our institution, relapse occurred in 4 patients, and new infection occurred in 1 patient. NTM lung disease was controlled in 17 patients (77.3%). In the four cases that relapsed, the median relapse-free interval was 29.5 months.

Conclusions

Surgical resection was a feasible treatment for NTM lung disease and was associated with favorable outcomes, although there was 1 case of hospital mortality. VATS procedures were considered adequate for the treatment of NTM lung disease; however, the surgical indications must be carefully considered.

Incidence and Risk Factors for Nontuberculous Mycobacterial Infection after Allogeneic Hematopoietic Cell Transplantation

Allogenic hematopoietic stem cell transplant (HCT) recipients are at risk of many infections. Nontuberculous mycobacteria (NTM) are increasingly recognized as clinically significant pathogens in this population. We investigated the incidence and risk factors for NTM infection after allogeneic HCT. This retrospective cohort study included all patients with allogeneic HCT at our institution during 2001 to 2013. Patients who developed significant NTM infection (NTM disease) were identified. Multivariable modeling was used to identify risk factors for NTM disease, and a risk score model was constructed to identify high-risk patients. Of 1097 allogeneic HCT patients, 45 (4.1%) had NTM isolated and 30 (2.7%) had NTM disease (28 [93.3%] exclusively pulmonary, 2 [6.7%] pulmonary plus another site). Incidence of NTM infection by competing risk analysis was 2.8% at 5 years (95% CI, 1.9% to 4.0%). The median time to diagnosis was 343 days (range, 19 to 1967). In Fine-Gray proportional hazards modeling, only global severity of chronic graft-versus-host disease (cGVHD) (HR, 1.99; 95% CI, 1.12 to 3.53; P = .019,) and cytomegalovirus (CMV) viremia (HR, 5.77; 95% CI, 1.71 to 19.45; P = .004) were significantly associated with NTM disease. Using these variables a risk score was calculated: 1 point for CMV viremia or moderate cGVHD and 2 points for severe cGVHD. The score divided patients into low risk (0 to 1 points, n = 820 [77.3%], 3-year NTM risk 1.2%), intermediate risk (2 points, n = 161 [15.4%], 3-year NTM risk 7.1%), and high risk (3 points, n = 56 [5.4%], 3-year NTM risk 14.3%). NTM disease after allogeneic HCT is common. Severe cGVHD and CMV viremia are associated with increased risk, permitting risk stratification.

The Zebrafish Breathes New Life into the Study of Tuberculosis

Tuberculosis (TB) is a global health emergency. Up to one-third of the world’s population is infected with Mycobacterium tuberculosis, and the pathogen continues to kill 1.5 million people annually. Currently, the means for preventing, diagnosing, and treating TB are unsatisfactory. One of the main reasons for the poor progress in TB research has been a lack of good animal models to study the latency, dormancy, and reactivation of the disease. Although sophisticated in vitro and in silico methods suitable for TB research are constantly being developed, they cannot reproduce the complete vertebrate immune system and its interplay with pathogens and vaccines. However, the zebrafish has recently emerged as a useful alternative to more traditional models, such as mice, rabbits, guinea pigs, and non-human primates, for studying the complex pathophysiology of a mycobacterial infection. The model is based on the similarity between Mycobacterium marinum – a natural fish pathogen – and M. tuberculosis. In both zebrafish larvae and adult fish, an infection with M. marinum leads to the formation of macrophage aggregates and granulomas, which resemble the M. tuberculosis infections in humans. In this review, we will summarize the current status of the zebrafish model in TB research and highlight the advantages of using zebrafish to dissect mycobacterial virulence strategies as well as the host immune responses elicited against them. In addition, we will discuss the possibilities of using the adult zebrafish model for studying latency, dormancy, and reactivation in a mycobacterial infection.

Mycobacterium marinum infection: a case report

The infection by Mycobacterium marinum in humans is relatively uncommon. When it occurs, it mainly affects the skin, usually with a chronic, indolent and benign evolution. The diagnosis requires a high index of suspicion, and a significant delay may be observed between the first symptoms to the final diagnosis. This present case reports a M. marinum infection in an immunocompetent patient that had a chronic undiagnosed injury on the dominant hand for at least five years. The patient had several medical consultations, without proper suspicion, hampering adequate diagnostic investigation. Histopathology detected tuberculoid granulomas, but showed no acid-fast bacilli. The culture in appropriate medium and the polymerase chain reaction-restriction enzyme analysis (PRA)-hsp65 confirmed the diagnosis. Treatment with clarithromycin (1 g/day) for three months was effective. Although uncommon, this infection is a contact zoonosis. Therefore, it is important for clinicians to be aware of this diagnosis and properly guide preventable measures to professionals that are in risk group.

