Concomitantly Diagnosed Disseminated M kansasii Infection and Hairy Cell Leukemia With Review of Pathophysiology

The association between Hairy Cell Leukemia (HCL) and non-tuberculous mycobacterial infections (NTMs) is well described, most notably Mycobacterium kansasii. The exact pathophysiology is not known. We report a case of a 31-year-old male with concomitantly diagnosed HCL and disseminated M kansasii infection who presented with rash, pancytopenia, and bulky axillary lymphadenopathy. The M kansasii was initially diagnosed through use of cell-free DNA detection and confirmed by bone marrow and lymph node cultures. Hairy Cell Leukemia was diagnosed with peripheral flow cytometry and confirmed via the same bone marrow sample. His HCL was put into remission with a single course of cladribine and rituximab chemotherapy; however, his M kansasii infection persisted for 6 months despite aggressive antimicrobial and surgical therapy. It was finally controlled using high-dose rifampin in combination with azithromycin and ethambutol. This case highlights the known link between HCL and M kansasii. Furthermore, it hints at potential causes beyond chemotherapy-induced immunocompromise. Notable possibilities include HCL cells acting as sanctuary sites for M kansasii to evade the immune system, and subclinical M kansasii infections causing NLRP3 inflammasome overactivation to trigger the oncogenic transformation to HCL. More research into the pathophysiologic link between HCL and M kansasii infections would allow for more effective prevention, diagnosis, and treatment of these severe atypical infections which are the major cause of morbidity in the cladribine era of HCL treatment.

Disseminated coinfection with Mycobacterium Avium complex and Mycobacterium Kansasii in a patient with idiopathic CD4+ lymphocytopenia: A case report

Simultaneously disseminated coinfection with two species of nontuberculous mycobacteria (NTM) is extremely rare and had been reported only in immunocompromised individuals. Here, we report a 59-year-old Thai man, previously healthy. He presented with a 2-month history of prolonged fever, constitutional symptoms, and hepatosplenomegaly. His chest and abdomen computed tomography illustrated multiple enlarged mediastinal lymph nodes accompanied with multifocal crazy-paving appearance in both lungs and hepatosplenomegaly. Endobronchial ultrasound-guided transbronchial needle aspiration was performed on the mediastinal nodes. The pathologic findings were necrotizing granulomatous lymphadenitis with numerous AFB-positive bacilli. Blood culture subsequently isolated M. intracellulare, while BAL and lymph node culture isolated M. intracellulare and M. kansasii, which confirmed species by multiplex PCR and 16s rRNA sequencing. Idiopathic CD4+ lymphocytopenia (ICL) was diagnosed as the cause of secondary immune deficiency. Intravenous imipenem, amikacin, and azithromycin were administered as an empirical antibiotic regimen for 4 weeks, then substituted to oral rifampicin, clarithromycin, moxifloxacin, and ethambutol as definitive regimen. Unfortunately, it was found that he had died unexpectedly at home after 4 months of treatment, possibly related to this illness. In our view, patients with severe disseminated NTM disease should be evaluated to explore a secondary immune deficiency disorder. An ICL is a rare heterogenous syndrome but should be considered.

Dual M. kansasii infection in one household: a reconsideration of our understanding of transmission routes

Mycobacterium kansasii is one of the the most common non-tuberculous mycobacteria responsible for opportunistic human infection. Unlike M. tuberculosis, transmission remains poorly understood; spread is assumed to be from a shared geographical source, such as domestic plumbing, and human-to-human transmission is generally not considered by clinicians when evaluating patients and their environments. We describe M. kansasii infection in a husband and wife in the same household and in the same period, suggesting, in these cases, that transmission occurred directly from one patient to the other. This possibility of human-to-human transmission may inform a clinician's scrutiny of risks to household contacts in cases of M. kansasii infection.

Cumulative antimicrobial susceptibilities for respiratory clinical isolates of Mycobacterium avium Complex, Mycobacterium kansasii, and Mycobacterium abscessus from Pakistan 2018 to 2022

Background

Nontuberculous mycobacteria (NTM) are increasingly identified as causes of protracted pulmonary infections. Antibiotic susceptibility testing requires microdilution methods, which are often unavailable in laboratories in resource-poor settings. We report cumulative antibiograms for the most frequently isolated clinical pulmonary NTM from Pakistan to inform empiric antibiotic management of initial NTM infections.

Methods

We analyzed data from 2018 to 2022 for the most frequently isolated and clinically relevant NTM isolated from respiratory specimens, i.e., Mycobacterium avium complex (MAC), Mycobacterium abscessus group (MAG), and Mycobacterium kansasii (MK). Antibiograms were developed using the Clinical Laboratory Standards Institute's M39ED5 standard. Percentage susceptibilities and 95% confidence intervals (CI) were calculated.

Results

Over 4 years, 529 NTM, comprising 209 MAC, 249 MAG, and 71 MK were analyzed. For MAC and MAG, where clarithromycin (CLR)-based regimens are recommended, CLR was active for 94.8% (95% CI 91.3-96.9), and 77.5% (95% CI 71.4-82.7) isolates, respectively. Combination regimens comprising 3 active drugs CLR + linezolid (LZD) + moxifloxacin for MAC and CLR + LZD + Amikacin for MAG had 98.4% (95% CI 95.9-99.4) and 68.9% (95% CI 62.3-74.8) coverage for pulmonary disease, respectively. For MK, 91.5% (95% CI 82.8-96.1) isolates were susceptible to rifampin (RIF), with a combination of RIF + CLR covering 88.7% (95% CI 79.3-94.2) of MK pulmonary infections, respectively.

Conclusions

These data can inform empiric treatment guidance for the most common NTM pulmonary infections, i.e., for MAC, MAG, and MK disease in Pakistan.

Isoniazid pharmacokinetics/pharmacodynamics as monotherapy and in combination regimen in the hollow fiber system model of Mycobacterium kansasii

BACKGROUND

There is limited high quality evidence to guide the optimal doses of drugs for the treatment of Mycobacterium kansasii pulmonary disease (Mkn-PD).

