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Clinical Investigations: INFECTION |

Mycobacterium avium-intracellulare Pulmonary Infection in HIV-Negative Patients Without Preexisting Lung Disease*: Diagnostic and Management Limitations FREE TO VIEW

Judy H. Huang, MD; Peter N. Kao, PhD, MD; Virginia Adi, RN; Stephen J. Ruoss, MD
Author and Funding Information

*From the Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, CA.



Chest. 1999;115(4):1033-1040. doi:10.1378/chest.115.4.1033
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Study objectives: To review the experience of an outpatient pulmonary clinic with Mycobacterium avium-intracellulare (MAI) pulmonary disease in the HIV-negative population without preexisting lung disease.

Design: Retrospective clinical series.

Setting: University medical center.

Patients: The clinic charts of all patients who fulfilled the current American Thoracic Society criteria for MAI pulmonary infection and who had no preexisting lung disease or immunosuppression were reviewed.

Measurements and results: Of 31 patients identified, 94% were female, 90% were white, and the median age at diagnosis was 63 years. The median time interval from symptom onset to diagnosis was 10 months. Bronchiectasis or small nodules without predilection for any lobe was found in 93%. Bronchoscopy or open lung biopsy for diagnosis was required in 45% because of nondiagnostic sputum cultures. At ≥ 12 months, 50% failed therapy, 86% continued to be symptomatic, and 58% did not tolerate their initial multidrug regimen.

Conclusions: These results emphasize the observed chronic nature of MAI pulmonary disease in this population, both before diagnosis and despite therapy. The sensitivity of sputum culture in this population is low, so an aggressive diagnostic approach, including bronchoscopy, should be considered if sputum cultures are negative. Current treatments are suboptimal because of poor drug tolerance and significant failure rates. Last, the preponderance of disease in older white women argues for a genetic or acquired immune deficiency to explain disease susceptibility.

Abbreviations: AFB = acid-fast bacilli; ATS = American Thoracic Society; HRCT = high-resolution CT; MAI = Mycobacterium avium-intracellulare; MTB = Mycobacterium tuberculosis

Figures in this Article

Mycobacteriumavium-intracellulare (MAI) has been described traditionally as an opportunistic organism that causes disseminated disease in the HIV-positive population and that acts as a pulmonary pathogen in patients with underlying lung disease such as COPD or previously diagnosed tuberculosis. Recently, a new clinical presentation of MAI pulmonary disease was reported by Prince et al1in 21 patients with no predisposing factors. Patients were characterized as older, otherwise healthy, nonsmoking women, and they accounted for 25% of the total number of HIV-negative cases in this report. Subsequent reviews2,,3 have revealed that this patient population accounts for 24% to 59% of MAI cases seen in pulmonary practices, in either community or academic medical centers.

Despite recognition of this disease entity, the last decade has seen relatively few studies of MAI pulmonary infection in patients without predisposing factors. The majority of publications have focused on the clinical characteristics of this patient population while proposing hypotheses to explain why these patients succumb to this opportunistic pathogen.4,,5,,6,,7 The radiologic presentation of MAI pulmonary disease has been clearly delineated. A high-resolution CT (HRCT) pattern of multilobar bronchiectasis and small nodular disease is present in women without predisposing risk factors.8,,9,,10,,11,,12 This documentation of extensive and progressive radiographic changes, together with histologic evidence of granulomatous inflammation, has helped to clarify MAI as not merely an airway colonizer but as an invasive pathogen even in these apparently immunocompetent hosts.

The recently published American Thoracic Society (ATS) criteria for diagnosis and treatment of disease caused by nontuberculous mycobacteria summarized what is presently understood about MAI pulmonary disease and hopefully will increase awareness of this clinical entity in HIV-negative patients without predisposing factors.13 Currently, however, it appears that MAI pulmonary disease in previously healthy patients remains underappreciated, even by pulmonologists, which can lead to delays in diagnosis and treatment. This study retrospectively reviews the experience of our clinic with MAI pulmonary disease in the HIV-negative population without preexisting lung disease. It demonstrates a surprisingly low sensitivity of sputum cultures for the diagnosis of active MAI infection; our analysis argues for the consideration of bronchoscopy in the proper clinical context. In addition, current macrolide-based regimens are shown to have limited therapeutic success, which can be explained, only partially, by poor drug tolerance.

