TB OR NOT TB: A CASE OF NONTB MYCOBACTERIAL LUNG DISEASE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Nontuberculous mycobacteria (NTM) are naturally-occurring organisms found in water and soil. NTM lung infection occurs when a person inhales the organism from their environment. Most people do not become ill but some susceptible individuals develop progressive and destructive lung disease. CASE PRESENTATION: 80-year-old female with a past medical history of emphysema presented with complaints of malaise and fatigue for 3-4 months. She also complained of dry cough, shortness of breath, hoarseness of voice and right upper chest wall discomfort. She was a non-smoker and retired nurse by profession. Physical exam was notable for a thin, frail build, supraclavicular hollowing, along with increased vocal fremitus and vocal resonance in the right upper lung fields. Further history revealed that she had secondhand smoke exposure from her husband years ago as well as a history of suspected Tuberculosis when she was young. Chest X-Ray and follow up CT scan revealed a 7 cm cavity in her right upper lobe. Her vitals and labs were within normal limits and her Sputum Acid Fast Bacilli smear x 3 was negative. Sputum cultures grew out mycobacteria 6 weeks later. Rapid speciation via Mass spectrometry revealed Mycobacterium abscessus. The patient was started on a long course of a triple-drug regimen of parenteral Amikacin and Imipenem along with oral Clarithromycin for treatment. DISCUSSION: M. abscessus is 1 of the 3 clinically relevant species among Nontuberculous mycobacteria. It is the third most frequently recovered nontuberculous mycobacteria in the US and accounts for 80% of the rapidly growing mycobacteria respiratory disease isolates. The demographic affected by M. abscessus generally include white nonsmoking females over the age of 60 with no predisposing lung conditions and those who were less than 50 years of age usually had a recognized underlying lung disease. There are clinical and microbiological criteria required for diagnosing nontuberculous mycobacterial lung disease, and it is a diagnosis of exclusion. M. abscessus are uniformly resistant to the standard anti-tuberculous agents. As per current guidelines, the only predictable curative therapy for limited (focal) lung disease is surgical resection combined with multidrug therapy, including a macrolide and one or more parenteral agents over several months to help control symptoms and progression. The major drawback of therapy stems from the adverse drug reactions associated with long-term use of parenteral agents. CONCLUSIONS: In the United States, the incidence of nontuberculous mycobacterial lung disease is rising, particularly among the elder age groups and hence must be considered in the differential diagnosis once more common etiologies have been excluded. Unfortunately, at present there are recommendations but there is no reliable and dependable antibiotic regimen to produce a cure for extensive Mycobacterium abscessus lung disease. Reference #1: Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175:367–416. DOIPubMed Reference #2: Pillai SK, Beekmann SE, Santibanez S, Polgreen PM. The Infectious Diseases Society of America Emerging Infections Network: bridging the gap between clinical infectious diseases and public health.Clin Infect Dis. 2014;58:991–6. DOIPubMed Reference #3: Lyu J, Jang HJ, Song JW, Choi CM, Oh YM, Lee SD, Outcomes in patients with Mycobacterium abscessus pulmonary disease treated with long-term injectable drugs. Respir Med. 2011;105:781–7.DOIPubMed DISCLOSURES: No relevant relationships by Sneha Lakshman, source=Web Response