METHODS

We performed (1) minimum inhibitory concentration experiment, (2) isoniazid dose-response study using the hollow fiber system model (HFS-Mkn) to determine PK/PD optimized exposure, and (3) another HFS-Mkn study to determine the efficacy of high dose isoniazid (15 mg/kg/day) with standard dose rifampin (10 mg/kg/day) and ethambutol (15 mg/kg/day). Inhibitory sigmoid maximal effect model and linear regression was used for data analysis.

RESULTS

MIC of the 20 clinical isolates ranged between 0.5 mg/L to 32 mg/L. In the HFS-Mkn, isoniazid monotherapy failed to control the bacterial growth beyond day 7. On day 7, when the maximal Mkn kill was observed, the optimal isoniazid exposure for Mkn kill was calculated as 24hr area under the concentration-time curve to the MIC of 12.41. Target attainment probability of 300 mg/day dose fell below 90% above the MIC of 1 mg/L. High dose isoniazid combination sterilized the HFS-Mkn in 30-days with a kill rate of -0.15 ± 0.02 log10 CFU/mL/day.

CONCLUSION

Despite initial kill, isoniazid monotherapy failed due to resistance emergence. Our pre-clinical model derived results suggest that higher than currently recommended 300 mg/day isoniazid dose may achieve better clinical efficacy against Mkn-PD.

Diagnosing and treating Mycobacterium kansasii

ABSTRACT

This article describes an 18-year-old immunocompetent patient who developed Mycobacterium kansasii, manifested with shortness of breath and a cavitary lung lesion seen on radiograph. Initial sputum smears were negative; however, after 2 weeks, the cultures grew M. kansasii and the patient was started on an antimycobacterial regimen.

Non-tuberculous mycobacterial thoracic osteomyelitis in an immunocompetent host: a rare presentation of Mycobacterium kansasii

An immunocompetent man in his 40s presented with 3 months of mid-thoracic back pain which progressed to include progressive paraesthesias and lower extremity weakness. Investigations revealed thoracic spine osteomyelitis with signs of cord compression. He underwent neurosurgical intervention, including laminectomy, spinal cord decompression and partial resection of an epidural mass. Initial intraoperative biopsy and surgical pathology results were concerning for an acid-fast bacillus as the causative pathogen, and the patient was given empiric therapy for presumed Mycobacterium tuberculosis However, microbiology speciation revealed the presence of the non-tuberculous mycobacterium (NTM) Mycobacterium kansasii, which resulted in an alteration of his antimicrobial therapy. This case highlights the importance of considering NTM as a possible aetiology of spinal osteomyelitis, even among immunocompetent individuals or in low-prevalence regions.

Ethambutol-induced bullous skin lesions in mycobacterium kansasii lung infection

Mycobacterium kansasii is the second most common cause of nontuberculous mycobacterial (NTM) lung disease after Mycobacterium avium complex infection in the United States.^[1] The first-line therapy for M. kansasii is a three-drug regimen including rifampin, isoniazid, and ethambutol. We present a case of a patient with pulmonary M. kansasii who developed bullous skin lesions while receiving this regimen and again after rechallenge with ethambutol. In patients with intolerance to one of the first-line antibiotics, a multidisciplinary team approach to starting second-line agents is needed. Ethambutol should be included in the differential diagnosis of drug-induced bullous skin lesions in treated patients with NTM, who develop new onset rash with blisters or ulceration.

Hypercalcaemia in Mycobacterium kansasii pulmonary infection

A gentleman in his 60s with end-stage kidney disease status post kidney transplantation on prednisone and tacrolimus presented with generalised weakness for 7 days, associated with altered mental status. Investigations revealed pancytopenia, acute kidney injury, hypercalcaemia, decreased parathyroid hormone (PTH) and normal calcitriol levels. CT of the chest showed multifocal lung opacities suspicious for malignancy. Bronchoscopy with biopsy yielded no malignant cells, and bronchoalveolar lavage specimens grew Mycobacterium kansasii The patient was treated with bisphosphonates, calcitonin and antibiotics for non-tuberculous mycobacteria pulmonary infection, with improvement in serum calcium levels, and was discharged after 5 weeks of hospitalisation.The work-up for hypercalcaemia begins with PTH measurement, and low PTH levels are consistent with malignancy, immobilisation and granulomatous diseases. Hypercalcaemia in the lattermost is classically caused by overproduction of calcitriol by activated macrophages. However, there are case reports of mycobacterial infections with hypercalcaemia despite normal calcitriol levels, supporting the existence of an additional mechanism of hypercalcaemia in granulomatous infections.

Huge cutaneous abscess and severe symptomatic hypercalcaemia secondary to Mycobacterium kansasii infection in an immunocompetent patient

Mycobacterium kansasii is among the most common non-tuberculous mycobacteria causing human infections. Apart from pulmonary infection, the most common infection caused by M. kansasii is skin and soft tissue infection, and it is very rare in immunocompetent people. In this report, we present a case of a huge cutaneous abscess caused by M. kansasii A 63-year-old man living in Bangkok presented with progressive pain at the left lateral chest wall for 3 weeks and altered mentation for a few days. Examination revealed a non-tender fluctuated cutaneous mass 20×10 cm in size. An aspiration of the mass yielded 50 mL pus with many positive acid-fast bacilli. Mycobacterial PCR was positive for M. kansasii with culture confirmation. There was severe hypercalcaemia. The treatment included surgical drainage, and medical treatment consisted of isoniazid, rifampicin, ethambutol and levofloxacin, along with adequate hydration and calcitonin for hypercalcaemia. The patient gradually improved and was discharged 12 days after hospitalisation.

Chronic Mycobacterium kansasii tenosynovitis in an immunocompromised host : case report

Mycobacteriuim kansasii is a nontuberculous atypical mycobacterium which typically causes respiratory infections. Localized extrapulmonary diseases, such as tenosynovitis or arthritis are rarely seen in the immunocompetent population (1) . We present a case of an immunocompromised 55-year-old man with a chronic Mycobacteriuim kansasii tenosynovitis of the hand.

