Detailed analysis of the radiographic presentation of Mycobacterium kansasii lung disease in patients with HIV infection

BACKGROUND: Published criteria for the diagnosis of Mycobacterium kansasii lung disease require the presence of clinical symptoms, positive microbiologic results, and radiographic abnormalities. In patients with HIV infection, the radiographic findings of M kansasii lung disease are not well described. METHODS: Medical records and chest radiographs of all patients with HIV infection and at least one respiratory specimen culture positive for M kansasii at San Francisco General Hospital between December 1989 and July 2002 were reviewed. RESULTS: Chest radiographic results were abnormal in 75 of 83 patients (90%) included in the study. Radiographic abnormalities were diverse, with consolidation (66%) and nodules (42%) as the most frequent findings. The mid or lower lung zones were involved in 89% of patients. The pattern of radiographic abnormalities did not differ based on acid-fast bacilli smear status, the presence or absence of coexisting pulmonary infections, or CD4+ T-lymphocyte count. In multivariate Cox regression analysis, cavitation was the only radiographic abnormality independently associated with mortality (hazard ratio, 4.8; 95% confidence interval, 1.2 to 19.6). CONCLUSION: Patients with HIV infection and M kansasii lung disease present with diverse radiographic patterns, most commonly consolidation and nodules predominantly located in the mid and lower lung zones. This finding is in contrast to the upper-lobe cavitary presentation described in patients without HIV infection. Although rare, the presence of cavitary disease in patients with HIV infection and M kansasii independently predicts worse outcome. The diversity in the radiographic presentation of M kansasii lung disease implies that clinicians should obtain sputum mycobacterial culture samples from any patient with HIV infection and an abnormal chest radiograph finding.     

Mycobacterium kansasii infection in a Paris suburb: comparison of disease presentation and outcome according to human immunodeficiency virus status. Groupe dEtude Des Mycobactéries de la Seine-Saint-Denis.

SETTING: Department of Seine-Saint-Denis, France. OBJECTIVE: To compare the presentation and outcome of Mycobacterium kansasii infections according to human immunodeficiency virus (HIV) status. DESIGN: Retrospective analysis of all the medical charts of adults meeting the diagnostic criteria of the American Thoracic Society for M. kansasii infection between 1991 and 1995. RESULTS: Between 1991 and 1995, 35 cases (23 HIV-[6%] and 12 HIV+ [34%]) were found, giving an annual incidence of 0.5/100000. The following particularities were common to both groups: 1) frequency and prominence of respiratory and general symptoms, 2) rarity of clinically apparent extra-thoracic involvement, 3) bacteriological confirmation mostly obtained with respiratory tract specimens, 4) favourable bacteriological outcome, and 5) low mortality attributable to the mycobacterial infection. The most striking differences concerned chest radiography: HIV- patients had apical cavitated and nodular lesions, while HIV+ patients exhibited a variety of other patterns, including alveolar infiltrates, miliary lesions and/or thoracic lymphadenopathy. CONCLUSION: Apart from pulmonary radiographic differences, presentation and short-term outcome of M. kansasii infections were similar in HIV+ and HIV-patients.     

Mycobacterium xenopi, Mycobacterium fortuitum, Mycobacterium kansasii, and other nontuberculous mycobacteria in an area of endemicity for AIDS.

Between 1981 and 1990, cultures of specimens from 86 patients at State University of New York-Health Sciences Center at Brooklyn were positive for nontuberculous mycobacteria other than Mycobacterium avium/Mycobacterium intracellulare complex or Mycobacterium gordonae. The most common species isolated were Mycobacterium xenopi (33), Mycobacterium fortuitum (28), Mycobacterium kansasii (7), and Mycobacterium chelonae (6). Thirty-five patients (41%) had clinical and/or serological evidence of human immunodeficiency virus (HIV) infection. Patients from whom M. xenopi and M. kansasii were isolated were significantly more likely to be infected with HIV than were the remaining patients in this series. Most of the mycobacterial isolates were cultured from respiratory secretions. However, extrapulmonary infections with M. fortuitum, M. xenopi, M. kansasii, Mycobacterium terrae, and Mycobacterium scrofulaceum did occur among the HIV-infected patients.     

Disseminated Mycobacterium kansasii infection with pulmonary alveolar proteinosis in a patient with chronic myelogenous leukemia

A 64-year-old woman with chronic myelogenous leukemia (CML) was admitted due to prolonged fever and lung infiltrates. An open lung biopsy was required to make the diagnosis of pulmonary alveolar proteinosis (PAP) and infection with Mycobacterium kansasii. She was treated successfully with combined antimycobacterial therapy for 14 months. However, the leukemia progressed and the patient developed recurrent bilateral lung infiltrates. Blood and bronchoalveolar fluid cultures yielded growth of Acinetobacter. She died shortly thereafter due to septic shock. The relationship between M. kansasii infection, PAP, and abnormal host defense in CML is discussed.     