Patient Selection

The Stanford University Medical Center Chest Clinic is an outpatient pulmonary clinic in an academic, tertiary care center. All currently active charts of patients who were seen from August 1995 to August 1997 were reviewed and screened for at least one documented positive MAI culture from a pulmonary source. The diagnosis of MAI pulmonary disease was made based on the 1997 ATS criteria for diagnosis of disease caused by nontuberculous mycobacteria.13 These criteria are listed in Table 1 . Patients were excluded from this series if they had an alternative diagnosis, were immunocompromised or immunosuppressed (including HIV infection and malignancy), or had underlying pulmonary pathology, including a history of Mycobacterium tuberculosis (MTB) or COPD. Patients with pulmonary function tests that documented only a mild obstructive pattern were included, as well as patients with a more severe obstruction but no history of tobacco exposure.

Chart Review

All charts were reviewed for the following information, if available: age at diagnosis; history of tobacco use; history of pulmonary disease, as well as a general medical history; earliest pulmonary function test; presenting symptoms; time interval from the reported onset of symptoms to diagnosis; earliest and most recent chest radiograph that had a printed report in the chart; earliest and most recent chest CT scan that had a printed report in the chart; pulmonary source of positive MAI cultures; treatment regimens and duration; and follow-up, focusing on those patients for whom there was clear intention to treat for at least 12 months, noting clinical course, drug tolerance, MAI culture conversion, and radiographic evolution. All radiographs and CT scans were reviewed by the treating physician as well as a radiologist.

Isolation of MAI

The treating physicians attempted to obtain at least three adequate sputum cultures from all patients, by induction if necessary. Further testing was performed if the patient was unable to produce sputum or if there was an inadequate number of positive sputum cultures for diagnosis. All specimens were cultured using BACTEC liquid medium (Becton Dickinson; Sparks, MD). MAI isolates were identified by Gen-Probe (Gen-Probe Inc; San Diego, CA), and drug-sensitivity studies were processed at the Medical Reference Library reference laboratory (Cypress, CA).

Of the 64 patients who had at least one positive MAI culture from any pulmonary source, 31 fulfilled inclusion criteria for MAI pulmonary disease without predisposing risk factors. Of the 33 patients excluded, 2 were given alternative diagnoses (allergic bronchopulmonary aspergillosis and coccidioidomycosis), 2 were immunosuppressed (multiple myeloma and sarcoid), 16 had underlying pulmonary disease (7 with COPD, 6 with a history of MTB, 1 with bronchogenic carcinoma, and 2 with bronchial stenosis), and the remaining 13 did not fulfill the current ATS criteria for active disease.

Patient Characteristics

The clinical characteristics of these patients were strikingly uniform. Twenty-nine of 31 patients (94%) were women, and 28 of 31 patients (90%) were white. This differed from the overall clinic demographics during the same time period, in which there was a 1:1.1 ratio of men to women and in which 61% of patients were white. The median and mean ages at diagnosis of MAI pulmonary disease were 63 and 64 years, respectively (range, 31 to 79 years), whereas the median and mean age of all clinic patients was 55 years.

A smoking history was available for 28 patients. Eighteen of 28 patients (64%) had never smoked. The mean number of pack-years smoked in the remaining 10 patients was 14 (range, 1 to 30 pack-years), and none were actively smoking.

Clinical Presentation

Symptoms reflected the bronchocentric nature of MAI pulmonary disease in this patient population. All 31 patients complained of a chronic cough at some point in their course; 94% had chronic cough as one of their presenting symptoms. Forty-five percent had hemoptysis at some point in their clinical course, but there were no reports of massive hemoptysis. Forty-eight percent had constitutional complaints, including weight loss (26%), fatigue (16%), night sweats (10%), and fever (10%). Five patients experienced dyspnea, and two had pleuritic chest pain.