Treatment of Nontuberculous Mycobacterial Pulmonary Disease: An Official ATS/ERS/ESCMID/IDSA Clinical Practice Guideline

Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. A panel of experts was carefully selected by leading international respiratory medicine and infectious diseases societies (ATS, ERS, ESCMID, IDSA) and included specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy. Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the recommendations were formulated, written, and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Thirty-one evidence-based recommendations about treatment of NTM pulmonary disease are provided. This guideline is intended for use by healthcare professionals who care for patients with NTM pulmonary disease, including specialists in infectious diseases and pulmonary diseases.

Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline

Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. A panel of experts was carefully selected by leading international respiratory medicine and infectious diseases societies (ATS, ERS, ESCMID, IDSA) and included specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy. Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the recommendations were formulated, written, and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Thirty-one evidence-based recommendations about treatment of NTM pulmonary disease are provided. This guideline is intended for use by healthcare professionals who care for patients with NTM pulmonary disease, including specialists in infectious diseases and pulmonary diseases.

Outcome of patients with and poor prognostic factors for Mycobacterium kansasii-pulmonary disease

BACKGROUND

Aggressive therapy for Mycobacterium kansasii-pulmonary disease (MK-PD) is recommended because of the virulence of MK. However, some clinicians may be concerned regarding the lengthy course and numerous adverse effects. This study evaluated the natural course of MK-PD and investigated its prognostic factors.

METHODS

Radiographic outcome, prognostic factors, and mortality within 1 year for MK-PD were obtained from patients in 6 hospitals in Taiwan from 2010 to 2014 (derivation cohort) and validated using patients in 2015 and 2016 (validation cohort).

RESULTS

Of the 109 patients with MK-PD in the derivation cohort, radiographic progression occurred in 70 (64%), with a 1-year mortality rate of 43% and median survival of 71 days, whereas none of the 39 cases without radiographic progression died. All patients with acid-fast smear (AFS) grade ≥ 3 experienced radiographic progression. For the others, the independent risk factors of radiographic progression were fibroCavitary pattern, Leucocyte count >9000/μL, Old age (age >65 years), pUre MK in sputum (no other mycobacteria), and no Diabetes mellitus (the CLOUD factors). By applying these criteria to the validation cohort (n = 112), 3 (9%) of the 33 patients with MK-PD who initially had AFS grade < 3 and < 3 CLOUD risk factors experienced radiographic progression, and none of the 3 died of MK-PD.

CONCLUSIONS

Because of the high risk of radiographic progression and subsequent fatal outcome, immediate anti-MK treatment is recommended. For patients with MK-PD who have sputum AFS grade <3 and < 3 CLOUD risk factors, regular follow-up may be an alternative.

Risk factors for developing Mycobacterium kansasii lung disease: A case-control study in Korea

Previous studies have suggested that development of Mycobacterium kansasii lung disease (MKLD) was associated with COPD, pneumoconiosis, aging, male, immunosuppression, alcohol, malignancy, and certain occupations such as mining and sandblasting. However, previous studies were outdated and used non-comparative statistical methods. We aimed to determine the current risk factors for developing MKLD in Korea by using appropriate statistical techniques.Eighty-six MKLD patients were identified through a search of the Ulsan University Hospital database between January 2010 and December 2014. These cases were matched with 172 controls who had normal respiratory systems in a health examination during the same period (matching variables, age and sex; case: control ratio of 1:2). Clinical and demographic characteristics were gathered by reviewing the medical record and telephone survey. Multivariate logistic regression analyses were performed to evaluate risk factors for developing MKLD.Multivariate analysis showed that occupation in heavy industries (adjusted odds ratio (aOR) 6.41, 95% confidence interval (CI) 2.19-18.74, P = .001) and low body mass index (BMI) (aOR [per kg/m] 0.73, 95% CI 0.63-0.85, P < .001) were independent risk factors for development of MKLD. Educational attainment more than high school was associated with a lower risk of MKLD development (aOR 0.22, 95% CI 0.08-0.63, P = .005).Employees in heavy industry and low BMI are independent risk factors for development of MKLD in Korea.

Coinfection of disseminated Talaromyces marneffei and Mycobacteria kansasii in a patient with papillary thyroid cancer: A case report

RATIONALE

Recently, Talaromyces marneffei (T. marneffei) has been reported in human immunodeficiency virus (HIV)-negative patient with underlying diseases, such as oral cancer, colon cancer, haematological malignancies, connective tissue disease, diabetes mellitus, and corticosteroids or immunosuppressive agents. Similar to HIV-positive ones, such patients were observed with CD4 lymphocytopenia.

PATIENT CONCERNS

We reported a case of a 45-year-old woman who was diagnosed with disseminated T. marneffei and Mycobacteria kansasii (M. kansasii) with papillary thyroid cancer as the underlying disease. T-cell subsets counts, CD4 T-cell%, CD8 T-cell%, CD4/CD8 ratio, and NK cell% were all turned out to be normal.

DIAGNOSES

Based on bronchoalveolar lavage fluid and skin lesions secretion cultures, blood culture, the patient was diagnosed with disseminated T. marneffei and M. kansasii. Pathological examination reported papillary thyroid cancer with cervical lymph node metastasis.

INTERVENTIONS

The patient received the combined and longer antifungal therapy and drug regimens for M. kansasii. She had total thyroidectomy with radical neck dissection to treat the papillary thyroid cancer.

OUTCOMES

The patient had a favorable outcome for 19 months without recurrence.

LESSONS

T. marneffei could infect non-HIV individuals with underlying disease under the condition of normal T-cell counts. The symptoms were lack of specificity and were more likely to be misdiagnosed. Such patients with unidentified T-cell dysfunction or other unidentified primary immunodeficiency disorders may prone to coinfect with other opportunistic pathogens, such as M. kansasii. Compared with HIV-positive ones, they need combined and much longer antifungal therapy.

nov., a novel species closely related to Mycobacterium kansasii and Mycobacterium gastri

Four strains isolated in Iran from pulmonary specimens of unrelated patients are proposed as representative of a novel Mycobacterium species. Similarity, at the phenotypic level, with Mycobacterium kansasii is remarkable with the photochromogenic yellow pigmentation of the colonies being the salient feature. They differ, however, genotypically from this species and present unique sequences in 16S rRNA, hsp65 and rpoB genes. The average nucleotide identity and the genome-to-genome distance fully support the status of an independent species. The name proposed for this species is Mycobacterium persicum sp. nov. with AFPC-000227T (=DSM 104278T=CIP 111197T) as the type strain.