Clinical and radiographic features of HIV-related tuberculosis

Human immunodeficiency virus (HIV)-related tuberculosis can be life-threatening for the individual, transmissible to others, and difficult to diagnose. We review the clinical, radiographic, and histopathologic features of HIV-related tuberculosis, and the ways in which these features are affected by the degree of immunodeficiency. At CD4 cell counts greater than 350 cells/microL, HIV-related tuberculosis has a similar presentation to tuberculosis in HIV-uninfected adults, predominantly pulmonary involvement with fibronodular and/or cavitary infiltrates. With progressive immunodeficiency, extrapulmonary involvement becomes increasingly common. Pulmonary involvement remains common at all stages of HIV disease, but the radiographic pattern is very different among persons with advanced immunodeficiency, in whom the most common abnormalities are intrathoracic adenopathy, focal lower or middle lobe infiltrates, and diffuse miliary or nodular infiltrates. The keys to the diagnosis of HIV-related tuberculosis are knowledge of the epidemiology of tuberculosis, recognition of the ways that immunodeficiency changes the clinical presentation, and an assiduous effort to obtain specimens for mycobacterial smear and culture.     

Mycobacterium kansasii in HIV patients: clarithromycin and antiretroviral effects.

SETTING: Charity Hospital New Orleans, Louisiana, USA. OBJECTIVE: To define the differences between the pre-HAART (highly active anti-retroviral treatment) and HAART eras in patients co-infected with Mycobacterium kansasii and the human immunodeficiency virus (HIV). DESIGN: A retrospective chart review revealed 82 patients with HIV and M. kansasii during the 6-year period from 1 July 1991 to 30 June 1997 (pre-HAART era), while the 6-year period from 1 July 1997 to 30 June 2003 (HAART era) revealed 55 cases. RESULTS: Among all patients with M. kansasii and HIV, 47 (34%) had an additional, concurrent mycobacterial infection and two had triple mycobacterial species isolation. More patients (17/82, 21%) had disseminated mycobacterial disease in the pre-HAART era than in the HAART era (3/55, 5%; P = 0.045). Pre-HAART patients treated without clarithromycin (CLM) survived a median of 2 months vs. 10 months for pre-HAART patients treated with CLM (P = 0.05). Those treated without CLM had a median survival of 2 months in the pre-HAART era (n = 19) vs. 10.5 months in the HAART era (n = 12, P < 0.02). CONCLUSION: CLM use in treatment of M. kansasii in HIV-co-infected patients is associated with significantly longer survival.     

Clinical and radiological features of Mycobacterium kansasii infection and Mycobacterium simiae infection

This retrospective study sought to systematically identify clinical and radiological features of Mycobacterium kansasii and Mycobacterium simiae infections. The sample included consecutive patients with a culture-positive diagnosis of M. simiae infection (n=102) or M. kansasii infection (n=62) derived from the databases of the Laboratory of Microbiology of a tertiary medical centre and two outpatient tuberculosis centres. Data on patient background and clinical features were collected, and chest radiographs were analysed. Sixty percent of the M. kansasii group were native born compared to 18% of the M. simiae group (p=0.0001). M. simiae infection was associated with a higher rate of co-morbid disease, including diabetes mellitus, heart disease, and malignancy. A similar rate of lung disease was found in both groups. Clinical symptoms were significantly more common in patients with M. kansasii infection. On radiological study, M. kansasii infection was associated with more cavitations, and M. simiae infection with more pulmonary infiltrates. Patients with M. simiae infection had a higher likelihood of middle and lower lobe disease whereas patients with M. kansasii infection had more upper lobe disease (p=0.001). Pleural effusions and lymphadenopathy were found only in the presence of M. simiae infection. We concluded that there are major differences in the epidemiologic features of M. kansasii and M. simiae infection which have important diagnostic and therapeutic implications.     

Case report: disseminated Mycobacterium gordonae infection in a nonimmunocompromised host.

