The most common site of the disease is the lungs; in most lung infections MAC is involved, but they are also caused by M. kansasii, M. xenopi or M. abscessus. (Editor’s note: M. kansasii is not widespread in Europe M. genavense here should, however, be mentioned too.!) Occasionally there is an involvement of lymph nodes, bones and joints, skin and wounds. Nevertheless, the number of disseminated non-tuberculous mycobacterial disease in HIV patients increases, and a resistance to antimycobacterial substances is the rule (except for M. kansasii and M. xenopi).

Rarely leads to infections caused by ubiquitous – non- M. tuberculosis – mycobacteria in humans. These pathogens are common in soil and water and are much less virulent than M. tuberculosis in humans. Infection with these pathogens are also called atypical, environmental and non-tuberculous mycobacterial infections. Most exposures and infections caused by these pathogens do not cause a disease for which usually a defect in the local or systemic host defenses is needed; frail elderly and immunocompromised individuals are at highest risk. The M. avium complex (MAC) – the closely related species of M. avium and M. intracellulare – is responsible for a large part of the disease. Other causative pathogens are M. kansasii, M. xenopi, M. marinum, M. ulcerans and M. fortuitum complex (M. fortuitum, M. abscessus and M. chelonae). A transmission from human to human has not been documented. The most common site of the disease is the lungs; in most lung infections MAC is involved, but they are also caused by M. kansasii, M. xenopi or M. abscessus. (Editor’s note: M. kansasii is not widespread in Europe M. genavense here should, however, be mentioned too.!) Occasionally there is an involvement of lymph nodes, bones and joints, skin and wounds. Nevertheless, the number of disseminated non-tuberculous mycobacterial disease in HIV patients increases, and a resistance to antimycobacterial substances is the rule (except for M. kansasii and M. xenopi). The diagnosis nontuberculous mycobacterial infection is typically via acid-fast stain and culture from the sample. Nontuberculous mycobacteria are best treated by a specialist with particular expertise in this area. The guidelines of the German Society for AIDS opportunistic infections and the The American Thoracic Society publish current diagnostic and therapeutic guidelines for the diagnosis and treatment of these challenging infections. Pulmonary Diseases The typical patients are older women and middle-aged women with bronchiectasis, scoliosis, pectus excavatum or mitral valve prolapse, but no known underlying lung disease. MAC is also in Caucasians middle-aged or older with preexisting pulmonary problems such. As chronic bronchitis, emphysema, healed TB, bronchiectasis, or silicosis, cause pulmonary disease. Whether MAC bronchiectasis caused or whether bronchiectasis resulting MAC is not always clear. In older, thin women with chronic cough without sputum, this syndrome is often called “Lady Windermere syndrome”; it seems to be increasing for unknown reasons in its frequency. Cough and sputum production are common, often associated with fatigue, weight loss and low grade fever. The course can be stable or only slowly progressive over time. It can develop respiratory failure and persistent hemoptysis. Fibronodulare infiltrates on chest radiographs can remember a pulmonary TB, but caverns tend to be rather thin-walled and it rarely comes to a pleural effusion. So-called “tree-and-bud-Inflltrate”, which can be seen in the breast CT, are also characteristic of a MAC disease. A determination of the drug sensitivity can be helpful in certain pathogens / drug combinations, however, is feasible only in highly specialized laboratories. The sensitivity for clarithromycin is a predictor of the therapeutic response in MAC. In a moderately symptomatic disease due to MAC positive Sputumpräparat and cultural evidence azithromycin should be preferably 600 mg p.o. 1 times a day, or the interaction more joyful and more toxic clarithromycin 500 mg po 2 times a day, in combination with rifabutin (RBT) 300 to 450 mg p.o. 1 times a day, and ethambutol (EMB) 15-25 mg / kg p.o. about 12 to 18 months or until receipt of negative cultures (over 12 months) are applied 1 times daily. In progressive cases that do not respond to standard substances, combinations of drugs can be tested 4-6, azithromycin 600 mg p.o. 1 times daily or clarithromycin 500 mg po 2 times a day and rifabutin 300 to 450 mg p.o. 1 times a day, Ciprofloxacin 250-500 mg po or iv 2 times daily, clofazimine 100-200 mg po 1 times a day, and amikacin 10-15 mg / kg i.v. 1 times included daily. Only in exceptional cases such. As well localized disease in young, otherwise healthy patients are advised resected surgical procedures. M. kansasii and M. xenopi infections can with isoniazid, rifabutin and EMB with or without