1b) @ShannonTurvey will be discussing nontuberculous mycobacteria lung disease #NTM_LD, focusing on early & accurate diagnosis & essentials of therapy. Follow this 🧵for expert-led education &🆓CE/#CME, and be among the first to FOLLOW US NOW for more expert-led 🫁 med education pic.twitter.com/7DPqbcIU9K
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
3) In most regions, nontuberculous mycobacteria (#NTM) are not reportable. This makes estimating disease prevalence challenging. There are over 180 species of NTM, but most are not important causes of human disease.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
🔓https://t.co/9T4nw2ecRn
5) #NTM are rising in prevalence as a cause of human disease globally. For example, a 2020 retrospective review of US cases estimated that from 2008 to 2015 NTM-PD prevalence increased from 6.78 to 11.7 cases per 100,000 persons.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
🔓https://t.co/OlWlLaRfUl
6b) The first and most important step in diagnosis is clinical suspicion which prompts appropriate imaging and microbiologic investigation.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
8a) Microbiologic criteria for #NTM-PD include positive culture results for the same NTM species from at least two separate #sputum samples or from one #bronchoscopy specimen.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
9a) Radiographic evidence of disease most commonly is either #nodular #bronchiectatic or #fibrocavitary.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
10a) Check out this review of NTM-PD radiographic manifestations by Martinez et al in the European Journal of Respirology: 🔓https://t.co/2UbBtHPPXh
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
11) An additional case presented by Martinez et al (🔓https://t.co/2UbBtHPPXh) shows an axial cut from a CT chest of a 73♀️ with #MAC #NTM-PD. Visible are cylindrical bronchiectasis (arrows) and partial right middle lobe and lingula volume loss pic.twitter.com/l6BZMWowEv
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
12b) Typical #HRCT findings with #hot_tub_lung (🥵🛁🫁 ❓) include widespread ill-defined centrilobular micronodules and/or ground glass, and air trapping on expiration.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
🔓https://t.co/QPlJAY2OiN
14) Management of hot tub lung consists of avoidance of ongoing exposure. Systemic corticosteroids may also have a role in management. Antimycobacterial agents have no role in the management of hot tub lung.
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
16) Some #NTM species are more pathogenic than others. Some species, such as M. #gordonae, almost never cause human disease. This schematic by Van Ingen et al. illustrates that the clinical relevance of pulmonary NTM isolates varies by species:
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
🔓https://t.co/QAZhEAkNTz pic.twitter.com/ZhnXiXLr6Y
17b) This image from a 2020 paper by Musaddaq et al shows a thick-walled left upper lobe cavity, visible on plain radiograph, due to M. #kansasii:
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
🔓https://t.co/0cXMGHoBit pic.twitter.com/caBxoL8eVZ
19) Here’s a 🔑question: of the following #riskfactors, which is most significant for #NTM-PD?
— pulmmed_ce (@Pulmmed_CE) October 5, 2022
a. chronic aspiration
b. exogenous immune suppression
c. #cysticfibrosis
d. structural lung disease including #bronchiectasis
21) Welcome back! You are learning from 🫁 ID expert @ShannonTurvey about nontuberculous mycobacteria lung disease #NTM_LD, esp early & accurate diagnosis & essentials of therapy. And you are well on your way to 🆓0.75h CE/#CME on your 🆕source for pulm education on Twitter!
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
23a) Well, a number of risk factors for #NTM-PD have been identified, but it can develop in the absence of any of these risk factors:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
🫁 Increasing age
🫁 Cystic fibrosis (CF)
🫁 Alpha-1 antitrypsin deficiency
(cont)
24a) Pts with #cysticfibrosis are at significant risk of #NTM-PD, w/ prevalence estimates ~ 10-25%. (🔓https://t.co/DzGbCr3KiW).
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
25) The interplay between host, organism and environment determines propensity to develop #NTM clinical disease, as beautifully laid out in this schematic by Ratnatunga et al in Frontiers in Immunology:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
🔓https://t.co/XUnTFk3E7D pic.twitter.com/cEqnwKlV48
27) Treatment of #NTM is complex, prolonged, at times controversial, and species dependent. The decision must be individualized, and patient driven. This schematic by Cowman et al lays it out beautifully:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
🔓https://t.co/CRZFNQyfyT pic.twitter.com/tA4rOggxgQ
28b) (cont)
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
👉Monitor clinically, radiographically, and microbiologically for response (should repeat #sputum cultures monthly until conversion then every 2-3 months thereafter).