Mycobacterium gordonae is considered the least pathogenic of the Runyon Group II mycobacteria, although there are now well-documented reports of infection varying from localized soft tissue infection to disseminated life threatening diseases. We report a 40-year-old Pakistani housewife, treated in childhood for tuberculosis, who presented with severe systemic illness, fever, ascites, hepatomegaly, persistent dysuria with sterile pyuria, pulmonary disease, and anorexia with weight loss. Liver biopsy histology showed multiple granulomata and multiple isolation of M. gordonae from sputum and urine, in keeping with disseminated mycobacterial infection. She had dramatic response to antituberculosis therapy with streptomycin, isoniazid, rifampicin, and pyrazinamide. No evidence existed for disturbed humoral or cellular immunity and HIV infection. This represents the fifth reported case of disseminated M. gordonae infection, the first from the Arabian Gulf. It was treated successfully with standard antituberculosis regimen.     

Mortality prediction in pulmonary Mycobacterium kansasii infection and human immunodeficiency virus

In the setting of human immunodeficiency virus (HIV) infection, the clinical implications of American Thoracic Society (ATS) diagnostic criteria and the significance of a single positive respiratory culture for Mycobacterium kansasii are unknown. We retrospectively studied HIV-infected patients with pulmonary M. kansasii isolated between 1989 and 2002 at one institution. Of 127 patients, 33% fulfilled ATS disease criteria. Twenty-nine percent received at least three active drugs for at least 3 months, and 53% died. In survival analysis, a lower CD4 count (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.3) and positive smear microscopy (HR, 2.8; 95% CI, 1.3-6.1) were associated with mortality, whereas antiretroviral therapy (HR, 0.3; 95% CI, 0.1-0.8) and M. kansasii treatment (HR, 0.4; 95% CI, 0.2-0.9) were associated with survival. ATS criteria did not predict mortality (HR, 0.9; 95% CI, 0.4-1.9). Fifteen patients (12%) apparently had indolent infection, not requiring immediate therapy. They had fewer positive cultures and lower rates of positive smear microscopy and ATS-defined disease. In HIV-infected patients with pulmonary M. kansasii infection, predictors of survival include higher CD4 counts, antiretroviral therapy, negative smear microscopy, and adequate treatment for M. kansasii infection, but not ATS diagnostic criteria. Withholding treatment in HIV-infected patients with respiratory M. kansasii isolates should only be considered with negative smear microscopy, few positive cultures, and mild immunosuppression.     

Mycobacterium kansasii infections in patients positive for human immunodeficiency virus

The experience with Mycobacterium kansasii infections in patients who are infected with human immunodeficiency virus (HIV) at Parkland Memorial Hospital in Dallas is presented, and the literature on such infections is reviewed. The absolute and relative paucity of reports of M. kansasii infections in HIV-positive patients is emphasized. M. kansasii infections in HIV-positive patients are classified as either pulmonary or disseminated. Evidence of the lack of therapeutic response in patients with disseminated infections and of the potential for therapeutic response in patients with infections limited to the lung is reviewed and documented. Other unresolved diagnostic and therapeutic issues concerning M. kansasii infections in HIV-positive patients are reviewed.     

Endobronchial lesions involved in Mycobacterium avium infection

Mycobacterium avium (M. avium) has been described traditionally as an opportunistic organism that causes disseminated disease in the human immunodeficiency virus (HIV)-positive population and that acts as a pulmonary pathogen in patients with underlying lung disease such as chronic obstructive pulmonary disease (COPD) or previously diagnosed tuberculosis. Pulmonary involvement of M. avium may range from asymptomatic colonization of the airway to invasive parenchymal or cavitary disease. However, endobronchial lesions involved in M. avium infection are rare in either immunocompetent or immunosuppressed hosts. We report here endobronchial mycobacterial infection in a HIV-negative patient.     

Mycobacterium kansasii infection following primary pulmonary malignancy.

The purpose of this study was to determine whether any of the Mycobacterium kansasii cases were the consequences of primary lung malignancy. The records and chest x-ray films of 295 patients with M kansasii pulmonary infection were reviewed. The infection was found to complicate the primary lung neoplasm in four cases. Three patients had had treatment for malignancy: one patient with small cell carcinoma received chemotherapy, steroids and radiation; one with adenocarcinoma underwent a lobectomy and radiation; and the third patient had a lobectomy and radiation for malignant fibrohistiocytoma. The fourth patient developed the infection three years after lung malignancy manifested itself, which was only a few months before the clinical evidence of distant metastasis with adenocarcinoma was detected. We suggest that this infection be considered in patients from M kansasii endemic areas, especially after they have received radiation treatment for lung malignancy. This association has never been described before.     

