Prevalencia de la resistencia a macrólidos y aminoglucósidos en los complejos Mycobacterium avium y M. abscessus y en Mycobacterium chelonae identificados en el Laboratorio Nacional de Referencia de Colombia entre el 2018 y el 2022 / Prevalence of resistance to macrolides and aminoglycosides in Mycobacterium avium, M. abscessus, and M. chelonae identified in the Laboratorio Nacional de Referencia of Colombia from 2018 to 2022

Resumen Introducción. Mycobacterium chelonae y los complejos Mycobacterium avium y M. abscessus, son agentes patógenos emergentes causantes de micobacteriosis. El tratamiento de esta infección depende de la especie y la subespecie identificadas. Los fármacos de elección son los macrólidos y aminoglucósidos, contra los cuales se ha reportado resistencia; por esta razón, el determinar el perfil de sensibilidad le permite al médico tratante comprender mejor el pronóstico y la evolución de estas infecciones. Objetivo. Describir los perfiles de sensibilidad ante macrólidos y aminoglucósidos, de los cultivos identificados como complejo Mycobacterium avium, complejo M. abscessus o especie M. chelonae, en el Laboratorio Nacional de Referencia de Micobacterias durante los años 2018 a 2022. Materiales y métodos. Se llevó a cabo un estudio descriptivo del perfil de sensibilidad a macrólidos y aminoglucósidos, de los cultivos identificados como complejo M. avium, complejo M. abscessus o M. chelonae, mediante la metodología GenoType® NTM-DR. Resultados. Los cultivos del complejo M. avium fueron 159 (47,3 %), de los cuales, 154 (96,9 %) fueron sensibles y 5 (3,1 %) resistentes a los macrólidos; todos fueron sensibles a los aminoglucósidos. Del complejo M. abscessus se estudiaron 125 (37,2 %) cultivos, 68 (54,4 %) resultaron sensibles y 57 (45,6 %) resistentes a los macrólidos; solo un cultivo (0,8 %) fue resistente a los aminoglucósidos. De M. chelonae se analizaron 52 cultivos (15,5 %), todos sensibles a los macrólidos y aminoglucósidos. Conclusiones. En las tres especies de micobacterias estudiadas, la resistencia contra la amikacina fue la menos frecuente. La identificación de las subespecies y los perfiles de sensibilidad permiten instaurar esquemas de tratamiento adecuados, especialmente en las micobacteriosis causadas por M. abscessus.

Abstract Introduction. The Mycobacterium chelonae species and the M. avium and M. abscessus complexes are emerging pathogens that cause mycobacteriosis. Treatment depends on the species and subspecies identified. The drugs of choice are macrolides and aminoglycosides. However, due to the resistance identified to these drugs, determining the microbe's sensitivity profile will allow clinicians to improve the understanding of the prognosis and evolution of these pathologies. Objective. To describe the macrolide and aminoglycoside susceptibility profile of cultures identified by Colombia's Laboratorio Nacional de Referencia de Mycobacteria from 2018 to 2022, as Mycobacterium avium complex, M. abscessus complex, and M. chelonae Materials and methods. This descriptive study exposes the susceptibility profile to macrolides and aminoglycosides of cultures identified as M. avium complex, M. abscessus complex, and M. chelonae using the GenoType® NTM-DR method. Results. We identified 159 (47.3 %) cultures as M. avium complex, of which 154 (96.9 %) were sensitive to macrolides, and 5 (3.1 %) were resistant; all were sensitive to aminoglycosides. From the 125 (37.2 %) cultures identified as M. abscessus complex, 68 (54.4 %) were sensitive to macrolides, 57 (45.6 %) were resistant to aminoglycosides, and just one (0.8 %) showed resistance to aminoglycosides. The 52 cultures (15.5 %) identified as M. chelonae were sensitive to macrolides and aminoglycosides. Conclusions. The three studied species of mycobacteria have the least resistance to Amikacin. Subspecies identification and their susceptibility profiles allow the establishment of appropriate treatment schemes, especially against M. abscessus.