Time Interval to Diagnosis

The time interval from reported onset of symptoms to recognition of MAI pulmonary disease varied greatly. Adequate documentation was available for 27 patients. Overall, the median length of time from onset of symptoms to diagnosis was 10 months (range, 1 month to 6 years). Of the eight patients who were given their diagnosis at an outside clinic, the median length of time to diagnosis was 15 months (range, 4 months to 5 years). Of the patients who were diagnosed in our clinic, the median time interval to diagnosis was 10 months (range, 1 month to 6 years), with a median of only 1 month (range, 1 month to 2.5 years) from the first visit to our clinic.

Radiographic Findings

The evaluation of all radiographs and CT scans was based on interpretations by the clinician and a radiologist. Thirty of the 31 patients had at least one final report from a chest radiograph documented in the chart, which was not necessarily from the initial studies, in view of our criterion that only radiographs with a printed report be included. Of the earliest available reports for these 30 patients, only seven (23%) had disease localized to the middle lobe and/or lingula on radiograph. Radiographic changes were generally nonspecific and showed infiltrate (63%), reticular and/or nodular changes (40%), bronchiectasis (17%), apical thickening (13%), scarring (13%), and other changes, such as cavities, bullae, atelectasis, and coin lesions (13%).

Twenty-eight patients had a documented chest CT scan. Again, these scans were not necessarily the initial scans. Based on the earliest available scans, the average number of lung lobes involved was 3.3. The distribution of the number of patients with disease in a specific lobe was as follows: right upper lobe, 18; middle lobe, 21; right lower lobe, 14; left upper lobe, 7; lingula, 17; and left lower lobe, 14. Four patients had involvement of all lung fields. Except for a sparing of the left upper lobe, there was no obvious predilection of MAI disease in any of the lobes, including the middle lobe and lingula. In addition, there appeared to be no correlation between duration of symptoms and location of disease on radiographs.

Of the 28 patients with CT scans, 10 had both nodular disease and bronchiectasis, 10 had bronchiectasis without nodules, 6 had nodules without bronchiectasis, and only 2 patients had neither nodular disease or bronchiectasis (infiltrates only). The CT scans revealed no predilection for either nodular or bronchiectatic predominant disease as a function of anatomic location.

Specimen Source of Positive MAI Cultures

Confirmation of active pulmonary disease was made by obtaining an adequate number of positive MAI cultures from spontaneously expectorated or saline-induced sputum according to the 1997 ATS criteria,13 or failing that, BAL, transbronchial biopsies, or open lung biopsy (Fig 1 ). Seventeen of 31 patients (55%) produced sputum with positive MAI cultures at presentation. However, 14 of 31 patients (45%) were either unable to produce sputum or had negative sputum cultures. Thirteen of the 14 patients underwent bronchoscopy with diagnosis established by culture from BAL. Seven of these 13 patients also had transbronchial or endobronchial biopsies, with biopsies from all but one demonstrating granulomatous inflammation. One patient was diagnosed by open lung biopsy. Of the patients who were not originally diagnosed by sputum culture, five eventually produced positive sputum cultures during monitoring of their treatment. Of note, although subsequent sputum cultures from some of the patients yielded other organisms in addition to MAI, the initial sputum samples grew MAI as the sole organism.

Antimycobacterial Drug Therapy and Clinical Course

Medical management of these patients varied widely, even among the five faculty physicians in our clinic. There was no standardized treatment protocol in our clinic for this patient population, and the choices of drug regimen and duration of treatment were determined by the individual physician. Treatment of some patients was initiated at outside institutions. All of the patients treated were initially started on a macrolide-based regimen, with the most common drug combination consisting of a macrolide (azithromycin, 250 to 500 mg, or clarithromycin, 500 to 1,000 mg, daily), a rifamycin (rifampin, 600 mg, or rifabutin, 300 mg, daily), and ethambutol, 15 mg/kg/d. We focused only on those patients for whom there was a clear intention to treat with a multidrug regimen for at least 12 months. Although many of the patients used recognized methods for improving pulmonary secretion clearance, there was no systematic regimen used in this population.

Four patients were not treated with a multidrug regimen for their MAI pulmonary disease. None of them had constitutional symptoms, but three did have persistent intermittent hemoptysis, and all of them had multilobar disease. Only one patient is still being followed by our clinic; the other three showed no significant change in their clinical courses or radiographs after 3 years of follow-up. The remaining patient has been followed-up for < 1 year with no clinical changes.