👉Monitor for toxicity
Strategies to improve medication tolerability can be very helpful:
29) While susceptibility testing should be done when treatment of #NTM-PD is being considered, results of in vitro susceptibility testing for NTM species generally do not reliably predict clinical outcomes.
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
31a) Many M. #abscessus subspecies have a functional erm(41) gene which codes for inducible macrolide resistance. Mycobacterium abscessus subspecies abscessus may have a thymine to cytosine point mutation at position 28 of the erm(41) gene . . .
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
32a) Let's talk treatment naïve MAC:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
👉#Macrolides are the cornerstones of MAC therapy but check for macrolide resistance!
👉Typical MAC tx regimen includes azithromycin/ethambutol/rifampin
👉Nodular bronchiectatic form of MAC can consider therapy three times weekly vs daily
32c) Regardless of in vitro susceptibility results, #ethambutol as part of combination tx of #MAC #NTM-PD is the most important strategy to 🛑emergence of macrolide resistance. Macrolide susceptibility is the most important determinant of likelihood of sputum clearance & cure.
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
33b) Refractory #MAC: defined as ongoing smear or culture positivity after 6 months of MAC therapy. #CONVERT study demonstrated that the addition of amikacin liposome inhalation suspension – #ALIS – to optimized background therapy durably increased culture conversion. See:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
33d) Patients with refractory #MAC NTM-PD should have their regimen intensified with inhaled amikacin (parenteral formulation or #ALIS).
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
34a) What about Macrolide-resistant MAC?
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
Challenging to treat & associated with significantly lower sputum culture conversion rates when compared to macrolide-susceptible #MAC #NTM-PD.
35) Mycobacterium #kansasii: water-borne, often clinically behaves like M tuberculosis complex & has tendency to cause fibrocavitary disease w/apical predominance. Tx typically azithromycin, rifampin or rifabutin, & ethambutol for total 12mos (not 12mos from culture conversion).
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
37) This schematic from the summary of the 2020 #CID #NTM-PD guidelines (🔓https://t.co/MGyO1shp2t) describes recommended therapy for slow-growing mycobacteria (#SGM) groups: pic.twitter.com/XvlhXxg20N
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
38b) … does not have constitutive/inducible macrolide resistance, then a macrolide should be included in the regimen. Use 3 or more drugs initially, 4 or more if organism is macrolide-resistant. Tx should be continued for at least 12 months beyond #sputum culture conversion.
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
39a) For patients with focal or #cavitary #NTM-PD, surgical #resection may be considered. Similarly, surgery may play a role for patients with more drug resistant isolates, those with failure of medical management, …
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
40) In addition to pharmacological and surgical treatments, there are several other key components of #NTM treatment: airway clearance, optimized nutrition, and psychosocial supports.
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
42a) Treatment of NTM-PD is challenging. There are several websites with patient resources and resources for healthcare providers. For example:
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
🫁 https://t.co/4eWjUTpFaj
🫁 https://t.co/niqt6LEi7S
🫁 https://t.co/A93Gm4vbhK
🫁 https://t.co/XtUyE7n4S2
(cont)
43) There is a research registry for patients living in the U.S. with NTM-PD and/or bronchiectasis:https://t.co/extHILEdZI
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
45a) And now 🥁
— pulmmed_ce (@Pulmmed_CE) October 6, 2022
🔑take-home messages:
🫁 Treatment of #NTM-PD is complex and involves multiple antibiotics for prolonged periods
🫁 Early treatment can be important
🫁 The first step is considering the diagnosis and initiating appropriate testing
(cont) pic.twitter.com/nV8IePm4LN
46) NOW go and claim your 🆓0.75h CE/#CME. Your certificate is waiting at https://t.co/ut6qzMBmvv. Thanks to @ShannonTurvey for launching @pulmmed_ce! pic.twitter.com/qTk8nO0sAt
— pulmmed_ce (@Pulmmed_CE) October 6, 2022