1he ACC u|monary 8oard

kev|ew:
1ubercu|os|s and Cther
Mycobacter|a| u|monary D|seases

uavld Ashkln M.u., lCC
SLaLe 18 Medlcal ulrecLor, llorlda ueparLmenL of PealLh
vlslung AsslsLanL rofessor, ulvlslon of ulmonary and Crlucal Care
Medlclne, unlverslLy of Mlaml School of Medlclne
Co-rlnclpal lnvesugaLor, SouLheasL nauonal 18 CenLer
Ad[uncL AsslsLanL rofessor, unlverslLy of llorlda College of Medlclne

I|nanc|a| D|sc|osure
1o Lhe besL of my knowledge, nelLher l, nor Lhe
deparLmenL wlLh whlch l am amllaLed, have recelved
someLhlng of value (any lLem, paymenL or servlce
valued ln excess of $730) from a commerclal or oLher
parLy relaLed dlrecLly or lndlrecLly Lo Lhe sub[ecL of
my presenLauon.
Which one of the following statements is false concerning
the epidemiology of TB?
1) The number of new cases (8.8 million) of TB is decreasing
worldwide but not to the same extent as seen in the U.S.
2)In the U.S., more cases of TB occur in foreign-born
individuals as compared to US born individuals.
3)More cases of active TB occur among women as compared
to men
4)TB is one of the leading infectious causes of death worldwide
3)The increase in incidence of TB that was witnessed in the
U.S. in the 1990s has been attributed to the HIV epidemic,
increased immigration of individuals from countries endemic
for TB, increased number of individuals living in congregate
settings and the decrease in funding for the public health
infrastructure.
1U8LkCULCSIS
CLC8AL uSA

Infected Cases 1.7 8||||on 10 m||||on
(33 opu|anon) (4 opu|anon)
Case Inc|dence 8-9 M||||on]yr ~10,000]yr
Case reva|ence 11-13 M||||on 17 thousand
Deaths 1.4 M||||on]yr 1,000-2,000]yr
MDk (kDk) Up to 28 <1
(Iormer USSk)

8eporLed 18 Cases
unlLed SLaLes, 1982-2012
uaLa are updaLed as of 2/22/13 and are provlslonal
2012 uaLa
9,931 Cases
8aLe 3.2/100,000
8aLe* of Luberculosls cases, by sLaLe/area - unlLed SLaLes, 2012
s 2012 national average of 3.2
> 2012 national average of 3.2
D.C.
* Per 100,000 population.
Data are updated as of 2/22/13 and are
provisional
8aLe* of 18 Cases Among u.S.- and lorelgn-born ersons, by ?ear 8eporLed -
unlLed SLaLes, 1993-2012
* Per 100,000 population
Data are updated as of 2/22/13 and are provisional.
11x
9x
5x
Which one of the following statements is true?
1. All of Lhe organlsms LhaL comprlse M. 18 complex (eg M.
tobetcolosls, M. bovls, M. oftlcooom, M. mlctou ooJ M.
cooem) are Lransmlued only vla Lhe alrborne rouLe.
2. MosL lndlvlduals ln prolonged, close conLacL wlLh a pauenL
wlLh acuve 18 become lnfecLed wlLh 18
3. All lndlvlduals lnfecLed wlLh 18, have a 3-10 chance of
progresslng Lo acuve 18 durlng Lhelr llfeume
4. A ma[orlLy of cases of acuve dlsease ln Lhe u.S. resulLs from
Lhe reacuvauon of slLes of remoLe lnfecuon
3. Whlle Plv may cause 18 Lo dlssemlnaLe, 18 has llule eecLs
on Lhe progresslon of Plv dlsease
1ransm|ss|on Cf 1ubercu|os|s