[A SURGICAL CASE OF MYCOBACTERIUM KANSASII LUNG DISEASE MIMICKING PRIMARY LUNG CANCER]

We report a rare surgical case of a solitary pulmonary nodule due to Mycobacterium kansasii. A 59-year-old man was admitted to our hospital for examination of an abnormal shadow in the left upper lobe incidentally found on a chest radiogram. Computed tomography of the chest showed that the nodule was located in the left segment 1+2 and was irregularly shaped with a diameter of 35 mm. Thoracic fluorine-18 fluoro-deoxy-glucose positron emission tomography showed a high metabolic pulmonary lesion, with a maximum standardized uptake value of 5.1, consistent with findings for lung cancer. A bronchoscopy was performed to establish the diagnosis of lung cancer; however, it failed to show malignant cells. Because we could not confirm the diagnosis by bronchoscopic examination, video-assisted thoracoscopic surgery was performed. The intraoperative rapid diagnosis of the nodule was epithelioid cell granuloma. Smear test of the resected specimen was positive for acid-fast bacilli, and a culture was also positive for mycobacteria, which were identified as Mycobacterium kansasii. Antibiotic treatment for M. kansasii infection was administered for a year after the surgical resection. Few cases of Mycobacterium kansasii infection present with solitary pulmonary nodules.

[A case of pulmonary Mycobacterium kansasii infection with pleural effusion, distinguished from pulmonary tuberculosis]

A case of pulmonary Mycobacterium kansasii infection with pleural effusion is very rare. We report a case of pulmonary Mycobacterium kansasii infection with pleural effusion, distinguished from pulmonary tuberculosis. A 44-year-old man presented to a clinic with a productive cough, sputum, and loss of appetite for several months. Chest X-ray and chest computed tomography (CT) showed right pleural effusion, centrilobular nodules and infiltrative shadows with cavities in the bilateral lung fields. The direct smear examination showed positive acid-fast bacilli (Gaffky 5). He was referred to our hospital for suspected recurrent pulmonary tuberculosis. We started anti-tuberculosis drugs because pulmonary tuberculosis complicated with pleurisy was first suspected from the findings of high ADA level (78.6 IU/l) of the effusion and positive result of interferon-gamma release assay (QuantiFERON TB-2G). But Mycobacterium tuberculosis and M. avium complex was not identified by the polymerase chain reaction method and the culture of the sputum was negative. At a later date, Mycobacterium kansasii was detected by sputum culture. The patient was diagnosed as pulmonary Mycobacterium kansasii infection and treatment with anti-tuberculosis drugs including RFP resulted in a good clinical response. This case was a rare case of pulmonary Mycobacterium kansasii infection with pleural effusion, distinguished from pulmonary tuberculosis.

Mycobacterium kansasii cutaneous infection in a patient with sarcoidosis treated with anti-TNF agents

We describe a Mycobacterium kansasii cutaneous infection that was diagnosed in a 52-year-old female patient with sarcoidosis receiving anti-TNF agents. The diagnosis was based on the positive culture of the foot ulcerative tissue. The isolation and identification of bacterium was based on phenotypic and molecular methods. Therapy and follow-up of the patient is discussed.

[10 years comparative clinico-epidemiological analysis of smoking and alcohol consumption in TB patients (Myc. Tuberculosis) and with mycobacteriosis (Myc. Kansas]

INTRODUCTION

Smoking and alcohol consumption are a major public health problem. More and more are mentioned, also, these two drugs, tobacco and alcohol as risk factors for tuberculosis and mycobacteriosis.

AIM OF STUDY

Comparative analysis of epidemiological and clinical patients with tuberculosis and mycobacteriosis M.kansasii smoking cigarettes and abuse alcohol.

MATERIAL AND METHOD

The study included 2025 patients with tuberculosis and 140 patients with diagnosed lung mycobacteriosis hospitalized in Kuyavian-Pomeranian Center of Pulmonology in the years 2003-2013. Data were obtained from the central database of the hospital on admission to the hospital.

RESULTS

There were 1403 smokers (69.3%) of tuberculosis patients and 79 (56.4%) with mycobacteriosis, and alcohol dependence were 534 (26.4%) and 16 (11.4%) respectively. Both of smokers and drinkers, men prevailed. Smokers who have developed tuberculosis were significantly younger than patients with mycobacteriosis, often touched their homelessness and unemployment, and often lived in rural areas. Conversely, smokers with mycobacteriosis are people often married, professionally active. In the group of abusers, patients with tuberculosis were younger, living in the country. side, often unemployed, homeless and single compared to patients with my. cobacteriosis. The clinical picture of patients with tuberculosis and mycobacteriosis did not differ significantly between the groups.

CONCLUSIONS

A retrospective study of patients with tuberculosis and my. cobacteriosis showed significantly more use of tobacco and alcohol abuse than in the general Polish population. It should be noted that cigarette smoking and alcohol abuse are major risk and mycobacteriosis. Therefore, it is important to conduct anti-tobacco education and prevention of alcohol abuse.

[A comparison of chest radiographs between patients with pulmonary Mycobacterium kansasii infection and those with Mycobacterium tuberculosis infection in the initial stage of disease]

OBJECTIVES

To elucidate the differences in affected lung segments between patients with pulmonary M. kansasii infection and those with M. tuberculosis infection in the initial stage of disease, we examined chest radiography images and CT scans. The initial stage of disease was defined as the period when less than one-sixth of the total lung area was affected by the infection, as visualized on chest radiography and CT.

SUBJECTS AND METHODS

One hundred eighty-four patients were diagnosed with M.kansasii infection between 1996 and 2010 and 835 patients, with M.tuberculosis infection between 2008 and 2009 at our hospital. The diagnosis was made on the basis of the results of sputum culture and/or bronchial washing. After excluding the patients with underlying lung diseases such as chronic pulmonary emphysema, interstitial pneumonia, and old pulmonary tuberculosis as well as those in advanced stages, 24 patients with M. kansasii infection and 62 patients with M. tuberculosis infection were included in this study. The affected segments of the lungs and the rates of cavity development were determined by using CT scans.

