Clinical and Therapeutic Features of Pulmonary Nontuberculous Mycobacterial Disease, Rio de Janeiro, Brazil

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Learning Objectives

Upon completion of this activity, participants will be able to:
• Analyze the epidemiology of pulmonary nontuberculous mycobacterial (PNTM) disease
• Evaluate the clinical presentation of PNTM disease
• Distinguish mycobacteria associated with the most cases of PNTM disease in the current study
• Distinguish the mycobacterium species associated with the lowest cure rates of PNTM in the current study.

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Charles P. Vega, MD, Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine. Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

Authors

Disclosures: Karla Mello, Fernanda Mello, Liamar Borga, Rafael Duarte, Elizabeth Sampaio, Steven Holland, Rebecca Prevots, and Margareth Dalcolmo have disclosed no relevant financial relationships. Valeria Rolla has disclosed the following relevant financial relationships: served as an advisor or consultant for Janssen-Cilag; received grants for clinical research from Janssen-Cilag.

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Volume 19, Number 3– March 2013

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Clinical and Therapeutic Features of Pulmonary Nontuberculous Mycobacterial Disease, Rio de Janeiro, Brazil - Vol. 19 No. 3 - March 2013 - Emerging Infectious Disease journal - CDC

Clinical and Therapeutic Features of Pulmonary Nontuberculous Mycobacterial Disease, Rio de Janeiro, Brazil

Karla Gripp Couto de Mello, Fernanda C.Q. Mello, Liamar Borga, Valeria Rolla, Rafael S. Duarte, Elizabeth P. Sampaio, Steven M. Holland, D. Rebecca Prevots, and Margareth P. Dalcolmo

Author affiliations: Author affiliations: National School of Public Heath, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil (K.G.C. de Mello, L. Borga, M.P. Dalcolmo); School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro (F.Q. Mello); Oswaldo Cruz Institute, Rio de Janeiro (V. Rolla, E.P. Sampaio); Federal University of Rio de Janeiro (R.S. Duarte); and National Institutes of Health, Bethesda, Maryland, USA (S.M. Holland, D.R. Prevots)

Abstract

To identify clinical and therapeutic features of pulmonary nontuberculous mycobacterial (PNTM) disease, we conducted a retrospective analysis of patients referred to the Brazilian reference center, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, who received a diagnosis of PNTM during 1993–2011 with at least 1 respiratory culture positive for NTM. Associated conditions included bronchiectasis (21.8%), chronic obstructive pulmonary disease (20.7%), cardiovascular disease (15.5%), AIDS (9.8%), diabetes (9.8%), and hepatitis C (4.6%).Two patients had Hansen disease; 1 had Marfan syndrome. Four mycobacterial species comprised 85.6% of NTM infections: Mycobacterium kansasii, 59 cases (33.9%); M. avium complex, 53 (30.4%); M. abscessus, 23 (13.2%); and M. fortuitum, 14 (8.0%). A total of 42 (24.1%) cases were associated with rapidly growing mycobacteria. In countries with a high prevalence of tuberculosis, PNTM is likely misdiagnosed as tuberculosis, thus showing the need for improved capacity to diagnose mycobacterial disease as well as greater awareness of PNTM disease prevalence.

Pulmonary disease caused by nontuberculous mycobacteria (PNTM) frequently causes sickness and death. These bacteria are found in water sources and soil and are particularly concentrated in biofilms (1,2). Certain clinical conditions are known to be associated with an increased risk of PNTM, particularly immunosuppressive conditions and structural changes in the lung, such as those associated with chronic obstructive pulmonary disease (COPD), bronchiectasis, sequelae from prior pulmonary tuberculosis (TB), and cystic fibrosis (3).
Recent studies have documented the emergence of NTM lung diseases in industrialized countries, such as the United States (4,5). The current prevalence estimated for PNTM is ≈6 cases/100,000 population, with the highest prevalence in persons >50 years of age (4–6). In many developing countries with a high prevalence of TB, the prevalence of PNTM among immunocompetent persons remains unknown, largely because of the lack of routine culture and species identification from samples of persons with suspected cases. In Brazil in 2010, 70,601 cases of TB were reported, indicating a prevalence of 38 cases/100,000 population. In the same year, 4,500 deaths from TB were reported. In 2011, TB was the third leading cause of death (from infectious diseases) and the first among AIDS patients, according to surveillance data from Brazil’s National TB Control Program (7). However, because TB is routinely diagnosed presumptively, solely on the basis of identifying acid-fast bacilli (AFB) from sputum samples, an unknown proportion of patients may in fact be infected with NTM. Therefore, the true prevalence of NTM in Brazil remains unknown.
In Brazil, the Professsor Helio Fraga Reference Center (CRPHF) has served as a reference center for multidrug-resistant TB (MDR TB) and NTM since 1993. From 1993 to 2011, 5,638 cases of MDR TB were reported in Brazil, 1,894 of them in Rio de Janeiro; 1,595 of these patients were treated at CRPHF (8).
Prior studies have described some of the features of clinical isolates from PNTM patients (9–14), and others have described the clinical features for small populations infected with NTM clinical isolates in Brazil (15,16). To more fully describe the emerging prevalence and associated conditions of PNTM in a large urban population in Brazil, we present results of a large and detailed review of PNTM case-patients with PNTM who were treated at CRPHF.