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Updated: Jan 15 2019

Mycobacteria Other Than Tuberculosis (MOTTS)

  • Snapshot
    • A 36-year-old HIV positive woman, non-compliant with treatment, presents to the clinic with a 1 month history of fever, fatigue, cough, and weight loss. Her temperature is 102.2°F (39°C), blood pressure is 135/90 mmHg, pulse is 100/min, and respirations are 22/min. The patient appears cachectic and markedly pale on physical exam. CD4 count is 39 cells/mm3. Chest radiography demonstrates nodular bronchiectatic changes and an upper lobe fibrocavitary pattern.
  • Introduction
    • Definition
      • infectious mycobacterium that is not tuberculosis, which can cause 4 clinical syndromes
        • pulmonary disease
          • caused by Mycobacterium avium complex (MAC)
        • superficial lymphadenitis
          • caused by
            • MAC (more common in children)
            • M. scrofulaceum
            • M. malmoense
        • disseminated disease in immunocompromised patients (e.g., AIDS)
          • most commonly caused by MAC
        • skin and soft tissue infection
          • most commonly caused by M. marinum
            • typically due to direct inoculation of the organism
    • Epidemiology
      • incidence
        • the most common nontuberculous species that cause disease in humans in the United States are
          • MAC
          • M. kansasii
      • Nontuberculous Mycobacterium
      • Disease
      • Clinical Presentation
      • Making the Diagnosis
      • Comments
      • Pulmonary disease
      • Symptoms are typically non-specific and depend on if the patient has underlying pulmonary disease
        • patients with underlying pulmonary disease typically present similar to tuberculosis (e.g., cough, weight loss, upper lobe infiltrates, and cavities)
      • Symptoms include
        • cough (dry or productive)
        • fatigue
        • malaise
        • dyspnea
        • weakness
      • Based on clinical and radiographic findings (e.g., nodular or cavitary opacities or multifocal bronchiectasis)
      • Sputum acid-fast bacilli and culture
      • Lung biopsy with mycobacterial histopathologic features (granulomatous inflammation or acid fact bacillus), if needed
      • -
      • Superficial lymphadenitis
      • Enlarged lymph nodes
        • most commonly the cervicofacial node in children
        • nontender and unilateral
        • enlarges over the course of weeks
      • Culture or polymerase chain reaction (PCR) of the fistula drainage, tissue, or caseous material
      • Most commonly affects children < 5 years of age
      • Disseminated disease
      • Fever
      • Fatigue
      • Malaise
      • Anorexia
      • Sequelae of organ involvement
        • bone marrow (neutropenia and anemia)
        • hepatosplenomegaly
      • Blood cultures of the Mycobacterium
      • Risk factors include
        • advanced HIV infection
        • hematologic malignancy
        • tumor necrosis alpha inhibitors or other immunosuppressive agents
      • Skin and soft tissue infection
      • Skin lesion
        • erythematous or bluish papule or nodule at the site of abrasion
          • lymphadenopathy may be present
      • Culture or PCR of the lesion
      • Fisherman or people who work at aquariums are at risk of developing M. marinum infection
  • Treatment
    • Medical
      • macrolide, rifamycin, and ethambutol
        • indication
          • initial empiric treatment option for MAC
        • comments
          • in cases of macrolide-resistance, the regimen is changed to rifamycin, ethambutol, clofazimine, and an intravenous aminoglycoside
          • note, the appropriate treatment for M. marinum has not been identified
  • Complications
    • Dissemination of the nontuberculous mycobacterium can occur in severely immunocompromised patients
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