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Atypical Mycobacterial Infection: Follow-up

Author: Arry Dieudonne, MD, Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital
Coauthor(s): James M Oleske, MD, MPH, François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary, Allergy, Immunology and Infectious Diseases, Department of Pediatrics, New Jersey Medical School; Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Sep 18, 2009

Follow-up

Further Inpatient Care

  • Inpatient care is not mandatory for immunocompromised patients with M avium complex (MAC) disease unless their treatment is complicated by the presence of severe diarrhea with moderate-to-severe dehydration requiring intravenous fluid replacement and hyperalimentation, severe anemia requiring transfusion of blood products, or for further medical investigation.

Further Outpatient Care

  • Decrease in fever and a decline in quantity of mycobacteria in blood or tissue can be expected within 2-4 weeks after initiation of appropriate therapy; however, for those with more extensive disease or advanced immunosuppression, clinical response may be delayed.41,55 A repeat blood culture for MAC should be obtained in 4-8 weeks after initiation of antimycobacterial therapy for patients who do not have a clinical response to their initial treatment regimen (ie, demonstrate little or no reduction in fever or systemic symptoms). Treatment failure is defined by the absence of clinical response and the persistence of mycobacteremia after 4-8 weeks of treatment.
  • Testing of MAC isolates for susceptibility to azithromycin and clarithromycin is recommended for patients who do not respond microbiologically to initial therapy, who have relapse after initial response, or who develop MAC disease while receiving clarithromycin or azithromycin for prophylaxis. Results of susceptibility should be used to construct a new multidrug regimen consisting of at least 2 new drugs not previously used and to which the isolate is susceptible, including the following: ethambutol, rifabutin, ciprofloxacin or levofloxacin, or amikacin.30 Resistance to clarithromycin in patients with pulmonary disease caused by MAC has been reported.77 Data are insufficient to support the use of adjunctive treatment with immunomodulators, such as IFN-gamma, TNF-alpha, granulocyte-macrophage colony stimulating factor, and IL-12 alone or in combination with other cytokines, which appear to inhibit intracellular replication or invitrointracellular killing of M avium.

Inpatient & Outpatient Medications

Deterrence/Prevention

  • Because optimal therapy does not guarantee a better outcome, disseminated MAC disease still carries significant morbidity. Therefore, preventing its occurrence may be the best approach. Data from multicenter studies have shown the presence of resistant strains in patients receiving prophylaxis. With a high frequency rate and a high rate of antimicrobial resistance, primary chemoprophylaxis for MAC infection, in conjunction with effective antiretroviral therapy, should be considered. Prophylaxis for prevention should be offered to children younger than 13 years with the following CD4+ T-lymphocyte counts:61
    • Children aged 6 years or older with fewer than 50 cells/µL
    • Children aged 2-6 years with fewer than 75 cells/µL
    • Children aged 1-2 years with fewer than 500 cells/µL
    • Children younger than 12 months with fewer than 750 cells/µL
  • Azithromycin or clarithromycin is recommended. Rifabutin is another alternative prophylactic agent. However, it should not be used until active tuberculosis has been excluded to avoid the development of rifampin-resistant tuberculosis. Disseminated MAC disease should also be excluded based on a negative blood culture result before prophylaxis is initiated.61,78 Discontinuation of prophylaxis for MAC disease in adult patients infected with HIV who have a response to antiretroviral therapy is supported by some published data.79 Children with a history of disseminated MAC disease should be administered lifelong prophylaxis to prevent recurrence. The safety of discontinuing MAC prophylaxis has not been studied in children whose CD4+ lymphocyte counts have increased in response to HAART.30

Complications

  • Gastrointestinal obstruction and gastrointestinal bleeding caused by bulky intra-abdominal adenopathy or extensive ileal disease have been reported.53 Pulmonary complications from disseminated MAC disease are uncommon in children. Culture and histologic evidence of infection have been reported in the heart, eye (keratitis), brain, skin, thyroid, tongue, adrenals, stomach, pancreas, skeletal system, and peripheral nerves.80,81,82

Prognosis

  • In the early years of the HIV epidemic, descriptive and retrospective studies were mostly aimed at defining the population of children infected with HIV at risk for MAC infection and at analyzing the predictors of survival in patients with AIDS and disseminated MAC disease.35,83,84 MAC was a contributor to mortality in HIV infection, and its presence was considered an indication that death is imminent.54,85
  • The development of HAART has resulted in marked changes in the outcome of HIV disease, with reductions in hospitalizations and death as well as opportunistic infections, including MAC.59 Established treatment, previously discussed, has reduced the morbidity and mortality caused by disseminated MAC disease. MAC infection is still a problem in developing countries where access to antiretroviral therapy is still limited and in severely immunocompromised patients whose adherence and tolerance to treatment raise a lot of questions. The prognosis for children without HIV with disseminated mycobacterial infection secondary to IFN-gamma receptor ligand-binding deficiency is poor.

Patient Education

Miscellaneous

Medicolegal Pitfalls

Standard precautions are recommended. Patients with HIV infection should receive chemoprophylaxis and the use of sterile equipment for middle ear instrumentation, including otoscopic equipment, for the prevention of M abscessus otitis media. No specific recommendations about avoidance of exposure for people infected with HIV exist because M avium complex (MAC) organisms are common in environmental sources such as food, water, and soil. Sterile techniques should be used to avoid central catheter infections caused by fast-growing atypical mycobacteria. Patients infected with HIV at risk for MAC infection or those with MAC infection should be educated about drug interactions and the immune reconstitution inflammatory syndrome (IRIS) when antiretroviral therapy is started.

 


More on Atypical Mycobacterial Infection

Overview: Atypical Mycobacterial Infection
Differential Diagnoses & Workup: Atypical Mycobacterial Infection
Treatment & Medication: Atypical Mycobacterial Infection
Follow-up: Atypical Mycobacterial Infection
References
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Further Reading

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Keywords

atypical mycobacteria, mycobacterial disease, mycobacterial infection, Mycobacterium tuberculosis, M tuberculous, nontuberculous mycobacteria, NTM, lymphadenitis, Mycobacterium avium complex infection, disseminated MAC disease, MAC infection, HIV-associated infections, human immunodeficiency virus, highly active antiretroviral therapy, HAART, interferon-gamma, IFN-gamma, opportunistic infections, Buruli ulcer, IFN-gamma receptor ligand-binding deficiency, Mycobacterium phlei, Mycobacterium aurum, Mycobacterium flavescens, Mycobacterium vaccae, Mycobacterium neoaurum, Mycobacterium thermoresistible, Mycobacterium smegmatis, Mycobacterium scrofulaceum, Bacillus Calmette-Guérin, AIDS, pulmonary disease, Mycobacterium ulcerans, Buruli ulcer, cystic fibrosis, CF

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Contributor Information and Disclosures

Author

Arry Dieudonne, MD, Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital
Arry Dieudonne, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Coauthor(s)

James M Oleske, MD, MPH, François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary, Allergy, Immunology and Infectious Diseases, Department of Pediatrics, New Jersey Medical School
James M Oleske, MD, MPH is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Pediatrics, American Public Health Association, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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