RESULTS

In patients with M.kansasii, 17 had an infected right lung, while 7 had an infected left lung. Additionally, in patients with M.tuberculosis, 58 had an infected right lung, 3 had an infected left lung, and 1 had a bilateral infection. In patients infected with M. kansasii, the upper lobes were affected in 22 cases and the lower lobes in 3 cases. In patients infected with M. tuberculosis, the upper, middle, and lower lobes and the lingular segment were affected in 41, 8, 24, and 1 cases, respectively. Upper lobe lesions were seen more frequently in patients with M. kansasii infection than in those with M. tuberculosis infection (p < 0.05). Cavity formation was identified more frequently in patients infected with M. kansasii (91.7%) than in those infected with M. tuberculosis (32.3%) (p < 0.001). Cavitary lesions were more frequently localized to the apical, posterior, and apico-posterior regions (S1, S2 or S1 +2) of the upper lobes in patients infected with M. kansasii (86.4%) than in those infected with M. tuberculosis (35%) (p < 0.001). A solitary lesion without endobronchial spread, which is characterized by centrilobular micronodules and tree-in-bud appearance, was more frequently demonstrated in patients infected with M.ka nsasii (45.8%) than in those infected with M. tuberculosis (6.5%) (p < 0.001).

CONCLUSION

Our study revealed that the apical, posterior, and apico-posterior regions of the upper lobes are vulnerable to infection by not only M.tu berculosis, but also M.ka nsasii. It is likely that M.ka nsasii might gain access to these regions via the airways and that its weak virulence may lead to higher localization.

Clinical analysis of patients with pulmonary nontuberculous mycobacterial disease complicated by pneumothorax

OBJECTIVE

We clarified the clinical characteristics of patients with pulmonary nontuberculous mycobacterial (NTM) disease complicated by pneumothorax.

METHODS

We retrospectively selected 220 patients who satisfied the diagnostic criteria for NTM disease proposed by the American Thoracic Society (ATS). Nine patients with pulmonary NTM disease were complicated with pneumothorax. We investigated the patients' background, laboratory findings, radiological findings, treatment and prognoses.

RESULTS

There were nine patients, including six men and three women, with a mean age of 73.2 years. Seven patients had underlying respiratory diseases such as chronic obstructive pulmonary disease (COPD) excluding pulmonary NTM disease. The causative microorganisms was Mycobacterium avium in four patients, M. intracellulare in four patients, and M. kansasii in one patient. Regarding the radiological findings, pneumothorax was recognized in the right lung in five patients, in the left lung in three patients, and in both lungs heterogeneously in one patient. Although most patients exhibited multiple cavities and extensive lesions over the unilateral lung fields, three patients were simultaneously diagnosed with pulmonary NTM disease at the onset of pneumothorax. As for treatment, thoracic drainage was performed in seven patients, while one patient was advised only to rest and one patient required both thoracic drainage and surgery. The responses to the treatment was poor in each case, and five patients died due to pneumonia or heart failure.

CONCLUSION

In this study, the rate of pneumothorax complications in the patients with pulmonary NTM disease (4.1%) was higher than that of other reports. The responses to treatment, and prognoses were poor due to the presence of other complications.

Mixed pulmonary infection with three types of nontuberculous mycobacteria

A 71-year-old man with a history of chronic obstructive pulmonary disease (COPD) and silicosis was referred to our hospital for an evaluation of dyspnea. A progressively enlarging cavity found in the patient's left lower lung was associated with a worsening respiratory status. One year after the initial referral, the patient was diagnosed with nontuberculous mycobacterial (NTM) infection. We herein report the case of a patient with a mixed infection of M. kansasii, M. avium complex and M. abscessus, the various organisms having been isolated in succession. Recognizing a diagnosis of mixed pulmonary NTM infection is therefore crucial in patients with underlying diseases.

[Three cases of Mycobacterium kansasii pulmonary diseases in previously healthy young women]

Mycobacterium kansasii pulmonary diseases account for 20% of cases of non-tuberculous mycobacteria. Most patients are male. However, a recent study has found that radiological examinations in female patients often reveal nodular, bronchiectatic opacities. We describe 3 young women with cavitary opacities. Patient 1 was a 35-year-old woman in whom thin-walled cavitary opacities were detected in the upper lobe during a routine checkup. Sputum examination and fiberoptic bronchoscopy led to a diagnosis of M. kansasii pulmonary disease. Patient 2 was a 23-year-old woman who presented with hemoptysis. Thin-walled cavitary opacities were detected in the right upper lobe. Infection with M. kansasii was diagnosed after a sputum examination. Patient 3 was a 43-year-old woman in whom thin-walled cavitary opacities were detected in the left upper lobe during a routine checkup. Infection with M. kansasii was diagnosed after a fiberoptic bronchoscopic examination. Patient 1 was successfully treated with rifampicin, ethambutol, and levofloxacin, and patients 2 and 3 were successfully treated with isoniazid, rifampicin, and ethambutol. The possibility of M. kansasii pulmonary diseases should be considered in a previously healthy young woman with thin-walled cavitary opacities in the upper lobe.

[Present status of studies on epidemiology and molecular epidemiology of Mycobacterium kansasii, in special reference to its epidemiology]

Mycobacterium kansasii, a slow-growing photochromogen, causes serious pulmonary diseases in humans. Since the 1980s the isolation rate of M. kansasii has been surpassed by that of Mycobacterium avium complex (MAC). Pulmonary disease caused by M. kansasii is known to be more common in urban areas than in rural areas, and its changing epidemiologic features and geographical distribution have been known for several decades. The disease had been found almost only in and around Tokyo areas until the 1970s, but after the 1990s, the disease spread to the rest of Japan. The incidence rate of the disease due to M. kansasii remained at the same level, while non-tuberculous mycobacterioses as a whole are rapidly increasing, especially because of the increase in Mycobacteriu avium complex diseases, and because of the improvement of identification techniques in recent years. This change in the epidemiologic picture of M. kansasii in Japan seems to be influenced by the international trends of this disease. The complicated environmental and other factors related to M. kansasii infection are discussed in this review.

