RESPIRATORY


Image 3. Sourced from: http:// www.prescriber.co.uk/wp-content/ uploads/sites/23/2017/06/Conf- Nontuberculosis-EB-edit-lsw.pdf6


Table showing clinical and microbiological criteria for diagnosing NTM-PD Image sourced from: www.atsjournals.org/doi/pdf/10.1164/rccm.200604-571ST


BIBLIOGRAPHY 1. Margaret M. Johnson JAO. Nontuberculous mycobacterial pulmonary infections. J Thorac Dis [Internet]. 2014 Mar [cited 2017 Jun 27];6(3):210. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3949190/ 2. Nontuberculous Mycobacterial Lung Disease - NORD (National Organization for Rare Disorders) [Internet]. NORD (National Organization for Rare Disorders). [cited 2017 Jun 27]. Available from: https://rarediseases.org/rare-diseases/ nontuberculous-mycobacterial-lung- disease/


lung tissue9


Nodular bronchiectasis is mainly seen in nonsmoking, middle-aged or elderly (postmenopausal) caucasian women with low BMIs. These women have no previous history of lung disease; however, they suffer from a chronic cough that does not respond to treatment with antibiotics. These women also have similar clinical characteristics and body types which can include: scoliosis, pectus excavatum (sunken chest) and mitral valve prolapse1


.


Cavitary disease is presence of cavities, found particularly on the upper lobes of the lung7


, caused by necrosis of . This is present typically


in males in their late 40s and early 50s, who are smokers or former smokers, consume excessive alcohol and who may have existing respiratory conditions10


. The presentation of


cavities indicate the severity of the infection and if the disease is allowed to progress, it could potentially lead to respiratory failure within one to two years. Although NTM-PD is the most common manifestation of NTM infections, the infection can affect the bones, lymph nodes and the skin (shown in the image below)11


. TREATMENT


A diagnosis of NTM-PD does not always mean that treatment should start immediately, as usually therapy


A) Neck and chest of a 53-year-old woman (case-patient 1, displaying a nontuberculous mycobacterial infection) 14 days after fractionated CO2 laser resurfacing. B) Neck of the patient after 5 months of multidrug therapy and pulsed dye laser treatment. Image sourced from: wwwnc.cdc.gov/eid/article/19/3/12-0880-f1


involves a combination of antibiotics for twelve to 24 months. In some cases there can even be spontaneous remission of the disease7


. The risks


and the benefi ts must be weighed before commencing treatment as many of the drugs used carry some serious side-effects, often are poorly tolerated and are quite expensive. Presently, the mean cost of treating a patient with NTM-PD is €39,559.60, nearly four times the amount for a matched control group (€10,006.71)12


Hospitalisations for NTM-PD patients were three times higher than the control group, and accounted for 63 per cent of the total costs. Only 74 per cent of NTM-PD patients received antibiotics and nearly twelve per cent were prescribed macrolide therapy12


.


Currently, the 2007 American Thoracic Society (ATS) guidelines are being used as they are the most up-to- date; however, in October 2017, the British Thoracic Society is set to publish guidelines for the diagnosis and management of NTM-PD. According to ATS guidelines, MAC eradication in nodular bronchiectasis involves a three-times-weekly regimen of clarithromycin (1,000 mg) or azithromycin (500 mg), rifampin (600 mg) and ethambutol (25 mg/kg)13


.


With the exception of Mycobacterium kansasii, NTM-PD is diffi cult to control with antimicrobial therapy alone. Surgery has been seen as an option for patients where medical treatment has failed. Surgery aims to slow disease progress by removing areas of destroyed lung; however, patients will still need postoperative antimicrobial therapy14


. Although amikacin is used


Image sourced from: www.bronchiectasisandntminitiative.org/Bronchiectasis/ Bronchiectasis-Resources/Basics-of-Bronchiectasis


systemically, recent data has shown that inhaled liposomal amikacin is effective in treating refractory NTM-PD and is less toxic. Other drugs such as linezolid, tigecycline, bedaquiline and clofazimine all show excellent promise in eradicating NTM14


. • .


