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Nontuberculous mycobacteria (NTM) disease is an important cause of disease in immunosuppressed hosts.
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Mycobacterium avium complex is the leading cause of NTM disease in immunosuppressed patients, but rapid growers including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium fortuitum, and a variety of rare species are also important.
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In immunosuppressed patients, about half of NTM disease is pulmonary and the remainder is split between skin/soft tissue and disseminated.
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Treatment is
Nontuberculous Mycobacteria Infections in Immunosuppressed Hosts
Section snippets
Key points
Disease description
NTM disease is increasing in the United States. Prevots and colleagues11 used data from several large health maintenance organizations in the western United States and found an increase of 2.6% per year from 1994 to 2006. The first incidence estimate of NTM disease is 5.7 per 100,000 in Oregon in 2012, with rates 3 to 4 times higher in individuals older than 70 years.14 Most of this is pulmonary disease whereby a large proportion occurs outside of recognized settings of immunosuppression. For
Epidemiology
The epidemic of disseminated MAC infection began in 1982 with a sharp increase in the number of cases associated with the AIDS epidemic.3 Up to 24% of AIDS patients had disseminated MAC by 1989/1990.2 Distinguishing it from other opportunistic infections that occurred earlier in the course of HIV infection, disseminated MAC was associated with very low CD4+ counts, generally fewer than 50 cells/mm3.2, 3 The introduction of HAART in 1997 led to a sharp decline in the number of disseminated MAC
Corticosteroids
Oral and inhaled corticosteroids are routinely prescribed to suppress inflammation in several chronic conditions, including chronic obstructive pulmonary disease (COPD), asthma, and rheumatoid arthritis. Corticosteroids are known to increase the risk of pneumonia in patients with COPD and tuberculosis as much as 5-fold,33 while the relative risks of NTM are likely even greater. Oral prednisone use was 8 times higher among NTM cases than in controls in a case-control study in Oregon and
Solid organ transplants
Solid organ transplant recipients take a variety of immunosuppressive medications after transplantation. The most common maintenance drugs include calcineurin inhibitors (tacrolimus and cyclosporine), mammalian target of rapamycin (mTOR) inhibitor (sirolimus), prednisone, and others depending on the organ being transplanted. All data on NTM in transplants is found in case reports and institutional case series. To the authors’ knowledge there are no population-based prevalence or incidence
Solid tumors and hematologic malignancies
Patients with cancer are at higher risk for NTM disease. Underlying cellular immunity impairment and immunosuppression from antineoplastic chemotherapy also contribute to the increased risk.1, 8, 55 Patients with lung tumors are at increased risk of pulmonary NTM infection probably because of localized airway destruction or damage, and hematologic malignancies put patients at higher risk of both localized infections near the site of catheter placement and disseminated infections. Hairy cell
Hematopoietic stem cell transplants
Hematopoietic stem cell transplants (HSCTs) are used to treat several hematologic malignancies, including leukemia, multiple myeloma, and others. The number of HSCTs has increased dramatically from 200 in 1980 to 20,000 in 2010.57 The risks of NTM are higher before the transplant, owing to underlying immune cell abnormalities, and during the phase of immune reconstitution that follows induction immunosuppression and the HSCT. HSCTs are most frequently associated with catheter and blood
Primary immunodeficiency diseases
Primary immunodeficiency diseases include a large number of conditions associated with defects in antibody responses, and cellular and innate immunity.63 A subset of these is associated with a documented or theoretic risk, and most are associated with the IL-12/IFN-γ axis.63, 64 Other conditions predisposing to NTM include chronic granulomatous disease, common variable immune deficiency, and hypogammaglobulinemia.63 A recent study of conditions associated with death from NTM found that primary
Summary
Diseases and therapies that reduce cell-mediated immunity increase the risk of NTM disease. The broadening use of immunosuppressive drugs including anti-TNF biologics in the United States, and the expanding practice of stem cell and solid organ transplantation, places an increasing number of patients at risk for NTM disease.38 With the exception of population-based studies of anti-TNF biologics and corticosteroids that report the risk of NTM at 8 to 50 times that of the general population, to
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Disclosures: None.