athogenes|s
of
1ubercu|os|s
D|sease rogress|on
rogresslon from lnfecuon Lo dlsease caused by an
lnablllLy Lo conLaln lnfecuon
3-10 of all Plv(-) wlll progress from lnfecuon Lo dlsease
up Lo 8 per year of u(+), Plv(+) pLs wlll progress
from lnfecuon Lo dlsease
ApproxlmaLely 23-30 of close conLacLs become lnfecLed
on average
1he average pauenL wlLh acuve 18 lnfecLs 30 oLher
lndlvlduals
All of the following persons should be considered for
treatment of latent infection except:
1. A 33 year old Afrlcan Amerlcan healLhy male, who ls found Lo have a
12mm Luberculln skln LesL reacuon on a bus drlver employmenL physlcal
examlnauon. Pe has no hlsLory of exposure Lo 18 and cannoL recall ever
belng LesLed before.
2. A 33 year old nurslng home resldenL was prevlously found Lo have a 4mm
skln LesL reacuon aer Lwo sLep Lesung lasL year, now presenLs wlLh a
19mm skln LesL reacuon. She ls asympLomauc and a chesL x ray ls
negauve.
3. A 33 year old Plv posluve male, asympLomauc wlLh a 7mm skln LesL
reacuon and normal chesL x-ray
4. A 33 year old asympLomauc male wlLh a hlsLory of sandblasung and a 16
mm skln LesL reacuon. ChesL x-ray has bllaLeral upper lobe lnlLraLes and
nodules. SpuLum for 18 ls culLure negauve.
3. A 33 year old healLh care worker wlLh a 12mm Luberculln skln LesL
reacuon. Was prevlously negauve Lhe lasL Lhree years on annual Lesung.
Sens|nv|ty and Spec|hc|ty of the
1ubercu||n Sk|n 1est (1S1)
uependlng on prevalence of dlsease ln populauon
you are Lesung and geographlcal area
up Lo 20 of posluve reacuons mlghL be false posluves
up Lo 20 of lndlvlduals wlLh acuve 18 may be false
negauve
Interferon Gamma ke|ease Assays
(IGkAs) for L18I
lC8As recenLly approved by luA
Culdellnes from Lhe CuC now recommend LhaL Lhe use of
such lnLerferon-y release assays for M18 (lC8A) may be used
ln all clrcumsLances ln whlch Lhe 1S1 ls currenLly used,
lncludlng conLacL lnvesugauons, Lhe evaluauon of recenL
lmmlgranLs, and sequenual Lesung survelllance programs for
lnfecuon conLrol (eq, Lhose for healLhcare workers)
May be able Lo dlscern reacuon Lo 8CC and n1M
More sLudles needed Lo dlscern role ln L18l dlagnosls
(especlally performance ln cerLaln populauons eq, young
chlldren and lmmunosuppressed persons)
1argeted 1esnng
(Iormer|y known as Screen|ng)
1argeLed Luberculln Lesung programs should be deslgned for
one prlmary purpose:
1o idennfy persons ot hiqh risk for 18 who wou/d beneft by
treotment of L18l.
1argeLed Luberculln Lesung programs should be conducLed
among groups aL rlsk of recenL lnfecuon wlLh M. tobetcolosls
and Lhose who, regardless of durauon of lnfecuon, are aL
lncreased rlsk of progresslon Lo acuve 18
"1he uecision to 1ubercu/in 1est is the uecision to 1reot {ond
comp/ete)"
Cr|ter|a for 1ubercu||n os|nv|ty 8y k|sk Group
> S mm |nduranon
Plv posluve persons
8ecenL conLacLs of 18 case
llbrouc changes on chesL radlograph conslsLenL wlLh old 18