There was the intention to treat for at least 12 months in 27 patients (see Table 2 ). The three-drug treatment was recommended in three patients who did not follow-up at this clinic, and no additional information was available. Of the remaining 24 patients, the mean duration of follow-up after diagnosis was 32.8 months (range, 1 to 108 months). Three or more drugs were initially recommended for therapy for the majority of patients (21/24). Three patients were started on a two-drug therapy, two of whom eventually added a third drug to their regimen. Duration of therapy ranged from 1 month to 8 years.

Fourteen patients finished at least 12 months of therapy. Failure of therapy was considered when persistence of positive MAI cultures or reconversion to positive cultures occurred. Four patients continued therapy beyond 12 months because of persistently positive cultures. Three patients have subsequently relapsed, as documented by the recurrence of positive cultures, and have resumed therapy. Time from completion of therapy to diagnosis of relapse ranged from 9 months to 6 years. Thus, 7 of 14 patients (50%) failed after at least 12 months of therapy. In six of the patients who had failed therapy, in vitro drug-sensitivity testing was completed and showed the development of single-drug resistance in three patients; medications were altered accordingly in two patients.

Five of the remaining seven patients who were not treatment failures had persistent symptoms, most commonly cough and/or hemoptysis, albeit fewer symptoms than than those at presentation. Thus, with the 7 patients who failed therapy, 12 of 14 patients (86%) continued to have symptoms, despite being on a multidrug regimenat for at least 12 months. Of the 12 patients who had subsequent radiologic studies performed, only 3 demonstrated improvement, and no patient had normalization of their films.

Ten patients did not complete a 12-month regimen. Four patients had only recently been started on therapy, and two were lost to follow-up after < 12 months. One patient refused therapy, despite persistent symptoms, progressive bronchiectasis on HRCT, and repeated positive cultures. Three patients were unable to finish a full course of multidrug treatment because of drug intolerance and two continued to be symptomatic. None of the patients died during available follow-up. One patient, after receiving 22 months of three antimycobacterial drugs, underwent wedge resection because of recurrent hemoptysis; surgical pathology revealed granulomatous disease, bronchiectasis, and a 1+ acid-fast bacilli (AFB) smear but negative AFB cultures.

Tolerance of Antimycobacterial Drug Therapy

Drug intolerance was a common observation in this population, and often resulted in revision of the therapeutic regimen (Table 3 ). In addition to the three patients who were unable to continue with any of their medications, one patient who had relapsed could not tolerate her previous regimen. Ten patients had to change their medications or reduce the number of drugs because of drug toxicity or side effects. The most common complaints were GI disorders, dermatologic changes, fever, and ophthalmologic disorders. Thus, of the patients for whom there was the intention to treat and who had follow-up, 14 of 24 (58%) were unable to complete the initially recommended therapeutic regimen.

As mentioned previously, seven patients had failed after at least 12 months of therapy. Three of these patients had changed their therapeutic regimen because of drug intolerance. Thus, four of the patients who failed therapy had tolerated the initially recommended therapy regimen.

MAI pulmonary disease in HIV-negative patients without predisposing factors was first reported by Prince et al.1 They, as well as subsequent investigators,2,,3,,4,,5 noted a preponderance of disease in older white women. The 1997 ATS guidelines on nontuberculous mycobacteria recognize the existence of this unique patient cohort.13 It is clear that MAI should not be ignored as an airway colonizer, and the ATS statement suggests that the diagnosis of active infection using multiple sputum cultures in the appropriate clinical and radiographic context is usually not difficult. The ATS statement does not clearly delineate the role of bronchoscopy in the diagnosis of infection. The recommendation for treatment is a macrolide and rifamycin-based three-drug regimen for 10 to 12 months beyond sputum culture conversion to negative. The statement predicts good success rates, as defined by long-term negative sputum cultures, for those patients who are able to tolerate therapy.