Enfermedad pulmonar por Mycobacterium intracellulare, un reto diagnóstico. Reporte de caso / Lung disease due to Mycobacterium intracellulare. A diagnostic challenge, Case report

La incidencia de infección por micobacterias no tuberculosas (MNT) y el número de casos han ido en aumento, especialmente en mujeres y personas mayores, teniendo en los Estados Unidos entre el 2008 y 2015 una incidencia de 4.16 a 6.69 por 100000 entre las mujeres y de 12.70 a 18.37 por 100000, entre los mayores de 65 años. "Los pacientes con compromiso estructural del parénquima pulmonar, antecedente de inmunosupresión o inmunodeficiencia tienen mayor riesgo de desarrollar infección por MNT". Sin embargo, se han presentado informes de pacientes inmunocompetentes en asociación con opacidades nodulares y bronquiectasias. Se trata de una mujer de 79 años con antecedente de tuberculosis pulmonar documentada en dos oportunidades: último proceso infeccioso en el año 2021. Recibió manejo por seis meses de esquema vigente con tetraconjugado. Actualmente acude a consulta con cuadro clínico de más de seis meses de evolución dados por pérdida de peso de más del 10 % en un año, disnea a moderados esfuerzos y tos con expectoración purulenta. Al examen físico se encontró índice de masa corporal (IMC) bajo, tórax hipoexpansible con estertores tipo crépitos en ambos hemitórax. En la tomografía de tórax se evidenciaron bronquiectasias generalizadas, algunas áreas de árbol en gemación y lesiones cavitadas. Se consideró la realización de fibrobroncoscopia con lavado broncoalveolar documentándose baciloscopias negativas, con cultivo positivo para micobacteria no tuberculosa. Se solicitó tipificación de micobacterias con coloración de Kinyoun, y pruebas bioquímicas a partir de cepas de cultivo del lavado broncoalveolar, con reporte positivo para Mycobacterium intracellulare. Se inició por lo tanto manejo con azitromicina 500 mg, rifampicina 600 mg y etambutol 975 mg diarios. Los profesionales sanitarios deben ser conscientes de la posible infección por MNT sobre todo existiendo afectación estructural pulmonar previa, basando el tratamiento en la sospecha clínica y/o las circunstancias epidemiológicas.

The incidence of non-tuberculous mycobacterial (NTM) infection and the number of cases have been increasing, especially in women and the elderly, having EE. Between 2008 and 2015 an incidence of 4.16 to 6.69 per 100,000 among women and from 12.70 to 18.37 per 100,000 among those over 65. "Patients with structural involvement of the pulmonary parenchyma, history of immunosuppression or immunodeficiency have a higher risk of developing NTM infection". However, immunocompetent patients have been reported in association with nodular opacities and bronchiectasis. This is a 79-year-old woman with a history of pulmonary tuberculosis documented on 2 occasions: the last infectious process in 2021. It received management for 6 months of the current tetraconjugate schema. He is currently in consultation with a clinical picture of more than 6 months of evolution given by weight loss of more than 10% in a year, dyspnea to moderate efforts and cough with purulent expectoration. Physical examination revealed low body mass index (BMI) and, a hypoexpandable thorax with a crescent-like sternum in both hemithorax. Chest tomography revealed widespread bronchiectasis, some groaning tree areas and cavitated lesions. Bronchoscopy fibro bronchoscopy with bronchoalveolar lavage has been reported negative bacilloscopies, positive culture for non-tuberculosis mycobacteria. Mycobacteria typing, Kinyoun coloration, and biochemical tests were requested from bronchoalveolar lavage culture strains with positive reports for Mycobacterium intracellulare. Management was therefore initiated with azithromycin 500 mg, rifampin 600 mg and ethambutol 975mg daily. Healthcare professionals should be aware of possible NTM infection especially existing prior lung structural involvement based on clinical suspicion and/or epidemiological circumstances.

Lung infection with nontuberculous mycobacteria.