Clinical characteristics and treatment outcomes of Mycobacterium kansasii lung disease in Korea

PURPOSE

While Mycobacterium kansasii is a common cause of nontuberculous mycobacterial (NTM) lung disease in many developed countries, M. kansasii is infrequently isolated in Korea. We investigated the clinical and radiological features and treatment outcomes of M. kansasii lung disease in Korea retrospectively.

MATERIALS AND METHODS

We identified 41 patients with M. kansasii lung disease who met the diagnostic criteria for NTM lung disease in two tertiary referral hospitals in Seoul, Korea, between January 1998 and December 2007.

RESULTS

Their median age was 63 years [interquartile range (IQR) 51-75 years] and 33 (81%) were men. Twenty-three patients (56%) were smokers and 13 patients (32%) had previous pulmonary tuberculosis. The most common radiographic findings were nodules (n = 22, 54%) and consolidation (n = 22, 54%). Cavitation was present in 13 patients (32%). Thirty-one patients (76%) were treated with isoniazid, rifampin, and ethambutol. The median treatment duration was 16 months (IQR 9-18 months). The negative conversion rate after 12 months of treatment was 95%.

CONCLUSION

Clinicians should be aware of the various radiographic manifestations of M. kansasii lung disease. With appropriate treatment, these patients have a good prognosis.

[A study on clinical features of Mycobacterium kansasii pulmonary disease in women]

OBJECTIVES

To clarify clinical features of M. kansasii pulmonary disease in women.

METHODS

We performed a retrospective analysis of M. kansasii pulmonary disease in women compairing with that in men. We focused on 8 female cases of M. kansasii pulmonary disease during the past 7 years from June 1998 to August 2005.

RESULTS

The cases of M. kansasii pulmonary disease in women have increased in the latter few years. The mean age of female cases was higher than that of male cases, 65.6 and 53.1 years old, respectively. The number of female cases with smoking history was lower than that of male cases, 37.5% and 90.0%, respectively. Two female cases had underlying pulmonary diseases, as compared with 10 male cases, 25.0% and 33.3%, respectively. The radiological findings in female cases included 2 cavitary opacities, 1 infiltrative opacity and 5 nodular, bronchiectatic opacities, as compared with 27 cavitary opacities, 1 infiltrative opacity, 1 solitary nodular opacity and 1 nodular, bronchiectatic opacity in male cases. MAC was also detected in 2 female cases, who presented with nodular, bronchiectatic opacities. On the other hand, there were 6 female cases, in which no other NTM was detected. 3 cases showed cavitary or infiltrative opacities, which improved with the following 3 tuberculous drugs INH, RFP, and EB (HRE), while others showed nodular, bronchiectatic opacities, in which 2 cases showed radiological exacerbations without any treatment and another one revealed an improvement with HRE.

CONCLUSIONS

M. kansasii pulmonary disease in women tends to be identified in elderly who smoke less and have no underlying pulmonary diseases, and most of radiological findings in female cases revealed nodular, bronchiectatic opacities. Summing up all these findings, clinical features of M. kansasii pulmonary disease in women was considered to resemble that of MAC infection, and it was speculated that the increase of M. kansasii pulmonary disease in women has some relationship with that of MAC infection in middle or lingular lobe. However, it was confirmed that some cases of M. kansasii pulmonary disease in women might primarily present with nodular, bronchiectatic lesions, regardless of MAC infection.

Broncholithiasis in an immune compromised boy with disseminated Mycobacterium kansasii

A case of broncholithiasis in a child is reported. To our knowledge, it has not been reported in children. Broncholithiasis is a condition in which a peribronchial calcified lymph node erodes into or distorts an adjacent bronchus. Symptoms of broncholithiasis include cough, recurrent episodes of fever, haemoptysis, and purulent sputum. The most common cause of broncholithiasis is Mycobacterium tuberculosis (M. tuberculosis). Here we describe a 14-year-old boy known to have disseminated Mycobacterium kansasii (M. kansasii) infection associated with hypoplastic myelodysplastic syndrome (MDS). He was presented with cough and fever. Computed tomography (CT) and bronchoscopy revealed a large calcified mass eroding in the right main bronchus. While surgical therapy was considered, haemoptysis developed and his condition deteriorated. Bone marrow puncture revealed acute myeloid leukemic transformation of the MDS. Curation was no longer possible. Post mortem examination revealed a large bronchiolith, evolving from a calcified lymph node.

Identification by surface plasmon resonance of the mycobacterial lipomannan and lipoarabinomannan domains involved in binding to CD14 and LPS-binding protein

The mycobacterial lipoglycans, lipomannan (LM) and lipoarabinomannan (LAM), regulate host defence mechanisms through their interaction with pattern recognition receptors such as Toll-like receptors (TLRs). We have developed a surface plasmon resonance assay to analyse the molecular basis for the recognition of Mycobacterium kansasii LM or LAM, by immobilized CD14 and LPS-binding protein (LBP) both being capable to promote presentation of bacterial glycolipids to TLRs. The affinity of either LM/LAM was higher to CD14 than to LBP. Kinetic and Scatchard analyses were consistent with a model involving a single class of binding sites. These interactions required the lipidic anchor, but not the carbohydrate domains, of LM or LAM. We also provide evidence that addition of recombinant LBP enhanced the stimulatory effect of LM or LAM on matrix metalloproteinase-9 expression and secretion in macrophages, through a TLR1/TLR2-dependent mechanism.

Mycobacterium kansasii olecranon bursitis

A case is reported of a post-traumatic olecranon bursitis caused by Mycobacterium kansasii following an injury sustained in a public swimming pool. It responded to surgical debridement and combined rifampicin, isoniazid, pyrazinamide and ethambutol antimicrobial therapy. A literature search was performed and a treatment regimen for this uncommon condition is suggested.