Our retrospective review of 31 patients identifies possible limitations in the approach recommended in the ATS guidelines in diagnosis and management of MAI pulmonary disease in this population. Foremost, sputum cultures had a high false-negative rate, as 45% of patients had nondiagnostic sputum cultures and required bronchoscopy or lung biopsy for diagnosis. This was an unexpected finding and does not reflect the generally held belief, including the bias of the 1997 ATS Consensus Statement, that sputum cultures are a sensitive diagnostic test. Second, there was a high failure rate, despite multidrug therapy, that could not be fully explained by drug intolerance. In addition, the tendency toward the development of bronchiectasis resulted in chronic morbidity even in those patients who had been successfully treated. Third, drug intolerance was a frequent problem, occurring in 58% of patients. Last, we corroborated the striking patient homogeneity reported in the literature, with the majority of patients being older, white, otherwise healthy women, which again raises the possibility of a host defense defect to explain disease susceptibility.

Atypical mycobacteria should be easily isolated from sputum in cavitary lung disease. However, cavities rarely form in this population, a fact which may explain the high false-negative rate of sputum cultures in this patient series. Negative sputum cultures were not an indicator of early disease, because those patients who required bronchoscopy to establish a diagnosis did not have a shorter duration of symptoms before presentation and diagnosis. Despite the fact that 94% of the patients complained of cough at presentation, a significant number of them produced sputum samples that were appropriate lower respiratory tract samples but culture negative for MAI. In fact, in 45% of cases it was necessary to proceed to bronchoscopy or lung biopsy to diagnose MAI disease.

These results raise the issue of whether sputum culture is a sufficiently sensitive method to exclude active MAI infection. This question has not been systematically addressed or answered by this or any prior study. The diagnostic recommendations in the 1997 ATS Consensus Statement reflect the current approach and bias, namely, to view sputum culture as a sufficiently sensitive test.13 In contrast to the amply proven circumstance with MTB pulmonary infection, sputum culture may not be very sensitive at all for MAI disease. Our data suggest that this question needs further investigation.

The poor sensitivity of sputum cultures strongly suggests that in situations where there is a significant clinical suspicion of nontuberculous mycobacterial infection and multiple sputum cultures are negative, bronchoscopy should be performed to adequately exclude disease. It also follows that obtaining culture samples from BAL rather than from sputum samples may be necessary to monitor the success of therapy in patients, particularly those who do not produce MAI in their sputum at presentation.

Previous trials of therapeutic efficacy have defined the success of treatment as durable sputum culture conversion to negative. In light of our finding that a significant number of patients cannot be diagnosed by sputum culture alone, there may have been unintended selection bias in previously reported patient series. In addition, our data suggest that trials that have used sputum conversion as the end-point may have significantly overestimated therapy success rates.

Because morbidity from MAI pulmonary disease is a consequence of progressive bronchocentric inflammation and destruction, early diagnosis and treatment may be critical. The median interval from onset of symptoms to diagnosis in our clinic was 10 months, longer than the 25 weeks reported by Prince in 1989.1 This interval was, in part, the result of delayed patient initiative in seeking medical advice but also reflected the lack of disease recognition by referring physicians, many of whom did not perform cultures for mycobacteria or who dismissed positive cultures as colonization. Falsely reassuring negative sputum cultures may also have contributed to a delay in diagnosis and, thus, in treatment.

In 1989, the standard treatment for MAI disease was an isoniazid- and rifampin-based regimen. This regimen was associated with a 19% mortality rate and a 44% relapse rate as reported by Prince et al.1 It is now appreciated that isoniazid resistance is common in MAI, and there is optimism that the currently recommended macrolide and rifamycin-based regimens will be more successful in eradicating the disease. Notwithstanding these changes, we found a 50% failure rate in those patients who had been treated for at least 12 months with a multidrug regimen. This disappointing observation cannot be explained completely by drug intolerance, because four of the seven failures occurred in patients who had tolerated their initially prescribed regimens. It is also unclear what role drug resistance played in these failures. However, given that drug-sensitivity testing revealed the development of resistance to at most one drug with which the patients were being treated, it was probably not a major contributor to therapy failure.

There are several other explanations, which may not be mutually exclusive. In vitro drug-sensitivity testing may not reflect in vivo drug efficacy, and the currently recommended therapy duration may not be adequate for infection eradication. The development of bronchiectasis following an initial atypical mycobacterial infection may, despite treatment, create the proper anatomic milieu for persistent or subsequent infections. Patient noncompliance with these multidrug regimens may also play a role. Last, the presence of any underlying immune defense defects that might be responsible for the increased susceptibility of these patients to MAI infection would be expected to make eradication of the infection more difficult and acquisition of a subsequent infection more likely. It is quite possible that some of these patients may have been successfully treated, only then to become reinfected with new strains of MAI.