OBJECTIVE: To describe the epidemiology and CT findings for nontuberculous mycobacterial lung infections and outcomes depending on the treatment. MATERIAL AND METHODS: We retrospectively studied 131 consecutive patients with positive cultures for nontuberculous mycobacteria between 2005 and 2016. We selected those who met the criteria for nontuberculous mycobacterial lung infection. We analysed the epidemiologic data; clinical, microbiological, and radiological findings; treatment; and outcome according to treatment. RESULTS: We included 34 patients (mean age, 55 y; 67.6% men); 50% were immunodepressed (58.8% of these were HIV+), 20.6% had COPD, 5.9% had known tumors, 5.9% had cystic fibrosis, and 29.4% had no comorbidities. We found that 20.6% had a history of tuberculosis and 20.6% were also infected with other microorganisms. Mycobacterium avium complex was the most frequently isolated germ (52.9%); 7 (20.6%) were also infected with other organisms. The most common CT findings were nodules (64.7%), tree-in-bud pattern (61.8%), centrilobular nodules (44.1 %), consolidations (41.2%), bronchiectasis (35.3%), and cavities (32.4%). We compared findings between men and women and between immunodepressed and immunocompetent patients. Treatment was antituberculosis drugs in 67.6% of patients (72% of whom showed improvement) and conventional antibiotics in 20.6% (all of whom showed radiologic improvement). CONCLUSION: The diagnosis of nontuberculous mycobacterial lung infections is complex. The clinical and radiologic findings are nonspecific and a significant percentage of pateints can have other, concomitant infections.

Identificación de Mycobacteria no pigmenteda de crecimiento rápido por el Método Molecular de Micobacterium de Genotipo CM / Identification of Fast-Growing Non-Pigmented Mycobacteria by the Genotype® Mycobacterium CM Molecular Method

Introducción: la micobacteria no terberculosa (NTM) forma un grupo heterogéneo de microorganismos que pueden causar infección en humanos. Las micobacterias no pigmentadas de rápido crecimiento (MNPCR) son de interés clínico debido al creciente número de pacientes infectados por ellos y a la dificultad del tratamiento. Dentro de este grupo, Mycobacterium fortuitum, Mycobacterium abscessus y Mycobacterium chelonae son reconocidos como patógenos potenciales; estas especies se han aislado de infecciones pulmonares y extrapulmonares. Objetivo: el objetivo de este trabajo es encontrar la frecuencia de aislamiento de especies micobacterianas de rápido crecimiento, específicamente el complejo Mycobacterium fortuitum, de muestras clínicas utilizando la técnica molecular de diagnóstico GenoType Mycobacterium CM. Material y Método: se analizaron 249 aislados de micobacterias no tuberculosas obtenidas de muestras pulmonares y extrapulmonares de pacientes sintomáticos en el período enero 2018-diciembre de 2022. La técnica molecular GenoType Mycobacterium CM se utilizó para identificar la especie. Resultados: Se obtuvieron 77 (3,9%) aislados de especies no pigmentadas de rápido crecimiento, estas se identificaron en orden decreciente: Mycobacterium fortuitum 65 (84,41%), Mycobacterium abcessus 9 (11,68%) y Mycobacterium chelonae 3 (4%). Conclusiones: los resultados reafirman que el complejo Mycobacterium fortuitum es responsable de la mayoría de las infecciones causadas por la micobacteria en rápido crecimiento en humanos. La técnica diagnóstica GenoType Mycobacterium CM es una herramienta útil para la rápida identificación de micobacterias; proporciona resultados precisos en menos tiempo, acortando significativamente el tiempo diagnóstico, permite la aplicación temprana de tratamiento específico, evitando así la propagación de la infección.