auenLs wlLh organ LransplanLs and oLher lmmunosuppressed
pauenLs (recelvlng Lhe equlvalenL of > 13mg/day of
prednlsone for > 1 monLh)*
auenLs who wlll be LreaLed wlLh 1nl- 8lockers
* 8lsk of 18 ln pauenLs LreaLed wlLh corucosLerolds lncreases
wlLh hlgher dose and longer durauon
Cr|ter|a for 1ubercu||n os|nv|ty 8y k|sk Group
> 1S mm |nduranon
ersons wlLh no rlsk facLors for 18
Cr|ter|a for 1ubercu||n os|nv|ty 8y k|sk Group
> 10 mm |nduranon
8ecenL arrlvals (<3 yrs) from hlgh prevalence
counLrles
ln[ecuon drug users
8esldenLs and employees of hlgh-rlsk congregaLe
semngs: prlsons and [alls, nurslng homes and oLher
long-Lerm faclllues for Lhe elderly, hosplLals and
oLher healLh-care faclllues, resldenual faclllues for
AluS pauenLs, and homeless shelLers
MycobacLerlal lab personnel
Cr|ter|a for 1ubercu||n os|nv|ty 8y k|sk Group
> 10 mm |nduranon (con't)
ersons wlLh cllnlcal condluons LhaL make Lhem
hlgh-rlsk:slllcosls, dlabeLes melllLus, chronlc renal
fallure, some hemaLologlc dlsorders (e.g. leukemlas
and lymphomas), oLher speclc mallgnancles (e.g.
carclnoma of Lhe head or neck and lung), welghL loss
of > 10 of ldeal body welghL, gasLrecLomy,
[e[unolleal bypass
Chlldren < 4 years of age or lnfanLs, chlldren, and
adolescenLs exposed Lo adulLs ln hlgh-rlsk caLegorles
8CG and 1S1
SLudles have shown emcacy of 8CC Lo vary from
0-80 (MeLa-analysls 30)
1S1 reacuvlLy wanes aer 10 yrs
CounLrles LhaL glve 8CC have hlgh lncldence of 18
SLudles have shown 1S1 reacuon from 8CC usually
<13mm
CuC/A1S recommend lgnorlng hlsLory of 8CC
admlnlsLrauon and proceed wlLh Lesung for laLenL
Luberculosls lnfecuon as recommended
"1reatment of Latent 1ubercu|os|s
Infecnon" (Iormer|y known as revennve
1herapy)
1reaLmenL of laLenL 18 lnfecuon
for Plv(-), 9 mo lnP preferred over 6 mo
for Plv(+), 9 mo lnP (lnsLead of 12 mo)
for brouc leslons on x-ray, 9 mo lnP
lor chlldren
AlLernauve 1reaLmenL of L18l
8ll for 4 monLhs as eecuve as lnP for 9 monLhs
lnP/81 weekly for 12 weeks for close conLacLs
Mon|tor|ng Ior INn 1herapy
Acuve 18 should be ruled ouL before sLarung 8x
8asellne Labs only lndlcaLed for Lhose who are aL
lncreased rlsk of llver or hemaLologlc dlsease (l.e.
L1CP abuse, llver dlsease, pregnancy, Plv)
Cllnlcal MonlLorlng ls lndlcaLed for mosL lndlvlduals
excepL lf evldence of lncreased rlsk
Whlch of Lhe followlng sLaLemenLs concernlng
dlagnosuc LesLs for 18 dlsease ls fa|se?
1. Al8 smears of spuLum are posluve ln approxlmaLely 40-60
of cases of acuve pulmonary 18 dlsease
2. CulLures of spuLum for 18 are posluve ln approxlmaLely 80
of cases wlLh acuve pulmonary 18 dlsease.
3. ChesL x-rays may have no lnlLraLes or cavlues ln up Lo 30
of Plv posluve lndlvlduals wlLh acuve pulmonary 18 dlsease.
4. auenLs wlLh acuve 18 dlsease wlll have a posluve skln LesL
reacuon ln 80-90 of cases.
3. leural euslons due Lo 18 dlsease wlll be Al8 smear
posluve ln over 73 of cases.

