Mysterious Mycobacterium
Location
Moultrie, GA
Start Date
17-4-2026 12:00 PM
End Date
17-4-2026 1:00 PM
Description
Pulmonary infections caused by nontuberculous mycobacteria (NTM) often progress insidiously and may resemble malignancy or other granulomatous diseases, resulting in delayed diagnosis. The prevalence of NTM pulmonary disease in North America has increased, particularly from 2008 to 2015, with estimates ranging from 10-15 cases per 100,000 persons and with substantially higher rates among older adults and those with structural lung disease [Winthrop]. Individuals at increased risk include patients with bronchiectasis, emphysema, chronic obstructive pulmonary disease, interstitial lung disease, cystic fibrosis, and prior tuberculosis. Additional risk factors include female sex, low body mass index, immunosuppression, and gastroesophageal reflux disease [Griffith]. NTM organisms get acquired from the environment, particularly water sources and soil, but typically do not get transmitted person-to-person [Daley].
Symptoms tend to be chronic and nonspecific. Typical pulmonary symptoms include persistent cough with sputum production, hemoptysis, dyspnea, and chest discomfort while systemic symptoms include malaise, fatigue, low-grade fever, chills, sweats, and weight loss. Usual examination findings comprise subtle crackles, wheezing, and prolonged expiratory time [Marras]. On imaging, two predominant patterns exist, including nodular bronchiectatic disease, which demonstrates bronchiectasis and small nodules with centrilobular configuration, and fibrocavitary disease, which exhibits cavitary lesions with irregular opacifications, typically in the upper lobes. [Marras]. Most commonly, cavitary disease can be observed in patients with emphysematous changes and smoking history, whereas nodular bronchiectatic pattern often occurs in middle-aged or older women without significant smoking exposure [Griffith]. Hemoptysis and progressive radiographic abnormalities usually occur in cavitary forms. The indolent presentation and symptom overlap with tuberculosis, fungal infections, and lung cancer complicate early recognition.
A 48-year-old female with a history of centrilobar and paraseptal emphysema, asthma-chronic obstructive pulmonary disease overlap syndrome, spontaneous pneumothorax on the left, secondhand smoke exposure, abnormal imaging of the right lung, and gastroesophageal reflux disease presented to the Archbold Pulmonology clinic with an intermittently productive cough, chest tightness, and an enlarging cavitary lesion in the right upper lobe with surrounding consolidation despite treatment with antibiotics and steroids. Two bronchoscopies with biopsy and bronchoalveolar lavage revealed no fungal or bacterial organisms, including acid-fast bacilli, and benign bronchial epithelial cells and inflammatory cells. Extensive laboratory workup revealed negative results. Due to nondiagnostic findings, the patient got referred to thoracic surgery for further evaluation. Eventually, the patient underwent a right upper lobectomy. Surgical resection revealed granulomatous cavitary inflammation with pathology initially suggestive of histoplasmosis but cultures eventually positive for Mycobacterium abscessus.
Mycobacterium abscessus, a rapidly growing Mycobacterium, represents a particularly challenging pathogen due to intrinsic multidrug resistance and aggressive clinical behavior. For management of Mycobacterium abscessus, current guidelines recommend macrolide-based multidrug therapy tailored to susceptibility testing, often including azithromycin, plus amikacin or imipenem or cefoxitin, and plus omadacycline or tigecycline or linezolid or tedizolid or clofazimine [Griffth]. Overall, this case highlights the increasing epidemiologic burden of NTM disease and emphasizes the importance of maintaining suspicion for NTM in patients with persistent cavitary lesions, respiratory or nonspecific symptoms like cough and shortness of breath, and risk factors for structural lung disease when initial evaluations remain unrevealing.
Embargo Period
5-26-2026
Mysterious Mycobacterium
Moultrie, GA
Pulmonary infections caused by nontuberculous mycobacteria (NTM) often progress insidiously and may resemble malignancy or other granulomatous diseases, resulting in delayed diagnosis. The prevalence of NTM pulmonary disease in North America has increased, particularly from 2008 to 2015, with estimates ranging from 10-15 cases per 100,000 persons and with substantially higher rates among older adults and those with structural lung disease [Winthrop]. Individuals at increased risk include patients with bronchiectasis, emphysema, chronic obstructive pulmonary disease, interstitial lung disease, cystic fibrosis, and prior tuberculosis. Additional risk factors include female sex, low body mass index, immunosuppression, and gastroesophageal reflux disease [Griffith]. NTM organisms get acquired from the environment, particularly water sources and soil, but typically do not get transmitted person-to-person [Daley].
Symptoms tend to be chronic and nonspecific. Typical pulmonary symptoms include persistent cough with sputum production, hemoptysis, dyspnea, and chest discomfort while systemic symptoms include malaise, fatigue, low-grade fever, chills, sweats, and weight loss. Usual examination findings comprise subtle crackles, wheezing, and prolonged expiratory time [Marras]. On imaging, two predominant patterns exist, including nodular bronchiectatic disease, which demonstrates bronchiectasis and small nodules with centrilobular configuration, and fibrocavitary disease, which exhibits cavitary lesions with irregular opacifications, typically in the upper lobes. [Marras]. Most commonly, cavitary disease can be observed in patients with emphysematous changes and smoking history, whereas nodular bronchiectatic pattern often occurs in middle-aged or older women without significant smoking exposure [Griffith]. Hemoptysis and progressive radiographic abnormalities usually occur in cavitary forms. The indolent presentation and symptom overlap with tuberculosis, fungal infections, and lung cancer complicate early recognition.
A 48-year-old female with a history of centrilobar and paraseptal emphysema, asthma-chronic obstructive pulmonary disease overlap syndrome, spontaneous pneumothorax on the left, secondhand smoke exposure, abnormal imaging of the right lung, and gastroesophageal reflux disease presented to the Archbold Pulmonology clinic with an intermittently productive cough, chest tightness, and an enlarging cavitary lesion in the right upper lobe with surrounding consolidation despite treatment with antibiotics and steroids. Two bronchoscopies with biopsy and bronchoalveolar lavage revealed no fungal or bacterial organisms, including acid-fast bacilli, and benign bronchial epithelial cells and inflammatory cells. Extensive laboratory workup revealed negative results. Due to nondiagnostic findings, the patient got referred to thoracic surgery for further evaluation. Eventually, the patient underwent a right upper lobectomy. Surgical resection revealed granulomatous cavitary inflammation with pathology initially suggestive of histoplasmosis but cultures eventually positive for Mycobacterium abscessus.
Mycobacterium abscessus, a rapidly growing Mycobacterium, represents a particularly challenging pathogen due to intrinsic multidrug resistance and aggressive clinical behavior. For management of Mycobacterium abscessus, current guidelines recommend macrolide-based multidrug therapy tailored to susceptibility testing, often including azithromycin, plus amikacin or imipenem or cefoxitin, and plus omadacycline or tigecycline or linezolid or tedizolid or clofazimine [Griffth]. Overall, this case highlights the increasing epidemiologic burden of NTM disease and emphasizes the importance of maintaining suspicion for NTM in patients with persistent cavitary lesions, respiratory or nonspecific symptoms like cough and shortness of breath, and risk factors for structural lung disease when initial evaluations remain unrevealing.