Introduction: non-tuberculous mycobacteria (NTM) form a heterogeneous group of mi-croorganisms that can cause infection in humans. Fast-growing non-pigmented my-cobacteria (MNPCR) are of clinical interest due to the increasing number of patients infected by them and the difficulty of treatment. Within this group, Mycobacterium fortuitum, Mycobacterium abscessus and Mycobacterium chelonae are recognized as potential pathogens; these species have been isolated from both pulmonary and ex-trapulmonary infections. Objective: the objective of this work is to find the frequency of isolation of fast-growing non-pigmented mycobacterial species, specifically the Myco-bacterium fortuitum complex, from clinical samples using the GenoType® Mycobacteri-um CM diagnostic molecular technique. Material and Method: 249 isolates of non-tu-berculous mycobacteria obtained from pulmonary and extrapulmonary samples from symptomatic patients in the period January 2018-December 2022 were analyzed. The G e n oTy p e® Mycobacterium CM molecular technique was used to identify the species. Results: 77 (30.9%) isolates of fast-growing non-pigmented species were obtained, these were identified in decreasing order: Mycobacterium fortuitum 65 (84.41%), Myco-bacterium abcessus 9 (11.68%) and Mycobacterium chelonae 3 (4%). Conclusions: the results reaffirm that the Mycobacterium fortuitum complex is responsible for most in-fections caused by fast-growing mycobacteria in humans. The GenoType® Mycobacte-riumCM diagnostic technique is a useful tool for the rapid identification of mycobacte-ria; it provides accurate results in less time, significantly shortening the diagnostic time, it allows the early application of specific treatment, thus avoiding the spread of infec-tion.

Eventos de precipitación extrema aumentan la circulación de patógenos infecciosos: detección de rotavirus, norovirus, astrovirus, adenovirus entérico y micobacterias no tuberculosas en agua de las inundaciones en Asunción, Paraguay, año 2014

Las precipitaciones extremas representan uno de los eventos naturales climáticos más importantes y pueden originar inundaciones devastadoras. De junio a agosto del 2014 se registró una de las más graves inundaciones en la historia de la ciudad de Asunción. Ocasionó un incremento considerable del nivel del río Paraguay y el desplazamiento de 300.000 personas a campamentos provisionales. Debido a que el contacto directo con el agua de inundación, el consumo de agua contaminada y la congregación de los afectados en refugios provisorios son factores de riesgo para enfermedades infecciosas, el objetivo de este estudio fue la implementación de una metodología estandarizada para la concentración y detección de virus entéricos y micobacterias no tuberculosas, por PCR en tiempo real y PCR-asociada al análisis de restricción enzimática (PRA), en muestras de agua de inundaciones y el reporte de los patógenos detectados en las zonas afectadas de Asunción y en la Bahía del Río Paraguay. La metodología propuesta demostró poseer buena sensibilidad y se registró la presencia de rotavirus, norovirus (genogrupos I y II), astrovirus, adenovirus entéricos y micobacterias no tuberculosas en 50% (N=4/8) de las muestras de los barrios Sajonia, San Jerónimo y Ricardo Brugada, Chacarita. Además, reportamos datos secundarios de casos de enfermedades infecciosas, registrados en los servicios de salud de los barrios afectados durante el periodo de inundación.

Extreme rainfall represents one of the most important natural climatic events and can cause devastating floods. From June to August 2014, one of the most serious floods in the history of the city of Asunción was recorded. It caused a considerable increase in the level of the Paraguay River and the displacement of 300,000 people to temporary camps. Since direct contact with flood water, consumption of contaminated water and the congregation of those affected in temporary shelters are risk factors for infectious diseases, the objective of this study was the implementation of a standardized methodology for the concentration and detection of enteric viruses and non-tuberculous mycobacteria, by real-time PCR and PCR-associated enzyme restriction analysis (PRA), in samples of flood water and the report of the pathogens detected in the affected areas of Asunción and in the Bay of the Paraguay River. The proposed methodology proved to have good sensitivity and the presence of rotavirus, norovirus (genogroups I and II), astrovirus, enteric adenovirus and non-tuberculous mycobacteria was recorded in 50% (N=4/8) of the samples from the Sajonia, San Jeronimo and Ricardo Brugada, Chacarita neighborhoods. In addition, we report secondary data on cases of infectious diseases, registered in the health services of the affected neighborhoods during the flood period.