1nINk 18!!!
Symptoms of 1ubercu|os|s
unexplalned cough (more Lhan Lhree weeks)
unexplalned cough wlLh fever (more Lhan Lhree
days)
unexplalned pleurluc chesL paln, hemopLysls and/or
dyspnea (prompLly)
unexplalned fever, nlghL sweaLs, welghL loss
Ind|v|dua|s w|th the above symptoms shou|d get a
Ckk
Table 1 From Pitchenik AE, Brooks R. The Most Common Clinical Mistakes in Prevention, Diagnosis And Therapy of
Tuberculosis. In: Tuberculosis in Florida:The Clinicians Desktop Reference. 1999 Florida TB Control Coalition
Infecnon Contro|
Many nosocomlal ouLbreaks of 18 (lncludlng Mu8)
have occurred
1Plnk 18, lSCLA1L & S1A81 MLuS
6-8 alr exchanges/hr
negauve ressure
uoors Closed
All enLerlng room wear n93 mask
keep ln lsolauon unul 3 negauve smears, on
medlcauons and respondlng cllnlcally
Chest k-kay
9S of nIV(-) cases w|th upper |obe
|nh|trates and]or cav|nes
Up to 30 of nIV (+), acnve 18 cases w|||
have no |nh|trates or cav|nes
18 ulagnosls
Smear
Cheap & rap|d
Cn|y 40-60 pos|nve |n cases of acnve 18
18 D|agnos|s
CulLure
osluve ~80 of acuve 18 cases
1akes 6-8 weeks by convenuonal
1akes 1-3 weeks by llquld medla
SensluvlLy
1akes 1-2 weeks aer posluve culLure
nuclelc Acld Ampllcauon
8esulLs avallable ln 4-6 hours
SpeclclLy ~98 on smear(+) speclmens
SensluvlLy 70-80 on muluple resplraLory speclmens
18 1kLA1MLN1
(CDC Gu|de||nes 2003)
SLarL wlLh 4 drugs ln all pauenLs (ln pauenLs from areas where lnP reslsLance
exceeds > 4)-PealLh uepL 1
o
responslblllLy for 8x
lnP, 8ll, ZA and LM8 or SM unul sensluvlues reLurn
Cnce pansensluve, u/C LM8, aer 2 monLhs of Lherapy, u/C ZA
Conunue lnP & 8ll for 4 more monLhs for LoLal of 6 monLhs
MusL have culLure converslon by 2 monLhs (prolong Lherapy)
6 monLh reglmen good for Plv(-) and (+)
Can use 8lW or 1lW reglmen
MonlLor adherence and LoxlclLy
uC1 preferred, Comblnauon pllls for self admlnlsLered
lnP, rlfampln, LM8 safe ln pregnancy, ?ZA (need 9 monLhs 8x w/o ZA)
CorucosLerolds for perlcardlal consLrlcuon, menlnglus ln chlldren, ? 8ole ln
endobronchlal dlsease
CulLure negauve (cllnlcal18")-four monLhs of Lherapy eecuve
Causes of kes|stance
Care of pauenLs by non-speclallsLs: cholce of drugs, dosages
rogram facLors: lnLermluenL drug supply, lack of Lralnlng, no uC1, lack of
adequaLe laboraLory supporL (eg lack of culLures and suscepublllues)
auenL facLors: lrregular self admlnlsLrauon, slde-eecLs, malabsorpuon, lnablllLy
Lo peneLraLe lnLo areas of dlsease, mlsundersLandlng, subsLance abuse, pregnancy,
menLal lllness and poverLy
- lf pansensluve>93 chance of cure
- lf reslsLanL Lo lnP>90 chance of cure
- lf reslsLanL Lo rlfampln>70 chance of cure
- lf reslsLanL Lo lnP and 8ll may be up Lo a 30 fallure raLe
- 8efore chemoLherapy~30 chance of cure
"uO1 wOkk5!!"
Lxtens|ve|y Drug kes|stant 18 (kDk)
ln 9/06 34 pauenLs wlLh Plv and 18 ln SouLh Afrlca were
descrlbed wlLh xu8 18"-32 of 34 uled
ln 11/06 xu8 was redened as Lhe occurrence of 18 ln
persons whose M. tobetcolosls lsolaLes are reslsLanL Lo
lsonlazld and rlfampln plus reslsLanL Lo any uoroqulnolone
and aL leasL one of Lhree ln[ecLable second-llne drugs
(l.e.,amlkacln, kanamycln, or capreomycln)-1hese sLralns
deemed vlrLually unLreaLable ln mosL of Lhe world.
2/08 WPC reporLed hlghesL raLes of reslsLanL sLralns ever
wlLh 3 of new cases Mu8 wlLh up Lo 20 of new cases ln
cerLaln areas (eg lormer uSS8)-10 of Mu8 cases are xu8
www.newtbdrugs.org
Showing promise
A 27-year-old man was diagnosed with active pulmonary
tuberculosis based upon positive sputum cultures. He was
discovered to be HIV positive. He was started on isoniazid,
rifabutin, ethambutol, and pyrazinamide along with combination
antiretroviral therapy that included efavirenz, emtricitabine and
tenofovir. Two weeks after the onset of antituberculous and
antiretroviral therapy, you are asked to consult because of the
development of fever and new hilar lymphadenopathy. There was
no change in the previously identified lung infiltrate attributed to
tuberculosis. Sputums for PCP are negative, blood and urine
cultures are negative. Patient is otherwise asymptomatic and
clinically is responding to anti-tuberculous therapy with weight gain
and improved cough.
At this point you would do which of the
following?