Given our results, including the observed 50% treatment failure rate, the present management algorithm that defines successful MAI treatment as conversion of sputum cultures to negative with antibiotic therapy should be viewed as problematic and potentially inadequate. The question of whether earlier recognition, and thus earlier treatment, of MAI infection would decrease morbidity in these patients is also not answered by this study or any currently published data. It is a very difficult and important question, and would best be addressed in a randomized prospective trial, particularly in light of the apparent limited successes of the current antibiotic regimens. Given the natural history of chronic airway inflammation and bronchiectasis, the only truly successful treatment approach may be prevention of MAI infection.

The goal of this retrospective review was to study treated MAI pulmonary disease in the group of patients who have no apparent immune defects and who have no previous pulmonary disease that would explain increased susceptibility to infection. This review highlights the tendency of MAI to cause nodular bronchiectasis in this group of patients. Despite successful eradication of MAI, the development of bronchiectasis resulted in a chronic clinical course. Bronchiectasis was documented by chest CT in 71% of our patients, and of those who had finished at least 1 year of therapy, 86% continued to be symptomatic. All had some degree of permanent abnormality on radiograph.

Intolerance of antimycobacterial therapy was common, because of either side effects or drug toxicity. Of the 24 patients in whom there was intent to treat for 12 months, 58% were unable to tolerate the initially recommended drug regimen. This, combined with the observed high failure rates of current standard regimens, makes it even more imperative for future investigations to improve therapeutic options.

Our findings must take into consideration two major limitations of this study. First, this was a retrospective study, which not only resulted in incomplete data points, but also did not control the diagnosis or treatment of these patients. Thus, there was no standardization of the number of diagnostic sputum samples obtained (beyond the initial three), treatment protocols, or timing and frequency of subsequent sputum cultures. Second, the 31 patients constitute a small sample size. Despite these limitations, this study provides intriguing insights into the many clinical questions posed by patients with MAI pulmonary disease and emphasizes the necessity of a larger prospective trial to further investigate these patients.

Resolution of MAI pulmonary disease will not be possible until there is an understanding of why these patients, who are apparently immune competent, develop progressive disease from an opportunistic pathogen. The striking patient homogeneity suggests that a common defect in the host response to MAI may explain susceptibility. Previous theories4,,6 have proposed that the phenotype itself was the defect, as exemplified by theories such as the “Lady Windermere Syndrome” or involvement of an unidentified connective tissue abnormality. Our retrospective study was unable to systematically address the question of any associated skeletal or cardiac anomalies in this population. However, the previous descriptions of these patients having a slender body habitus is consistent with the observations in our patient series.

We, and others,5,,14,,15 have proposed the presence of a subtle immune defect, in which the physical phenotype of the patient may be merely a coincidental marker, to explain susceptibility to MAI. This defect could be the result of a genetic allelism, or it could be acquired, perhaps being uncovered by the changing hormonal milieu in these generally postmenopausal women. It has been demonstrated that a single point mutation in the natural resistance-associated macrophage protein gene results in an inadequate host response to intracellular pathogens and overwhelming Mycobacterium bovis infection in the murine model.,16Recently, an association has been described between genetic polymorphisms in the human natural resistance-associated macrophage protein gene and MTB infection in a West African population.17In addition, disseminated atypical mycobacterial infection in children has been associated with multiple mutations in the interferon-γ receptor 1 gene.18,,19 We have investigated polymorphisms in the human human natural resistance-associated macrophage protein and interferon-γ receptor 1 genes and have demonstrated no correlations with MAI pulmonary disease.15

Although the mycobacterial diseases in these various populations clearly differ from our population of older women with localized MAI pulmonary disease, they do emphasize the importance of the cellular host immune response in determining disease progression. A subtle immune defect might explain why these women are initially infected only with MAI, develop slowly progressive symptomatic disease later in life, and why their endogenous immune defense responses are insufficient to eradicate these opportunistic organisms. It would also explain the high relapse rates seen in these patients, because theoretically the host response and not the virulence of the organism would determine disease reactivation or reinfection. Should disease susceptibility prove to be a result of an immune defect, it would also suggest the possibility of immunomodulatory therapy as a possible adjunctive, if not primary, therapeutic option.