A rapid proteomic system (MALDI-TOF) for nontuberculous-mycobacteria identification.

Proteomic techniques relaying upon mass spectrometry (MALDI_TOF) applied to nontuberculous mycobacteria (NTM) identification, constitute a difficult goal. Cell wall structure features complicates the protein extraction procedure. A total of 106 isolates belonging to a variety of MNTs species isolated from clinical samples taken at the Complejo Asistencial Universitario de León for a two years period (2019-20) were identified following a simplified method (MALDI-TOF Biotyper Bruker®) developped in our laboratory. The resultant identification was compared to a parallel one ruled on the Centro de Referencia de Majadahonda. A total of 22different MNTs species were tested, obtaining an agreement of 92,45%. Only 8 minor discrepancies between species belonging to same taxonomic group of MNTs were detected. The score obtained in the 67.92% of the cases was higher than 1.8. A time-saving of 24min compared to the manufacturer's proceeding was achieved.

Queratitis por Mycobaterium abscessus: comunicación del primer caso en Paraguay / Keratitis due to Mycobaterium abscessus: first case report in Paraguay

Resumen Se presenta un caso clínico de queratitis por Mycobacterium abscessus en una mujer de 76 años, residente en la ciudad de Asunción, sin traumatismo ni cirugía ocular previa y con antecedente de una queratouveitis herpética. Por tratarse de una queratitis causada por un agente etiológico poco frecuente y por la importancia de un diagnóstico correcto y oportuno para la instauración del tratamiento adecuado, se comunica el primer caso de queratitis por micobacterias en Paraguay.

Abstract We present a clinical case of keratitis caused by M. abscessus in a 76-year-old female patient, resident in the city of Asunción, without trauma or previous ocular surgery and with a history of herpetic keratouveitis. Because it is a keratitis caused by a rare etiological agent and because of the importance of a correct and timely diagnosis for the establishment of appropriate treatment, the present case is reported, the first of Mycobacteria keratitis in Paraguay.

A rapid proteomic system (MALDI-TOF) for nontuberculous-mycobacteria identification. / Identificación rápida de micobacterias no tuberculosas mediante técnicas proteómicas (MALDI-TOF).

Proteomic techniques relaying upon mass spectrometry (MALDI_TOF) applied to nontuberculous mycobacteria (NTM) identification, constitute a difficult goal. Cell wall structure features complicates the protein extraction procedure. A total of 106 isolates belonging to a variety of MNTs species isolated from clinical samples taken at the Complejo Asistencial Universitario de León for a two years period (2019-20) were identified following a simplified method (MALDI-TOF Biotyper Bruker®) developped in our laboratory. The resultant identification was compared to a parallel one ruled on the Centro de Referencia de Majadahonda. A total of 22 different MNTs species were tested, obtaining an agreement of 91,5%. Only 9 minor discrepancies between species belonging to the same taxonomic group of MNTs were detected. The score obtained in the 67.92% of the cases was higher than 1.8. A time-saving of 24 minutes compared to the manufacturer's proceeding was achieved.

Role of Soluble T-Cell Immunoglobulin Mucin Domain-3 in Differentiating Nontuberculous Mycobacterial Lung Disease from Pulmonary Colonization.