The Mycobacterium avium ssp. paratuberculosis specific mptD gene is required for maintenance of the metabolic homeostasis necessary for full virulence in mouse infections

Mycobacterium avium subspecies paratuberculosis (MAP) causes Johne's disease, a chronic granulomatous enteritis in ruminants. Furthermore, infections of humans with MAP have been reported and a possible association with Crohn's disease and diabetes type I is currently discussed. MAP owns large sequence polymorphisms (LSPs) that were exclusively found in this mycobacteria species. The relevance of these LSPs in the pathobiology of MAP is still unclear. The mptD gene (MAP3733c) of MAP belongs to a small group of functionally uncharacterized genes, which are not present in any other sequenced mycobacteria species. mptD is part of a predicted operon (mptABCDEF), encoding a putative ATP binding cassette-transporter, located on the MAP-specific LSP14. In the present study, we generated an mptD knockout strain (MAPΔmptD) by specialized transduction. In order to investigate the potential role of mptD in the host, we performed infection experiments with macrophages. By this, we observed a significantly reduced cell number of MAPΔmptD early after infection, indicating that the mutant was hampered with respect to adaptation to the early macrophage environment. This important role of mptD was supported in mouse infection experiments where MAPΔmptD was significantly attenuated after peritoneal challenge. Metabolic profiling was performed to determine the cause for the reduced virulence and identified profound metabolic disorders especially in the lipid metabolism of MAPΔmptD. Overall our data revealed the mptD gene to be an important factor for the metabolic adaptation of MAP required for persistence in the host.

Video-assisted thoracoscopic surgery for nontuberculous mycobacterial infection

BACKGROUND

The number of patients with nontuberculous mycobacterium infection is increasing in Japan, and therefore surgical treatment is also being applied with increasing frequency. Although the effectiveness of surgery for nontuberculous mycobacterium disease has been established and reported by a number of authors, the role of video-assisted thoracoscopic surgery in the surgical treatment of nontuberculous mycobacterium disease has not been sufficiently investigated.

PATIENTS AND METHODS

We retrospectively investigated 10 patients, comprising 5 males and 5 females, who underwent video-assisted thoracoscopic lobectomy or segmentectomy for nontuberculous mycobacterium disease at our institution between February 2006 and November 2012. The average patient age was 59.5 years (range 53-65 years). We performed lobectomy in 6 cases and segmentectomy in 4.

RESULTS

All surgical procedures were completed under video-assisted thoracoscopic surgery and none required conversion to thoracotomy. Postoperatively, air leakage continuing for 7 days occurred in 2 patients but there was no severe postoperative complication. The median periods of postoperative drainage and hospitalization were 4.0 and 5.5 days, respectively. Among 8 cases followed up at our institution, reactivation of nontuberculous mycobacterium disease occurred in one case 4 years after surgery.

CONCLUSION

Video-assisted thoracoscopic surgery is a safe and useful procedure for lobectomy and segmentectomy in patients with nontuberculous mycobacterium disease.

Diagnosis and species identification of mycobacterial infections by polymerase chain reaction-restriction fragment length polymorphism analysis of sterile body fluids

BACKGROUND/AIMS

The development of effective, accurate, and rapid diagnostic methods for Mycobacterium infection and mycobacterial species identification is required. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) is an easy, rapid and inexpensive technique for identifying Mycobacterium spp.

METHODS

We performed PCR-RFLP to detect and identify Mycobacterium spp. from 10 sterile body fluids, including ascites, cerebrospinal fluid, pleural fluid, synovial fluid, and peritoneal dialysis fluid. Clinical samples were collected from patients with diagnoses of definite, probable or suspected mycobacterial infection. The conserved RNA polymerase genes of Mycobacterium spp. were amplified by PCR.

RESULTS

The amplified 360-bp region of rpoB was digested with the restriction enzyme MspI or HaeIII. The PCR-RFLP results for the clinical samples were identical to those for M. tuberculosis, M. fortuitum, M. intracellulare, and M. avium. In addition, the results of the PCR-RFLP were identical to those obtained by DNA sequencing.

CONCLUSIONS

PCR-RFLP analysis of sterile body fluids may be a useful method for the diagnosis of mycobacterial infections and for the differentiation of mycobacterial species.