Correspondence to: Stephen J. Ruoss, MD, Division of Pulmonary and Critical Care Medicine, Room H3143, Stanford University Medical Center, Stanford, CA 94305-5236; e-mail: ruoss@leland.stanford.edu

Table Graphic Jump Location
Table 1. Criteria for Diagnosis of Nontuberculous Mycobacteria Pulmonary Disease With Presumed or Confirmed HIV-Seronegative Potential Risk Factors and No Local Immune Suppression*
* 

For a diagnosis of pulmonary disease, all three criteria (clinical, radiographic, and bacteriologic) must be satisfied (reprinted with permission from ATS13).

Figure Jump LinkFigure 1.  Patient distribution by source of diagnostic MAI culture.Grahic Jump Location
Table Graphic Jump Location
Table 2. Duration and Failure Rates of Multidrug Antimycobacterial Therapy in Patients with MAI Pulmonary Disease
Table Graphic Jump Location
Table 3. Patient Tolerance of Multidrug Antimycobacterial Therapy and Association With Failure of Therapy
* 

Defined either as relapse documented by reconversion to positive cultures or as persistently positive cultures.

 

One with inadequate follow-up.

ACKNOWLEDGMENT: We thank Dr. G. Rosen for his review of the manuscript and Dr. R. Doyle for helpful conversations, and acknowledge the contribution to this study of patients from Drs. R. Doyle, T. Raffin, and N. Rizk.

Prince, DS, Peterson, DD, Steiner, RM, et al (1989) Infection with Mycobacterium avium complex in patients without predisposing conditions.N Engl J Med321,863-868. [PubMed] [CrossRef]
 
Iseman, MD Mycobacterium avium complex and the normal host: the other side of the coin [editorial].N Engl J Med1989;321,896-898. [PubMed]
 
Reich, JM, Johnson, RE Mycobacterium avium complex pulmonary disease. Incidence, presentation, and response to therapy in a community setting.Am Rev Respir Dis1991;143,1381-1385. [PubMed]
 
Reich, JM, Johnson, RE Mycobacterium avium complex pulmonary disease presenting as an isolated lingular or middle lobe pattern: the Lady Windermere syndrome.Chest1992;101,1605-1609. [PubMed]
 
Kennedy, TP, Weber, DJ Nontuberculous mycobacteria: an underappreciated cause of geriatric lung disease.Am J Respir Crit Care Med1994;149,1654-1658. [PubMed]
 
Iseman, MD, Buschman, DL, Ackerson, LM Pectus excavatum and scoliosis: thoracic anomalies associated with pulmonary disease caused by Mycobacterium avium complex.Am Rev Respir Dis1991;144,914-916. [PubMed]
 
Pomerantz, M, Denton, JR, Huitt, GA, et al Resection of the right middle lobe and lingula for mycobacterial infection.Ann Thorac Surg1996;62,990-993. [PubMed]
 
Hartman, TE, Swensen, SJ, Williams, DE Mycobacterium avium-intracellularecomplex: evaluation with CT.Radiology1993;187,23-26. [PubMed]
 
Moore, EH Atypical mycobacterial infection in the lung: CT appearance.Radiology1993;187,777-782. [PubMed]
 
Miller, WT, Jr Spectrum of pulmonary nontuberculous mycobacterial infection.Radiology1994;191,343-350. [PubMed]
 
Swensen, SJ, Hartman, TE, Williams, DE Computed tomographic diagnosis ofMycobacterium avium-intracellularecomplex in patients with bronchiectasis.Chest1994;105,49-52. [PubMed]
 
Lynch, DA, Simone, PM, Fox, MA, et al CT features of pulmonary Mycobacterium avium complex infection.J Comput Assist Tomogr1995;19,353-360. [PubMed]
 
American Thoracic Society.. Diagnosis and treatment of disease caused by nontuberculous mycobacteria.Am J Respir Crit Care Med1997;(suppl); 156,S1-S25
 
Wallace, RJ, Jr Mycobacterium avium complex lung disease and women: now an equal opportunity disease [editorial].Chest1994;105,6-7. [PubMed]
 