BACKGROUND: Differentiating between nontuberculous mycobacterial lung disease (NTM-LD) and pulmonary NTM colonization (NTM-Col) is difficult. Compared with healthy controls, patients with NTM-LD generally present immune tolerance along with increased expressions of T-cell immunoglobulin mucin domain-3 (TIM-3) and programmed cell death-1 (PD-1) on T lymphocytes. However, the role of soluble TIM-3 (sTIM-3) and soluble PD-1 (sPD-1) in differentiating NTM-LD from NTM colonization (NTM-Col) remains unclear. METHODS: Patients with NTM-positive respiratory samples and controls were enrolled from 2016 to 2019. Patients were classified into NTM-Col and NTM-LD groups. Levels of sTIM-3, sPD-1, soluble PD-ligand-1 (sPD-L1), and TIM-3 expression were measured. Factors associated with NTM-LD were analyzed by logistical regression. RESULTS: TIM-3 expression on CD4+ and CD8+ T lymphocytes were highest in NTM-LD group, followed by NTM-Col, and control (P=.017 and P=.011 for trend). sTIM-3 elevated in the NTM-Col group compared with the NTM-LD and control groups (856.3±518.7 vs. 595.3±352.6pg/mL, P=.009; vs. 437.0±267.4pg/mL, P<.001). Levels of sPD-1 and sPD-L1 were similar among groups. Among the 79 NTM-positive patients, sTIM-3 was associated with NTM-LD (100-pg/mL increase, adjusted odds ratio (aOR) 0.658 [95% CI, 0.502-0.864], P=.003). Patients with ≥2 risk factors (sTIM-3≤530pg/mL, BMI≤22.5, and radiographic score ≥5) were 13 times more likely to exhibit NTM-LD than those without (aOR 13.234 [2.983-58.709], P=.001). CONCLUSIONS: sTIM-3 was an independent factor for differentiating NTM-LD from NTM-Col, suggesting the immunologic role of sTIM-3 in NTM-LD pathogenesis. By assessing sTIM-3 levels and other risk factors, physicians may be able to identify NTM-LD cases in a simplified manner.

Comportamiento clínico de la infección y enfermedad causada por micobacterias no tuberculosas en Latinoamérica: Revisión de alcance / Clinical behavior of infection and disease caused by non-tuberculous mycobacteria in Latin America: scoping review

Cada vez son más frecuentes los reportes de aislamientos y enfermedades producidas por micobacterias no tuberculosas (MNT). Esta revisión de alcance describe el comportamiento epidemiológico y clínico de la infección y enfermedad por MNT en Latinoamérica. Se realizó la búsqueda en las bases de datos MEDLINE vía OVID, Embase y LILACS. Después de la depuración, se incluyeron 44 artículos que representaron una población global de 2826 sujetos, a quienes se les diagnosticó infección y enfermedad por MNT; la mayoría de las investigaciones incluyeron sujetos de Brasil y Colombia (75%); los estudios transversales fueron los más frecuentes (36,6%), el sexo masculino fue el más afectado (61,3%), mientras que la mediana de edad fue 40,1 años. En 37 artículos se reportó enfermedad por MNT, siendo la localización extrapulmonar (54%) la más frecuente; las principales comorbilidades fueron las enfermedades pulmonares, VIH/sida, fibrosis quística, diabetes y desnutrición, reportadas en 13 estudios; en 15 artículos se reportó tuberculosis previa al evento por MNT. En 12 artículos se evidenciaron procedimientos estéticos; en tres, procedimientos clínicos previos. Se reportó variedad de especies de MNT, siendo Mycobacterium avium (52%), M. abscessus (34%), M. chelonae (18%), M. fortuitum (16%) y M. kansasii (9,1%) las más frecuentes. El método más usado para diagnosticar e identificar la enfermedad por MNT fue el cultivo, recientemente se agregaron también las pruebas moleculares. La literatura científica latinoamericana sobre la infección/enfermedad por MNT es escasa. Es apremiante conducir estudios de frecuencia e impacto clínico y fortalecer la capacidad diagnóstica y las redes de organizaciones existentes enfocadas al estudio de micobacterias para conocer la verdadera morbimortalidad asociada a las MNT en Latinoamérica.