At th|s po|nt you wou|d do wh|ch of
the fo||ow|ng?

1. Cbserve only.
2. erform medlasunoscopy.
3. CbLaln chesL C1 scan.
4. erform bronchoscopy/bronchoalveolar lavage.
3. Add clprooxacln and kanamycln Lo Lhe LreaLmenL
reglmen.
nIV and 18:
"1he Londmines"
Plv and 18:
18 becomes more common
18 ls more dlmculL Lo dlagnose
18 and Plv are more dlmculL Lo manage and LreaL:
muluple concomlLanL lnfecuons,
drug-drug lnLeracuons,
adverse slde-eecLs,
posslble lncreased raLe of relapse,
re-lnfecuon,
drug-reslsLance
oorer overall ouLcomes: ~3-fold lncrease ln morLallLy
1reatment of acnve 18 |n anents on
Annretrov|ra| 1herapy
May use rlfabuun (881) when uslng some non boosLed ls-
reduce from 300 mg qd Lo 130 mg qd (300mg 8lW) wlLh ls
(wlLh efavlrenz, dally or 8lW dose of 881 ls lncreased from
430mg Lo 600mg).
May need Lo lncrease some l dosage (eg nelnavlr, lndlnavlr)
lnP/881/ZA/LM8 dally for 2 wk, Lhen 1lW (due Lo ?
lncreased chance of rlf reslsLance) for 6 wk (don'L drop LM8)
Lhen lnP/881 for 4 more mo (881 LoxlclLy: arLhalgla, uvelus,
leukopenla) (monlLor vlral load)
AlLernauve reglmens ls noL Lo use a rlfamycln
Centers for D|sease Contro| and revennon. Updated gu|de||nes on manag|ng
drug |nteracnons |n the treatment of nIV-re|ated tubercu|os|s. Ava||ab|e at:
hup:]]www.cdc.gov]tb]pub||canons]gu|de||nes]18_nIV_Drugs]defau|t.htm
"Immune keconsntunon w|th
Inammatory kesponse (IkIS)"
Soon aer A8vs are sLarLed (2-6 weeks) ln pauenLs wlLh Plv and 18,
paradoxlcal responses (lnammaLory 8esponse wlLh lmmune
8econsuLuuon) may frequenLly be seen ( ~23 esp. ln pauenLs wlLh an
lnlually hlgh Plv vlral load who experlence a marked drop posL A8vs)
1hese paradoxlcal responses" frequenLly arouse concerns of unconLrolled
18 due Lo drug reslsLance and/or noncompllance, drug fever or alLernauve
dlagnosls, Lhey are dlsuncL from Lhese and may represenL an enhanced
anuLuberculous lmmune response aer Lhe lnluauon of anu-reLrovlral
Lherapy
Cllnlclans should be aware of Lhls phenomenon alLhough oLher
posslblllues for a worsenlng cllnlcal sLaLe musL rsL be excluded
unmasklng l8lS"-auenLs dlagnosed wlLh 18 soon aer sLarung A8v
When to Start 18 and nIV Meds (Ak1)
CDC and NIn Gu|de||nes*
8ecenL large sLudles (SAl1 & CAMLLlA) showed lncreased morLallLy ln 18 and
Plv pauenLs who elLher were noL LreaLed wlLh A8v durlng 18 Lherapy or
sLarLed laLe (esp ln pLs wlLh Cu4<30 cells/mm
3
)
A81 ls recommended ln all Plv-lnfecLed persons wlLh 18
lor A81-nalve pauenLs, A81 should be sLarLed wlLhln 2 weeks when Lhe
Cu4 counL ls <30 cells/mm
3
and by 8 Lo 12 weeks for all oLhers
Clven Lhe need for Lhe lnluauon of ve Lo seven new medlcauons ln a
shorL ume, adherence supporL should be oered.
ln pauenLs wlLh 18 menlnglus and low Cu4 cell counLs, early A81 may
pose a rlsk LhaL calls for careful monlLorlng and consulLauon wlLh experLs.
Larly A81 lnluauon requlres close collaborauon beLween Plv and 18 care
cllnlcs, experuse ln managemenL of A81 reglmen selecuon, and supporL
and adherence servlces for cllenLs.
*Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents:
recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed 7/10/13
A 45 year female with a six month history of
productive cough, low grade fevers and night sweats
is found on chest x-ray to have patchy bilateral
infiltrates and nodules. CT of the chest reveals shows
multifocal bronchiectasis and multiple small nodules in
the right middle lobe and lingula. One of three
sputums is 2
+
AFB positive and cultures grow
Mycobacterium avium-intracellulare.

Which of the following statements is
least applicable to this condition?

Wh|ch of the fo||ow|ng statements |s
|east app||cab|e to th|s cond|non?