Huang JH, Oefner PJ, Adi V, et al. Analyses of theNRAMP1andIFN-γ receptor 1 genes in women with MAI pulmonary disease. Am J Respir Crit Care Med 1998; 1998:157:377–381
 
Vidal, S, Gros, P, Skamene, E Natural resistance to infection with intracellular parasites: molecular genetics identifies Nramp1 as the Bcg/Ity/Lsh locus.J Leukoc Biol1995;58,382-390. [PubMed]
 
Bellamy, R, Ruwende, C, Corrah, T, et al Variations in the NRAMP1 gene and susceptibility to tuberculosis in West Africans.N Engl J Med1998;338,640-644. [PubMed]
 
Newport, MJ, Huxley, CM, Huston, S, et al A mutation in the interferon-gamma-receptor gene and susceptibility to mycobacterial infection.N Engl J Med1996;335,1941-1949. [PubMed]
 
Jouanguy, E, Altare, F, Lamhamedi, S, et al Interferon-gamma-receptor deficiency in an infant with fatal bacille Calmette-Guerin infection.N Engl J Med1996;335,1956-1961. [PubMed]
 

Figures

Figure Jump LinkFigure 1.  Patient distribution by source of diagnostic MAI culture.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Criteria for Diagnosis of Nontuberculous Mycobacteria Pulmonary Disease With Presumed or Confirmed HIV-Seronegative Potential Risk Factors and No Local Immune Suppression*
* 

For a diagnosis of pulmonary disease, all three criteria (clinical, radiographic, and bacteriologic) must be satisfied (reprinted with permission from ATS13).

Table Graphic Jump Location
Table 2. Duration and Failure Rates of Multidrug Antimycobacterial Therapy in Patients with MAI Pulmonary Disease
Table Graphic Jump Location
Table 3. Patient Tolerance of Multidrug Antimycobacterial Therapy and Association With Failure of Therapy
* 

Defined either as relapse documented by reconversion to positive cultures or as persistently positive cultures.

 

One with inadequate follow-up.

References

Prince, DS, Peterson, DD, Steiner, RM, et al (1989) Infection with Mycobacterium avium complex in patients without predisposing conditions.N Engl J Med321,863-868. [PubMed] [CrossRef]
 
Iseman, MD Mycobacterium avium complex and the normal host: the other side of the coin [editorial].N Engl J Med1989;321,896-898. [PubMed]
 
Reich, JM, Johnson, RE Mycobacterium avium complex pulmonary disease. Incidence, presentation, and response to therapy in a community setting.Am Rev Respir Dis1991;143,1381-1385. [PubMed]
 
Reich, JM, Johnson, RE Mycobacterium avium complex pulmonary disease presenting as an isolated lingular or middle lobe pattern: the Lady Windermere syndrome.Chest1992;101,1605-1609. [PubMed]
 
Kennedy, TP, Weber, DJ Nontuberculous mycobacteria: an underappreciated cause of geriatric lung disease.Am J Respir Crit Care Med1994;149,1654-1658. [PubMed]
 
Iseman, MD, Buschman, DL, Ackerson, LM Pectus excavatum and scoliosis: thoracic anomalies associated with pulmonary disease caused by Mycobacterium avium complex.Am Rev Respir Dis1991;144,914-916. [PubMed]
 
Pomerantz, M, Denton, JR, Huitt, GA, et al Resection of the right middle lobe and lingula for mycobacterial infection.Ann Thorac Surg1996;62,990-993. [PubMed]
 
Hartman, TE, Swensen, SJ, Williams, DE Mycobacterium avium-intracellularecomplex: evaluation with CT.Radiology1993;187,23-26. [PubMed]
 
Moore, EH Atypical mycobacterial infection in the lung: CT appearance.Radiology1993;187,777-782. [PubMed]
 
Miller, WT, Jr Spectrum of pulmonary nontuberculous mycobacterial infection.Radiology1994;191,343-350. [PubMed]
 
Swensen, SJ, Hartman, TE, Williams, DE Computed tomographic diagnosis ofMycobacterium avium-intracellularecomplex in patients with bronchiectasis.Chest1994;105,49-52. [PubMed]
 
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