Chapter 40 : Complex Disease

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There are over 170 known species and subspecies of mycobacteria that have been identified, and new species continue to be discovered (http://www.bacterio.net/mycobacterium.html). The most widely distributed and common of the mycobacteria are the nontuberculous mycobacteria (NTM), of which organisms in the complex (MAC) are most common. In the early 1980s, the complex was called MAI and represented the two primary pathogens, and . However, MAC consists of a growing number of species, including , , , , , , , and ( Table 1 ). The most important human pathogens are , , and . Unfortunately, most laboratories are unable to differentiate the many species and subspecies because they lack the molecular methods required. Precise species identification is important, as recent studies have demonstrated different sources of environmental exposure ( ), various degrees of pathogenicity ( ), and even differences in treatment outcome between MAC species ( ).

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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Figure 1

Prevalence of pulmonary NTM cases among a sample of U.S. Medicare part B enrollees aged 65 and older, 1997 to 2007. From reference , with permission.

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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Figure 2

Interplay between environmental exposure, host susceptibility, and pathogen virulence.

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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Figure 3

Chest CT scan with coronal (A) and transverse (B) images from a patient with fibrocavitary pulmonary MAC. Bilateral upper lobe cavitation is noted, with associated volume loss in the setting of severe emphysema.

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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Figure 4

Chest CT scan from a patient with nodular bronchiectatic MAC, demonstrating multiple pulmonary nodules throughout both lungs, including tree-in-bud nodularity in the dependent sections below the right middle lobe and lingula.

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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Figure 5

Treatment algorithm for MAC disease. If the isolate is macrolide susceptible and no cavities are present on chest imaging, a three-times-a-week 3-drug regimen is recommended. If cavitary changes are present, daily administration is recommended along with addition of parenteral amikacin (or streptomycin) and consideration of lung resection for focal disease. For macrolide-resistant disease, parenteral amikacin and lung resection should be strongly considered. IV, intravenous.

Citation: Daley C. 2017. Complex Disease, p 663-701. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0045-2017
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