Abstract
The aim of this study was to compare long-term mortality following diagnosis of pulmonary nontuberculous mycobacterial (NTM) disease between patients with and without rheumatoid arthritis (RA) and to evaluate predictive factors for death outcomes. We reviewed the electronic medical records of all patients who were newly diagnosed with pulmonary NTM disease at participating institutions between August 2009 and December 2018. Patients were followed until death, loss to follow-up, or the end of the study. Taking into consideration the presence of competing risks, we used the cumulative incidence function with Gray's test and Fine-Gray regression analysis for survival analysis. A total of 225 patients (34 RA patients and 191 non-RA controls) were followed, with a mean time of 47.5 months. Death occurred in 35.3% of RA patients and 25.7% of non-RA patients. An exacerbation of pulmonary NTM disease represented the major cause of death. The estimated cumulative incidence of all-cause death at 5 years was 24% for RA patients and 23% for non-RA patients. For NTM-related death, the 5-year cumulative incidence rate was estimated to be 11% for RA patients and 18% for non-RA patients. Gray's test revealed that long-term mortality estimates were not significantly different between patient groups. Fine-Gray regression analysis showed that the predictive factors for NTM-related death were advanced age (adjusted hazards ratio 7.28 [95% confidence interval 2.91-18.20] for ≥80 years and 3.68 [1.46-9.26] for 70-80 years vs. <70 years), male sex (2.40 [1.29-4.45]), Mycobacterium abscessus complex (4.30 [1.46-12.69] vs. M. avium), and cavitary disease (4.08 [1.70-9.80]). RA patients with pulmonary NTM disease were not at greater risk of long-term mortality compared with non-RA patients. Rather, advanced age, male sex, causative NTM species, and cavitary NTM disease should be considered when predicting the outcomes of RA patients with pulmonary NTM disease.
Highlights
Nontuberculous mycobacteria (NTM) are typically opportunistic pathogens that are ubiquitous in natural and man-made environments
FineGray regression analysis showed that the predictive factors for NTM-related death were advanced age, male sex (2.40 [1.29–4.45]), Mycobacterium abscessus complex (4.30 [1.46–12.69] vs. M. avium), and cavitary disease (4.08 [1.70–9.80])
rheumatoid arthritis (RA) patients with pulmonary NTM disease were not at greater risk of long-term mortality compared with non-RA patients
Summary
Nontuberculous mycobacteria (NTM) are typically opportunistic pathogens that are ubiquitous in natural and man-made environments. There has been increasing awareness among clinicians that pulmonary NTM disease is becoming more prevalent and can be seen as an emerging public health problem [2, 3]. According to nationwide surveys conducted in industrialized countries, the incidence of TB has decreased or stabilized, but the annual prevalence or incidence rate of pulmonary NTM disease is increasing and exceeds that of TB [4,5,6,7,8,9]. Population-based studies conducted in Japan and the United States have reported that the number of NTM-related deaths is increasing, there is significant geographical variation in each country [10, 11]. In a recent population-based comparative study in Korea, NTM-infected patients had poor prognosis compared with TB patients or the general population [12]
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