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Mycobacterium Chelonae: Differential Diagnoses & Workup
Updated: Aug 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Bacterial osteomyelitis
Contamination/pseudoinfection
Colonization
Cutaneous vasculitis
Fusarium species infection
Phaeohyphomycosis
Prototheca species infection
Pseudallescheria boydii infection
Workup
Laboratory Studies
According to American Thoracic Society (ATS) criteria,11,2 diagnosis of M chelonae lung disease requires (1) pulmonary symptoms with consistent radiographic features (see Imaging Studies), (2) exclusion of other diagnoses (especially tuberculosis), and (3) appropriate microbiological findings.
- Sputum smear for acid-fast bacilli and culture for mycobacteria
- Microbiological findings to satisfy ATS diagnostic criteria include the following (at least one must apply):
- Positive culture from 2 separate sputum samples
- One positive culture from bronchial wash or lavage
- A biopsy specimen with appropriate histopathologic features and a positive culture from an associated bronchial wash or biopsy culture
- Induced sputum samples may be substituted for expectorated sputum samples, but data establishing the effectiveness of this technique are lacking.
- A single positive isolate may represent a contaminant or a persistent or transient colonizer without pathogenicity.
- Microbiological findings to satisfy ATS diagnostic criteria include the following (at least one must apply):
- Swab culture for acid-fast bacillus
- Notifying the microbiology laboratory personnel that an NTM is suspected may help ensure appropriate processing of specimens. Most laboratories use liquid media (eg, BACTEC) for mycobacterial cultures.
- Swab specimens are less optimal than cultures obtained via aspiration. Consider contacting laboratory personnel for proper procedures regarding adequate specimen collection to increase the yield and significance of cultures.
- Interpret the result with caution because a single positive culture, especially of a superficial lesion, may represent a contaminant or an "innocent bystander." In one study from Spain, 13 of 24 isolates of M chelonae were deemed of questionable clinical significance12
- Additional testing if M chelonae or M abscessus infection is discovered
- An HIV test may be warranted, especially if disseminated disease is diagnosed without an obvious underlying condition.
- Sweat chloride and/or genetic screening for cystic fibrosis may be warranted if lung infection is found in a relatively young patient (<50 y).
- A purified protein derivative (of tuberculin) (PPD) test should be considered to assist in ruling out tuberculosis.
- Susceptibility testing should be performed on all isolates to guide treatment. General susceptibility results reported in the new ATS guidelines are as follows:2
- Tobramycin - 100%
- Clarithromycin - 100%
- Linezolid - 90%
- Imipenem - 60%
- Amikacin - 50%
- Clofazimine and doxycycline - 25%
- Ciprofloxacin - 20%
Imaging Studies
- Chest radiography
- Perform chest radiography if pulmonary symptoms are present. Typical findings are bilateral patchy nodular or cavitary opacities (15% are cavitary) with an upper lobe predominance.
- Normal chest radiographic findings with a single positive culture suggest that the organism is a contaminant or a transient colonizer and is not clinically significant. However, in the presence of chronic persistent pulmonary symptoms or repeatedly positive culture results, additional testing may be necessary.
- ChestCT scanning
- If the patient has significant respiratory symptoms or repeatedly positive cultures for the same organism with a lack of cavitary disease on chest radiography, high-resolution CT scanning is likely indicated.
- Typical CT scan findings include bronchiectasis or diffuse small nodules; these are often not revealed by routine chest radiography.
- If the chest radiographic findings are abnormal, chest CT scanning may be performed to obtain better definition of the abnormalities present. Lymphadenopathy may also be detected. This study is not necessary in every case but should be strongly considered.
- CT scanning of the abdomen and pelvis: This study may be indicated to detect local abscesses, including retroperitoneal abscesses, in disseminated disease, localizing signs or symptoms, or a history of injections in those locations.
- Bone imaging, MRI, and nuclear imaging
- These studies may be helpful in detecting suspected osteomyelitis or joint disease, especially in patients with a history of penetrating trauma.
- Gallium scanning may be useful to screen for supradiaphragmatic lymphadenopathy (intrathoracic or axillary).
Other Tests
- Erythrocyte sedimentation rate or C-reactive protein assessments may be useful to differentiate colonizer and pathogen, but these are nonspecific tests and the results must be carefully evaluated within the clinical context of the patient.
Procedures
- Lung procedures
- Perform bronchoscopy with bronchial washes for acid-fast bacillus (AFB) culture, ideally with transbronchial biopsy, for culture and histology. A bronchioloalveolar lavage may also be useful. Because the diagnosis is usually uncertain at this stage, fungal cultures are typically sent as well.
- Open or thorascopic lung biopsy may be considered if suspicion is high but diagnostic criteria have not been met. Send specimens for fungal and AFB cultures, as well as histology.
- A biopsy culture positive for M chelonae or M abscessus is considered diagnostic.
- The presence of either AFB or granulomas in a lung biopsy or a transbronchial biopsy specimen along with even a single positive culture of sputum or bronchial wash (even in low numbers) is considered diagnostic.
- Skin tests
- Perform a biopsy for localized or disseminated skin lesions. Send specimens for AFB and fungal cultures, as well as histology.
- PPD testing with nontuberculous mycobacterial specific antigens is nonspecific and generally not indicated. These tests are not commercially available.
- Aspiration biopsy
- Perform an aspiration biopsy of a localized abscess for culture; this method is preferred over culture via swab of draining abscess fluid.
- Perform a fine-needle aspiration biopsy of a lymphadenitis for histology and culture.
Histologic Findings
Histologic findings may reveal acute inflammation, microabscesses, granulomatous inflammation, or granulomas (with or without caseation). These findings may be mixed. Special tissue stains for AFB may reveal organisms.
Staging
Contamination, colonization, and localized and disseminated disease are present.
More on Mycobacterium Chelonae |
| Overview: Mycobacterium Chelonae |
 Differential Diagnoses & Workup: Mycobacterium Chelonae |
| Treatment & Medication: Mycobacterium Chelonae |
| Follow-up: Mycobacterium Chelonae |
| Multimedia: Mycobacterium Chelonae |
| References |
| Further Reading |
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Further Reading
Clinical trials
Study of Mycobacterial Infections
Genetic Disorders of Mucociliary Clearance in Nontuberculous Mycobacterial Lung Disease
Keywords
Mycobacterium chelonei, M chelonei, M chelonae, Mycobacterium chelonae, Mycobacterium abscessus, M abscessus, nontuberculous mycobacterium, nontuberculous mycobacteria, mycobacterium other than tuberculosis, MOTT, Mycobacterium tuberculosis, mycobacterial cutaneous infection, NTM, NTM lung disease, AIDS, HIV, Runyon classification, Runyon's classification, Runyon classification group IV, Runyon group IV, rapidly growing mycobacteria, osteomyelitis, keratitis, corneal ulcers
