Mycobacterium Fortuitum Workup

According to American Thoracic Society criteria^[3] , diagnosis of lung disease requires (1) pulmonary symptoms with consistent radiographic features, (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 at least 2 separate sputum samples
    • Positive culture from bronchial wash or lavage
    • 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 persistent or transient colonizer without pathogenicity.
• Swab culture for acid-fast bacilli

  • Notifying the microbiology laboratory personnel that a 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.
• Additional testing if M fortuitum 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 a lung infection is found in a relatively young patient (< 50 y). Most patients with cystic fibrosis also have a history of recurrent lung infections, although milder disease is being recognized more frequently.

• Chest radiography

  • Perform chest radiography if pulmonary symptoms are present.
  • 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.
• Chest CT 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 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 or lymphadenopathy, including retroperitoneal abscesses or lymph nodes, in patients with 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 osteomyelitis or joint disease if suspected, especially in patients with a history of penetrating trauma.

• Erythrocyte sedimentation rate, C-reactive protein, and other inflammatory markers may be useful if mycobacterial disease is suspected. However, these tests are nonspecific, and their precise role in aiding diagnosis and follow-up care is currently not well-defined.

• Lung procedures

  • Perform bronchoscopy with bronchial washes and/or bronchoalveolar lavage, ideally in conjunction with transbronchial biopsy, for acid-fast bacilli (AFB) smear, culture, and histology. Because the diagnosis is usually uncertain at this stage, bacterial and fungal cultures are often 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 specimen culture positive for M fortuitum is considered diagnostic. A positive AFB smear result correlates with an increased number of organisms and further supports the diagnosis.
  • The presence of either AFB or granulomas in a lung biopsy specimen or a transbronchial biopsy specimen along with even a single positive culture result 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 mycobacterial and fungal cultures, as well as histology.
  • PPD testing with nontuberculous mycobacterial specific antigens is non-specific and general not indicated. These tests are not commercially available.
• Aspiration biopsy

  • Perform an aspiration biopsy of a localized abscess for culture.
  • Perform a fine-needle aspiration biopsy or a surgical excision of lymph nodes for histology and culture.

Histologic findings may reveal acute inflammation, microabscesses, granulomatous inflammation, or granulomas (with or without caseation). These findings may be mixed. Special stains for AFB may reveal organisms.

The disease may be limited or disseminated (2 noncontiguous organs) or in the blood (mycobacteremia).