1)A macrolide antibiotic, combined with a rifamycin and
ethambutol should be started and continued for at least
one year after cultures become negative
2)It is likely the bronchiectasis is related to MAI
3)Routine susceptibility testing on the initial MAI culture is
not currently recommended
4)Observation of this condition is most appropriate at this
time given that the MAI is probably just colonizing the
airways.
3)Surgery for bronchiectasis is probably not indicated at
this time given the bilateral nature of the disease.
Lp|dem|o|ogy, 1ransm|ss|on and athogenes|s
of Nontubercu|ous Mycobacter|a (N1M)
noL reporLable dlsease so exacL lncldence unknown
ulseases caused by n1M are more common ln uS Lhan 18 buL noL
worldwlde
8ecenL appreclauon of n1M as paLhogens
normal lnhablLanLs of Lhe envlronmenL (soll and waLer)
noL conLaglous
robably opporLunlsuc more Lhan vlrulenL paLhogens
Sull unclear how usually spread ?aerosollzauon for pulmonary dlsease vs.
lngesuon for sysLemlc (lymphadenlus ln chlldren, dlssemlnauon ln Plv)
dlsease vs. lnoculauon for so ussue dlsease
? lf Lhere ls an lnfecuon sLage (laLency) before developmenL of dlsease
u|monary D|sease Assoc|ated w|th
MAC
1) upper lobe dlsease LhaL radlographlcally resembles
18
usually older males, smoklng hlsLory wlLh CCu
Most Common
2) MAC whlch develops as a compllcauon of
bronchlecLasls
common ln pLs wlLh hlsLory of 18
presenLs wlLh recurrence of sympLoms and worsenlng
lnlLraLe on radlographs areas of prevlous dlsease
Lend Lo be older lndlvlduals buL no sex or smoklng relauon
u|monary D|sease Assoc|ated w|th
MAC (con't)
3) ulsease ln lndlvlduals wlLh no prlor hlsLory of Lung ulsease
MosL recenLly descrlbed
redomlnanLly Women
non-smokers
Pave lnLersuual raLher Lhan cavlLary radlographlc changes, usually
conned Lo Lhe llngula and rlghL mlddle lobes (loJy wlJetmete
5yoJtome)
8ecenL sLudles suggesL LhaL Lhe developmenL of bronchlecLasls ln
Lhese pauenLs ls due Lo paLhologlc dlsease caused by MAC
oot coloolzouoo
some may progress Lo resplraLory fallure
? PypersensluvlLy (assoclaLed wlLh hoL Lubs, meLal workers)
S|gns and Symptoms of N1M
u|monary D|sease
varlable and nonspeclc
Chronlc cough
spuLum producuon
faugue
Less commonly malalse, dyspnea, fever, hemopLysls,
welghL loss
Lvaluauon oen compllcaLed by sympLoms of
underlylng lung dlsease
kad|ograph|c Appearance of N1M
1hln walled cavlues wlLh less surroundlng parenchymal
lnlLraLe
Less bronchogenlc buL more conuguous spread of dlsease
More marked lnvolvemenL of Lhe pleura over Lhe lnvolved
area
May produce dense pneumonlc process or sollLary nodule
wlLhouL cavlLauon
leural euslons are rare
n|gh keso|unon C1 (nkC1)
Appearance of N1M
P8C1 has shown>90 of pauenLs wlLh mld and lower lung
eld noncavlLary dlsease wlLh MAC have assoclaLed mulufocal
bronchlecLasls, wlLh many pauenLs havlng clusLers of small
(<3mm) nodules ln assoclaLed areas of Lhe lung
Cr|ter|a used to estab||sh d|agnos|s of
pu|monary d|sease caused by N1M
(A1S Gu|de||nes 2007)