Pulmonary and disseminated infection due to Mycobacterium kansasii: a decade of experience

Fifty-five patients with Mycobacterium kansasii isolates (47 pulmonary and eight disseminated) were identified at a large Texas hospital from 1975 to 1985. The mean age of patients was 60 years, and there was a slight male predominance. Isolation of M. kansasii usually represented disease. The great majority of patients with pulmonary infection due to M. kansasii had underlying pulmonary diseases, and 70% had nonpulmonary predisposing factors. M. kansasii pulmonary disease clinically and radiographically resembled pulmonary tuberculosis. Disseminated M. kansasii infection occurred in severely immunocompromised patients, who frequently had pulmonary predispositions as well. Disseminated infection most of ten involved the lung, reticuloendothelial system, bone, joint, and skin and presented with signs and symptoms related to these organs. Despite only moderate in vitro susceptibility of M. kansasii to routine antituberculous drugs, most patients responded to rifampin-containing regimens. The prognosis of patients with M. kansasii disease was determined primarily by their underlying diseases.     

Pulmonary Mycobacterium kansasii infection in Israel, 1999-2004: clinical features, drug susceptibility, and outcome

BACKGROUND: Mycobacterium kansasii infection is one of the most common causes of nontuberculous mycobacterial lung disease in world. However, little is known about its background characteristics or drug sensitivity in nonendemic areas. DESIGN: We assessed the clinical features, radiologic findings, and drug sensitivity associated with M kansasii infection in Israel. METHODS: Patients with a culture-positive diagnosis of M kansasii infection between April 1999 and April 2004 were identified from a clinic database of tuberculosis centers. Mycobacterial cultures were performed with standard methods. Data on patient background and clinical features were collected from the medical files. RESULTS: Mean age (+/- SD) of the 56 patients was 58 +/- 18 years, and 64% were men; 59% had associated lung disease. Fifteen percent were receiving immunosuppressive medications. None had HIV infection. Systemic comorbid diseases were noted in 27%. The most common clinical presentations were chest pain, cough, hemoptysis, fever, and night sweats. Cavitation was noted only in 54%. Older patients had more noncavitary disease than younger patients (p = 0.01, r = 0.35). Lower-lobe predominance was very rare (4%). None of the patients presented with pleural effusion or lymphadenopathy. Only seven patients (11%) underwent bronchoscopy for diagnosis. M kansasii isolates showed the highest sensitivity to rifampin, ethambutol, clarithromycin, and ofloxacin, and the highest resistance to ciprofloxacin and capreomycin. The mean duration of treatment was 21 +/- 7.2 months. There were no disease-related deaths. CONCLUSIONS: M kansasii disease in Israel has no association with HIV, more systemic comorbid diseases and associated lung disease, and fewer cavitations. Following appropriate treatment, patients with M kansasii disease have an excellent prognosis.     

M. kansasii lung infection occurring in a compromised host with idiopathic pulmonary fibrosis

A 61-year-old man was admitted to our hospital because of persisting cough, sputum and shortness of breath for four months. Brushing specimens and BALF bronchoscopically obtained revealed acid-fast bacilli and TBLB showed pathological findings consistent with interstitial pneumonia. Based on these results, clinical symptoms, chest roentgenograms on admission and identification of M. kansasii, a diagnosis of M. kansasii lung infection occurred in idiopathic pulmonary fibrosis was made. The patient's symptoms consistent with M. kansasii lung infection and his sputum became negative 6 weeks after antituberculosis chemotherapy with INH, SM and RFP. Because of an increasing dyspnea due to pulmonary fibrosis, however, the patient received oxygen therapy. This case suggested an increasing tendency of compromised hosts associated with M. kansasii lung infection.     

A rare case of disseminated Mycobacterium kansasii infection

Mycobacterium kansasii infection has been reported to be about 20 percent of non-tuberculous mycobacteriosis, and its disseminated type is uncommon and the prognosis is reported to be generally poor. We experienced one case of disseminated Mycobacterium kansasii infection. A 81 year-old man who had been short-bowel syndrome due to the operation for superior mesenteric artery occlusion since 1998 was admitted on April 24th, 2001 to our hospital because of slowly progressive consciousness disturbance and anorexia. He had shown progressive productive cough and respiratory failure and laboratory findings were C-reactive protein elevation and pancytopenia. Human immunodeficiency virus (HIV) antibody was negative. Chest X-ray and computed tomography showed diffuse miliary nodules and infiltrative shadow. Sputum examination was positive for mycobacteria. The cultured isolate was identified as Mycobacterium kansasii. Bone marrow aspirations revealed inflammatory granuloma with necrosis. He was diagnosed as disseminated Mycobacterium kansasii infection and heart failure, and was treated by anti-tuberculosis drugs and diuretics. Treatment was very effective and Chest X-ray findings and respiratory failure had been completely improved. In this case we speculated that the malnutrition due to short-bowel syndrome could be one of the most suspected reasons of Mycobacterium kansasii dissemination. Disseminated Mycobacterium kansasii infection has been rarely reported comparing with the other mycobacterial infections in Japan. However, due to the increasing numbers of immunocompromised hosts with aging, HIV infection, cancer, and steroid therapy, this type of infection will become more common and its earlier diagnosis and adequate treatment will be important to improve the prognosis.     