Immune responses to defined antigens of Mycobacterium bovis in cattle experimentally infected with Mycobacterium kansasii

Cross-reactive responses elicited by exposure to nontuberculous mycobacteria often confound the interpretation of antemortem tests for Mycobacterium bovis infection of cattle. The use of specific proteins (e.g., ESAT-6, CFP-10, and MPB83), however, generally enhances the specificity of bovine tuberculosis tests. While genes for these proteins are absent from many nontuberculous mycobacteria, they are present in M. kansasii. Instillation of M. kansasii into the tonsillar crypts of calves elicited delayed-type hypersensitivity and in vitro gamma interferon and nitrite concentration responses of leukocytes to M. avium and M. bovis purified protein derivatives (PPDs). While the responses of M. kansasii-inoculated calves to M. avium and M. bovis PPDs were approximately equivalent, the responses of M. bovis-inoculated calves to M. bovis PPD exceeded their respective responses to M. avium PPD. The gamma interferon and nitrite responses of M. kansasii-inoculated calves to recombinant ESAT-6-CFP-10 (rESAT-6-CFP-10) exceeded corresponding responses of noninoculated calves as early as 15 and 30 days after inoculation, respectively, and persisted throughout the study. The gamma interferon and nitrite responses of M. bovis-inoculated calves to rESAT-6-CFP-10 exceeded the corresponding responses of M. kansasii-inoculated calves beginning 30 days after inoculation. By using a lipoarabinomannan-based enzyme-linked immunosorbent assay, specific serum antibodies were detected as early as 50 days after challenge with M. kansasii. By a multiantigen print immunoassay and immunoblotting, serum antibodies to MPB83, but not ESAT-6 or CFP-10, were detected in M. kansasii-inoculated calves; however, responses to MPB83 were notably weaker than those elicited by M. bovis infection. These findings indicate that M. kansasii infection of calves elicits specific responses that may confound the interpretation of bovine tuberculosis tests.

Clinical features and follow up of 302 patients with Mycobacterium kansasii pulmonary infection: a 50 year experience

AIMS

To analyse clinical features and treatment outcomes of patients with pulmonary Mycobacterium kansasii infection treated at Hines VA Hospital between 1952 and 1995, and followed up until 2003.

FINDINGS

302 patients were confirmed to have M kansasii pulmonary infection; diagnosis was not made until death in 2%. The average age was 50 years old; 76% were white; all were men. Productive cough, dyspnoea, and chest pain were common; 16% were asymptomatic. Right sided, apical or subapical, thin walled cavitary infiltrate was the characteristic radiological feature. Heavy smoking, chronic obstructive pulmonary disease, alcoholism, peptic ulcer disease, coronary artery disease, prior tuberculosis, psychosis, prior pneumonia, and immunocompromising conditions were prevalent. Average follow up was 10 years and 2 months. PPD was positive in 58% of 179 tested. Two thirds of the patients required only first line drugs. Fourteen per cent required surgical intervention, none after 1977. Spontaneous resolution occurred in 1%. Aspergillosis developed in 4%. Bronchogenic carcinoma coexisted with M kansasii infection in 6% and followed it in 4%. Extrapulmonary malignancy coexisted with the infection in 4% and followed it in 6%; most involved head and neck. Eleven per cent of 224 deaths were attributed to M kansasii. Outcomes were affected by comorbidity, treatment compliance, rifampicin use, and extent of infection.

CONCLUSIONS

Prognosis of M kansasii pulmonary infection is good if diagnosed and treated early, together with control of underlying conditions. Clinicians should be aware of atypical radiological manifestations of the disease when coexisting with other pulmonary or immunocompromising conditions.

The mimetics of antiadhesive peptides as the inhibitors of Mycobacterium kansasii phagocytosis

The alpha-guanidino acids derived of 15 proteinaceous amino acids, omega-guanidino acids with gradually increased hydrocarbon chains, and amidinated dipeptides, were tested as the mimetics of antiadhesive peptides in Mycobacteria phagocytosis inhibition. The crystal structure of omega-guanidino acids used was determined by X-ray structural analysis. It follows from our experiments that the proper distance between guanidine and carboxyl groups of effector molecules is of decisive importance for their inhibitory activity.

Clinical and Epidemiological Study of Disease Caused by Mycobacterium kansasii in the Metropolitan Area of Bilbao, Spain

OBJECTIVE

Epidemiological description of individuals from whom Mycobacterium kansasii isolates were obtained in respiratory samples, and analysis of the isolates using molecular biological techniques.

MATERIAL AND METHODS

A descriptive retrospective/ prospective study was carried out from January 1994 to April 2002 in Basurto Hospital and Santa Marina Hospital and from January 2000 to April 2002 in Cruces Hospital, Galdakao Hospital, and San Eloy Hospital. Diagnosis of the disease was performed according to American Thoracic Society criteria; other definitions were also applied to allow inclusion of all cases. Disease caused by M. kansasii in patients who were not infected with the human immunodeficiency virus (HIV) was compared with disease caused by Mycobacterium tuberculosis in a control group. Polymerase chain reaction was applied with analysis of restriction fragment length polymorphisms to differentiate between species of mycobacteria and classify them into genotypes. Amplified fragment length polymorphisms were used to recognize clones within each genotype.

RESULTS

The patient charts of 334 patients in which an isolate of M. kansasii had been recorded were reviewed. We considered 220 patients to be suffering from disease caused by M. kansasii (American Thoracic Society criteria along with probable disease according to established definitions). The disease was more frequent in male patients (n=185; 84.1%) and in individuals who were not HIV positive (n=184; 83.6%). The highest incidence of disease in the Bizkaia region was found in Margen Izquierda-Encartaciones, where the rate was 8.05 per 100 000 inhabitants. In the Bilbao area, the highest rate was found in the districts lying on the outskirts. The underlying diseases were tuberculosis (20.5%), chronic obstructive pulmonary disease (25.9%), pulmonary neoplasia (7.7%), silicosis (0.9%), chronic liver disease (11.4%), and duodenal ulcer (8.6%). The most frequent constitutional symptoms were fever (39.1%), loss of appetite (23.2%), and weight loss (33.3%). Among the respiratory symptoms, the most outstanding were cough (70.9%) and expectoration (62.3%). The most frequent radiographic patterns were cavitation and pulmonary infiltration. The most common treatment regimen was rifampicin, isoniazid, and ethambutol (43.4%), and the average duration was 12 months in patients who were HIV negative. Analysis of antibiotic sensitivity, performed on 56 strains, revealed that 100% were resistant to isoniazid, while none displayed rifampicin resistance. Thirty-four cases of disease caused by M. kansasii were compared with 68 cases of tuberculosis, all of them without HIV infection. The comparison revealed a predominance of smokers, respiratory symptoms, and cavitation in patients with disease caused by M. kansasii. The majority of the isolates (98.5%) corresponded to genotype I. A total of 8 clones were obtained; the clones designated 1 and 3 were more common in HIV-positive and HIV-negative individuals respectively.