streptomycin or azithromycin / clarithromycin administered treatment for 18-24 months. M. abscessus infections are treated with three drugs: amikacin, cefoxitin or imipenem and an oral macrolide. All non-tuberculous mycobacteria are primarily resistant to pyrazinamide. Lymphadenitis in children of 1-5 years a chronic submaxillary and submandibular cervical lymphadenitis is often triggered by MAC or M. scrofulaceum. It is preferably acquired by oral ingestion of the ubiquitous, existing in the soil pathogens. The diagnosis is usually done through biopsy. In uncomplicated cases excision is the appropriate treatment and further chemotherapy is not required. The skin disease Schwimmbadgranulom is a tedious, but self-limited superficial granulomatous ulcerating disease that is usually caused by M. marinum. An infection may result from swimming in contaminated swimming pool water or by cleaning an aquarium. Occasionally, M. ulcerans and M. kansasii are involved. The lesions, reddish, expanding and purple discoloring bumps occur on the upper extremities or knees the most. There may be a spontaneous healing, but activity against M. marinum showed minocycline or doxycycline 100 to 200 mg po 1 times a day, clarithromycin 500 mg po 2 times daily or RMP plus EMB 3-6 months. Buruli ulcer, caused by M. ulcerans occurs in rural areas of> 30 tropical and subtropical countries. He starts as a painless subcutaneous nodules, a large painless Indurationsfläche or a diffuse painless swelling of the legs, arms or face. The infection proceeds caused by an extensive destruction of skin and soft tissue; large ulcers can form in the legs or arms. The healing can result in severe contracture, scarring and deformity. PCR for diagnosis should be used. The WHO recommends 8 weeks of once-daily combination therapy with rifampicin 10 mg / kg p.o. streptomycin plus either 15 mg / kg i.m., clarithromycin 7.5 mg / kg p.o. (During pregnancy preferred), or moxifloxacin 400 mg p.o. Wound – and foreign body infections, the M. fortuitum complex caused serious infections penetrating wounds of the eyes and skin (especially feet) to tattoos as well as in patients after receiving contaminated medical devices (eg porcine heart valves, breast implants, bone wax.). The therapy usually requires an extensive debridement, and removal of foreign material. Effective drugs are Imipinem 1g iv every 6 h, levofloxacin 500 mg i.v. or p.o. 1 times a day, clarithromycin 500 mg po 2 times a day, trimethoprim / sulfamethoxazole 1 tablet po dual drug content 2 times daily, doxycycline 100-200 mg po 1 times a day, cefoxitin 2 g iv every 6-8 h and amikacin 10-15 mg / kg i.v. 1 times daily for 3-6 months. Combination therapy with at least 2 drugs, which have in vitro activity is recommended. By M. abscessus and M. chelonae infections caused are usually resistant to most antibiotics, they proved to be extremely difficult, if not curable and should be treated by an experienced specialist. Disseminated disease Atypical mycobacteria often result in patients with advanced AIDS stage created to disseminated disease and occasionally in patients with other immunkompromittierenden states, including organ transplantation and hairy cell leukemia. In AIDS patients, disseminated MAC infection develops mostly late (as opposed to a TB that occurs early) and occurs at the same time on other opportunistic infections. Disseminated MAC infection leads (similar to Whipple’s disease characteristics) to fever, anemia, thrombocytopenia, diarrhea and abdominal pain. The diagnosis can be confirmed by culture of blood or bone marrow or by biopsy (for. Example, percutaneous fine needle biopsy of the liver or lymph nodes of necrotic). The pathogens can be identified in stool samples and respiratory materials, but detection of pathogens of these materials may also be more likely to represent colonization as real diseases. Combination therapy to treat bacteremia and alleviate the symptoms, usually requires two or three drugs; Azithromycin is a 600 mg p.o. 1 times daily or clarithromycin 500 mg po 2 times a day plus EMB 15-25 mg / kg 1 times daily. Sometimes rifabutin is 300 mg 1 time a day. After successful treatment, the chronic suppression with clarithromycin or azithromycin plus EMB is. Necessary to prevent a relapse. HIV-infected patients who were not diagnosed with disseminated MAC before the presentation should receive two weeks of antimycobacterial treatment before they start antiretroviral therapy to reduce the risk for the development of immune reconstitution inflammatory syndrome (IRIS). In Germany no primary prophylaxis is recommended for HIV-infected people. In the US, HIV-infected patients obtained with a CD4 cell count <70 cells / mm prophylaxis for disseminated MAC with azithromycin 1.2 g p.o. 1 times / week or clarithromycin 500 mg po 2 times a day.

Health Life Media Team

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