3. Shah NM, Davidson JA, Anderson LF, Lalor MK, Kim J, Lucy Thomas H, et al. Pulmonary Mycobacterium avium- intracellulare is the main driver of the rise in non-tuberculous mycobacteria incidence in England, Wales and Northern Ireland, 2007–2012. BMC Infect Dis [Internet]. 2016 [cited 2017 Jun 27];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4858927/ 4. Ryan KJ, George Ray C, Lawrence Drew W, Plorde JJ. Sherris Medical Microbiology - An Introduction to Infectious Diseases [Internet]. Fourth. Sherris JC, Ryan KJ, George Ray C, editors. McGraw Hill Professional; 2004. Available from: http://lalashan.mcmaster.ca/theobio/ projects/images/c/c0/An_Introduction_to_ Infectious_Diseases.pdf 5. Brown L, Wolf JM, Prados-Rosales R, Casadevall A. Through the wall: extracellular vesicles in Gram-positive bacteria, mycobacteria and fungi. Nat Rev Microbiol [Internet]. 2015 Sep 1 [cited 2017 Jun 27];13(10):620–30. Available from: http://dx.doi.org/10.1038/ nrmicro3480 6. Titmarsh S. The growing threat of nontuberculous mycobacteria [Internet]. Prescriber; 2017. Available from: http:// www.prescriber.co.uk/wp-content/uploads/ sites/23/2017/06/Conf-Nontuberculosis-EB- edit-lsw.pdf


7. Thomson RM, Yew W. When and how to treat pulmonary non‐tuberculous mycobacterial diseases. Respirology [Internet]. 2009 Jan 1 [cited 2017 Jun 28];14(1):12–26. Available from: http:// onlinelibrary.wiley.com/doi/10.1111/j.1440- 1843.2008.01408.x/abstract 8. Bronchiectasis - Pulmonary Disorders - MSD Manual Professional Edition [Internet]. MSD Manual Professional Edition. [cited 2017 Jun 28]. Available from: http://www. msdmanuals.com/en-gb/professional/ pulmonary-disorders/bronchiectasis-and- atelectasis/bronchiectasis 9. L. Beth Gadkowski JES. Cavitary Pulmonary Disease. Clin Microbiol Rev [Internet]. 2008 Apr [cited 2017 Jun 28];21(2):305. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC2292573/


10. NTMfacts | Who is Susceptible to NTM? [Internet]. [cited 2017 Jun 28]. Available from: https://www.ntmfacts.com/ susceptibility 11. Nontuberculous Mycobacterial Disorders [Internet]. [cited 2017 Jun 28]. Available from: http://www. clevelandclinicmeded.com/medicalpubs/ diseasemanagement/infectious-disease/ nontuberculous-mycobacterial-disorders/ Default.htm


12. Diel R, Jacob J, Lampenius N, Loebinger M, Nienhaus A, Rabe KF, et al. Burden of non-tuberculous mycobacterial pulmonary disease in Germany. Eur Respir J [Internet]. 2017 Apr 1 [cited 2017 Jun 28];49(4):1602109. Available from: http:// erj.ersjournals.com/content/49/4/1602109. abstract


13. Loebinger MR, Welte T, Medicine CR, Hospital RB, London, UK, et al. Current Perspectives in the Diagnosis and Treatment of Nontuberculous Mycobacterial Pulmonary Disease. European Respiratory & Pulmonary Diseases [Internet]. 2016;02(02):54. Available from: http:// dx.doi.org/10.17925/erpd.2016.02.02.54 14. Ryu YJ, Koh W-J, Daley CL. Diagnosis and Treatment of Nontuberculous Mycobacterial Lung Disease: Clinicians’ Perspectives. Tuberc Respir Dis [Internet]. 2016 Apr [cited 2017 Jun 29];79(2):74. Available from: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4823187/


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