Drug-resistant tuberculosis in a southern California hospital. Trends from 1969 to 1984

Resistance to one or more antituberculosis drugs was found in 98 of 281 (35%) patients hospitalized at Harbor-UCLA with culture-positive tuberculosis between 1980 and 1984. Resistance to antituberculosis drugs occurred in 23% of patients who had not been previously treated, whereas previously treated patients had a 59% rate of resistance. The overall rates of drug resistance had not significantly changed from prior studies at this hospital. Drug resistance was also found in patients with extrapulmonary disease, but tended to be less frequent than in patients with pulmonary disease. An analysis of risk factors for drug resistance rates revealed no significant differences between Hispanics, blacks, Caucasians, and Asians. Age was not found to be a significant factor to predict resistance rates. Resistance rates were higher if cavitary disease was present on radiographs. Furthermore, cavitary disease seems to be additive to prior antituberculosis treatment as a risk factor for drug resistance. Patients who had both of these risk factors present had 71% incidence of drug resistance rates.     

Diagnosis and treatment of tuberculosis or Mycobacterium avium-intracellulare complex infection in HIV-infected patients

The clinical features of tuberculosis vary according to its CD4 count. With CD4 count >350/microL pulmonary lesions are "typical" (upper lobe infiltrates +/- cavitation). With CD4 count< 50/microL extrapulmonary TB is more common, and chest X-rays show lower and middle lobe and miliary infiltrates, usually without cavitation. The treatment of tuberculosis in HIV-infected patients should follow the same principles for persons without HIV infection. Presence of active tuberculosis requires immediate initiation of anti-tbc therapy. The delay of antiretroviral therapy for 4-8 weeks after initiation of tuberculosis treatment is recommended. MAC is a relatively common cause of disseminated infection without pulmonary involvement in patients with AIDS. Preferred regimens contain clarithromycin and EB, and in case of high MAC load or absence of effective antiretroviral therapy rifabutin may be considered as a third drug. Start antiretroviral therapy simultaneously or within 1-2 weeks. In Japan, an increasing number of HIV infections are reported year after year. So HIV infection should be included in possible diagnosis for atypical Tbc or disseminated MAC infection.     

A study on clinical features of Mycobacterium kansasii pulmonary disease in women

OBJECTIVES: To clarify clinical features of M. kansasii pulmonary disease in women. METHODS: We performed a retrospective analysis of M. kansasii pulmonary disease in women compairing with that in men. We focused on 8 female cases of M. kansasii pulmonary disease during the past 7 years from June 1998 to August 2005. RESULTS: The cases of M. kansasii pulmonary disease in women have increased in the latter few years. The mean age of female cases was higher than that of male cases, 65.6 and 53.1 years old, respectively. The number of female cases with smoking history was lower than that of male cases, 37.5% and 90.0%, respectively. Two female cases had underlying pulmonary diseases, as compared with 10 male cases, 25.0% and 33.3%, respectively. The radiological findings in female cases included 2 cavitary opacities, 1 infiltrative opacity and 5 nodular, bronchiectatic opacities, as compared with 27 cavitary opacities, 1 infiltrative opacity, 1 solitary nodular opacity and 1 nodular, bronchiectatic opacity in male cases. MAC was also detected in 2 female cases, who presented with nodular, bronchiectatic opacities. On the other hand, there were 6 female cases, in which no other NTM was detected. 3 cases showed cavitary or infiltrative opacities, which improved with the following 3 tuberculous drugs INH, RFP, and EB (HRE), while others showed nodular, bronchiectatic opacities, in which 2 cases showed radiological exacerbations without any treatment and another one revealed an improvement with HRE. CONCLUSIONS: M. kansasii pulmonary disease in women tends to be identified in elderly who smoke less and have no underlying pulmonary diseases, and most of radiological findings in female cases revealed nodular, bronchiectatic opacities. Summing up all these findings, clinical features of M. kansasii pulmonary disease in women was considered to resemble that of MAC infection, and it was speculated that the increase of M. kansasii pulmonary disease in women has some relationship with that of MAC infection in middle or lingular lobe. However, it was confirmed that some cases of M. kansasii pulmonary disease in women might primarily present with nodular, bronchiectatic lesions, regardless of MAC infection.