c/inico/.
1. ulmonary sympLoms, nodular or cavlLary opaclues
on chesL radlograph, or an P8C1 scan LhaL shows
mulufocal bronchlecLasls wlLh muluple small
nodules.
ond
2. ApproprlaLe excluslon of oLher dlagnoses.
Cr|ter|a used to estab||sh d|agnos|s of
pu|monary d|sease caused by N1M
Microbio/oqic.
1. osluve culLure resulLs from aL leasL Lwo separaLe expecLoraLed spuLum samples. (lf Lhe resulLs
from Lhe lnlual spuLum samples are nondlagnosuc, conslder repeaL spuLum Al8 smears and
culLures.) or
2. osluve culLure resulLs from aL leasL one bronchlal wash or lavage. or
3. 1ransbronchlal or oLher lung blopsy wlLh mycobacLerlal hlsLopaLhologlc feaLures
(granulomaLous lnammauon or Al8) and posluve culLure for n1M or blopsy showlng
mycobacLerlal hlsLopaLhologlc feaLures (granulomaLous lnammauon or Al8) and one or
more spuLum or bronchlal washlngs LhaL are culLure posluve for n1M.
4. LxperL consulLauon should be obLalned when n1M are recovered LhaL are elLher lnfrequenLly
encounLered or LhaL usually represenL envlronmenLal conLamlnauon.
3. auenLs who are suspecLed of havlng n1M lung dlsease buL who do noL meeL Lhe dlagnosuc
crlLerla should be followed unul Lhe dlagnosls ls rmly esLabllshed or excluded.
6. Maklng Lhe dlagnosls of n1M lung dlsease does noL, pet se, necesslLaLe Lhe lnsuLuuon of
Lherapy, whlch ls a declslon based on poLenual rlsks and beneLs of Lherapy for lndlvldual
pauenLs.

1reatment of MAC
Macrolldes have lmproved Lhe chances of successful
Lherapy
usually macrollde (e.g. clarlLhromycln or
azLhromycln) wlLh rlfamycln and eLhambuLol for aL
leasL 1 year aer culLure converslon (can use
lnLermluenL reglmens)-Can 1reaL 1lW
rophylaxls for dlssemlnaLed dlsease ln Plv wlLh
Cu
4
<30
M. kansas||
Second mosL common lung dlsease caused by n1M
Spread by aerosol rouLe wlLh Lap waLer probably mosL llkely
source
Cccurs ln geographlc clusLers-"lnverLed 1" dlsLrlbuuon ln uS
(SouLhern sLaLes of 1exas, Loulslana, llorlda, and cenLral
sLaLes of llllnols, kansas and nebraska)-more llkely ln urban vs
rural (Lap waLer)
8esembles 18 ln sympLoms and radlographs
l/8/L for 18 monLhs-can LreaL 1lW
kap|d Grow|ng Mycobacter|a (kGM)
M abcessus and M forLulLum mosL llkely Lo cause pulmonary dlsease wlLh
M. abcessus Lhlrd mosL common n1M cause of pulmonary dlsease
Asplrauon of gasLrlc conLenLs ls Lhe mosL lmporLanL poLenually reverslble
underlylng condluon predlsposlng pauenLs Lo 8CM
Also seen ln Cl pauenLs
8adlographs slmllar Lo MAC pLs
usually reslsLanL Lo all rsL llne 18 meds
M abcessus ls usually reslsLanL Lo oral meds and 20 dle, mosL cured wlLh
addluon of surgery. A1S recommend Clarl/cefoxlun (12g/day)/Amlk-
usually does noL cure. auenLs wlLh M forLulLum may do beuer wlLh meds
alone
1reaLmenL ls dlmculL due Lo hlgh reslsLance, need for ln[ecLable drugs,
Loxlc meds and long durauon of Lherapy
SuscepublllLy Lesung should be done on all cllnlcally slgnlcanL 8CM
pauenLs who fall Lherapy or relapse-LesL for amlkacln, cefoxlun, clpro,
clarlLhro, doxycycllne, lmlpenlm and sulfameLhoxazole
kap|d Grow|ng Mycobacter|a (kGM)
8adlographs slmllar Lo MAC pLs
SuscepublllLy Lesung should be done on all cllnlcally slgnlcanL
8CM pauenLs who fall Lherapy or relapse-LesL for amlkacln,
cefoxlun, clpro, clarlLhro, doxycycllne, lmlpenlm and
sulfameLhoxazole
usually reslsLanL Lo all rsL llne 18 meds
M abcessus ls usually reslsLanL Lo oral meds and 20 dle, mosL
cured wlLh addluon of surgery. A1S recommend Clarl/cefoxlun
(12g/day)/Amlk-usually does noL cure. auenLs wlLh M forLulLum
may do beuer wlLh meds alone
1reaLmenL ls dlmculL due Lo hlgh reslsLance, need for ln[ecLable
drugs, Loxlc meds and long durauon of Lherapy
Slnce 8CM dlsease usually progresses slowly may wanL Lo observe
especlally ln elderly
Southeast National TB
Center/A.G. HOLLEY TB
HOTLINE
1-800-4TB-INF0
BEST OF LUCK!!!