CONCLUSIONS

In recent years, there has been an increase in the number of patients with disease caused by M. kansasii in the province of Bizkaia. The disease is more frequent in male patients, individuals who are HIV negative, and in urban areas. In addition, more respiratory symptoms and a higher incidence of cavitation were found in patients with disease caused by M. kansasii than in those with tuberculosis. Genotype I is the most common isolate, and clones 1 and 3 affect 80% of patients suffering from the disease.

[A rare case of disseminated Mycobacterium kansasii infection]

Mycobacterium kansasii infection has been reported to be about 20 percent of non-tuberculous mycobacteriosis, and its disseminated type is uncommon and the prognosis is reported to be generally poor. We experienced one case of disseminated Mycobacterium kansasii infection. A 81 year-old man who had been short-bowel syndrome due to the operation for superior mesenteric artery occlusion since 1998 was admitted on April 24th, 2001 to our hospital because of slowly progressive consciousness disturbance and anorexia. He had shown progressive productive cough and respiratory failure and laboratory findings were C-reactive protein elevation and pancytopenia. Human immunodeficiency virus (HIV) antibody was negative. Chest X-ray and computed tomography showed diffuse miliary nodules and infiltrative shadow. Sputum examination was positive for mycobacteria. The cultured isolate was identified as Mycobacterium kansasii. Bone marrow aspirations revealed inflammatory granuloma with necrosis. He was diagnosed as disseminated Mycobacterium kansasii infection and heart failure, and was treated by anti-tuberculosis drugs and diuretics. Treatment was very effective and Chest X-ray findings and respiratory failure had been completely improved. In this case we speculated that the malnutrition due to short-bowel syndrome could be one of the most suspected reasons of Mycobacterium kansasii dissemination. Disseminated Mycobacterium kansasii infection has been rarely reported comparing with the other mycobacterial infections in Japan. However, due to the increasing numbers of immunocompromised hosts with aging, HIV infection, cancer, and steroid therapy, this type of infection will become more common and its earlier diagnosis and adequate treatment will be important to improve the prognosis.

Epidemiological, clinical and therapeutic features of AIDS-related Mycobacterium kansasii infection during the HIV pandemic: an 11-year follow-up study

OBJECTIVES

Optimal diagnosis and timely treatment of atypical mycobacteriosis, and especially Mycobacterium kansasii disease, remain a serious challenge for clinicians engaged in the management of the immunocompromised host.

METHODS AND RESULTS

From more than 2700 hospitalizations (over 1800 patients) attributable to HIV-associated disorders over an 11-year period, 12 patients were found to have a confirmed M. kansasii infection. This reflects the recent reduction in the frequency of this HIV-related complication, which virtually disappeared after the introduction of potent antiretroviral combinations in 1996. In the early 1990s, the lack of effective antiretroviral regimens made frequent the association with AIDS, a mean CD4 lymphocyte count of nearly 20 cells/microL, and an extremely variable chest X-ray features. The recent detection of a further case was attributable to late recognition of very advanced HIV disease, complicated by multiple opportunistic disorders.

CONCLUSIONS

Mycobacterium kansasii respiratory or disseminated infection continues to occur, and poses diagnostic problems in terms of late or missed identification as a result of slow culture and frequently concurrent opportunistic disease. Serious therapeutic difficulties also arise from the unpredictable in vitro antimicrobial susceptibility profile of these organisms, and from the need to start an effective combination therapy that does not interfere with other medications as soon as possible.

Mortality Prediction in PulmonaryMycobacterium KansasiiInfection and Human Immunodeficiency Virus

In the setting of human immunodeficiency virus (HIV) infection, the clinical implications of American Thoracic Society (ATS) diagnostic criteria and the significance of a single positive respiratory culture for Mycobacterium kansasii are unknown. We retrospectively studied HIV-infected patients with pulmonary M. kansasii isolated between 1989 and 2002 at one institution. Of 127 patients, 33% fulfilled ATS disease criteria. Twenty-nine percent received at least three active drugs for at least 3 months, and 53% died. In survival analysis, a lower CD4 count (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.3) and positive smear microscopy (HR, 2.8; 95% CI, 1.3-6.1) were associated with mortality, whereas antiretroviral therapy (HR, 0.3; 95% CI, 0.1-0.8) and M. kansasii treatment (HR, 0.4; 95% CI, 0.2-0.9) were associated with survival. ATS criteria did not predict mortality (HR, 0.9; 95% CI, 0.4-1.9). Fifteen patients (12%) apparently had indolent infection, not requiring immediate therapy. They had fewer positive cultures and lower rates of positive smear microscopy and ATS-defined disease. In HIV-infected patients with pulmonary M. kansasii infection, predictors of survival include higher CD4 counts, antiretroviral therapy, negative smear microscopy, and adequate treatment for M. kansasii infection, but not ATS diagnostic criteria. Withholding treatment in HIV-infected patients with respiratory M. kansasii isolates should only be considered with negative smear microscopy, few positive cultures, and mild immunosuppression.

Pulmonary alveolar proteinosis associated with psoriasis and complicated by mycobacterial infection: Successful treatment with granulocyte-macrophage colony stimulating factor after a partial response to whole lung lavage

Pulmonary alveolar proteinosis (PAP) is a rare lung disease. Although whole lung lavage is considered the most effective treatment, not every patient shows a complete response. The case ofa young man with PAP in association with psoriasis who underwent frequent whole lung lavage but only achieved remission following treatment with granulocyte-macrophage colony stimulating factor (GM-CSF) is reported. His lung problem was complicated by atypical mycobacterial infection,which resolved with treatment. The role of GM-CSF is discussed.