Reports of infection and/or disease caused by non-tuberculous mycobacteria (NTM) are becoming increasingly frequent. This scope review describes the epidemiological and clinical trend of infection/disease caused by NTM in Latin America. OVID MEDLINE, Embase and LILACS databases were explored for relevant articles. After filtering, we included 44 articles, representing an overall population of 2,826 subjects diagnosed with NTM infection and disease; the majority of the publications included subjects from Brazil and Colombia (75%), cross-sectional studies were the most common (36.6%), most subjects were male (61.3%) and the median age of subjects was 40.1 years. Disease by NTM was reported in 37 publications, extrapulmonary presentation was the most frequent (54%), main comorbidities were other pulmonary diseases, HIV, cystic fibrosis, diabetes and malnutrition, as reported in 13 studies; tuberculosis diagnosis previous to NTM disease was reported in 15 articles. Aesthetic procedures were reported in 12 articles while clinical procedures were reported in 3 articles. Several NTM species were reported, being Mycobacterium avium (52%), M. abscessus (34%), M. chelonae (18%), M. fortuitum (16%) and M. kansasii (9.1%) the most frequent. Culture and molecular testing were the main methods for diagnosis and identification. Scientific literature on NTM from Latin American countries is scarce. There is an urgent need to conduct studies on the frequency and clinical impact of NTM infections, in order to accurately identify the current morbidity and mortality associated with NTM in Latin American. It is also important to strengthen the local diagnostic capacity and the existing networks focused on studying NTM.

Coinfección por Mycobacterium abscessus y Mycobacterium tuberculosis en un paciente con síndrome de Cushing exógeno y otras comorbilidades / Mycobacterium abscessus and Mycobacterium tuberculosis coinfection in a patient with exogenous Cushing syndrome and other comorbilities

RESUMEN Mycobacterium abscessus es una micobacteria no tuberculosa de crecimiento rápido, que produce infección pulmonar, cutánea, diseminada y otras, sobre todo en pacientes con comorbilidades. El diagnóstico se basa en la identificación de la micobacteria por medios de cultivo o por pruebas moleculares. El tratamiento con macrólidos y amikacina continúa siendo el ideal, aunque depende de la localización y de la gravedad de la infección, sin embargo, se han identificado genes de resistencia en algunas subespecies que limitan la eficacia antibiótica. Presentamos el caso de un paciente con coinfección cutánea por Mycobacterium abscessus y Mycobacterium tuberculosis, quien presenta un síndrome de Cushing exógeno, factor predisponente para estas infecciones. Además, se identificaron hidatidosis y aspergilosis pulmonares. El tratamiento antituberculoso del paciente se ajustó para manejar ambas micobacterias, y su evolución fue favorable.

ABSTRACT Mycobacterium abscessus is a fast-growing non-tuberculous mycobacterium that causes lung, skin, disseminated and other infections, mainly in patients with comorbidities. The diagnosis is based on the identification of the mycobacterium by culture media or molecular tests. Treatment with macrolides and amikacin remains the optimal choice, although it depends on the location and severity of the infection; however, resistance genes have been identified in some subspecies that limit antibiotic efficacy. We present the case of a patient with cutaneous coinfection by Mycobacterium abscessus and Mycobacterium tuberculosis, who presented exogenous Cushing syndrome, a predisposing factor for these infections. In addition, hydatidosis and pulmonary aspergillosis were identified. The patient's anti-tuberculosis treatment was adjusted to manage both mycobacteria, resulting in a favorable evolution.

Piauí Central Laboratory of Public Health: frequency of mycobacterial species and epidemiological aspects, 2014-2015 / Laboratorio Central de Salud Pública de Piauí: frecuencia de especies micobacterianas y aspectos epidemiológicos, 2014-2015 / Laboratório Central de Saúde Pública do Piauí: frequência de espécies de micobactérias e aspectos epidemiológicos, 2014-2015

Background and Objectives: Knowledge about species diversity of non-tuberculous mycobacteria (NTM) and the frequency of tuberculosis (TB) is an important issue in rural-urban regions such as Piauí (northeast of Brazil), of low incidence rate of TB , can help to improve diagnosis and prevention strategies. The aim of this study is to examine some epidemiological aspects and the frequency of Mycobacterium tuberculosis (Mtb) and NTM isolated at the central public health reference laboratory, Dr. Costa Alvarenga, Piauí (LACEN-PI). Methods: Data records of all mycobacterosis and tuberculosis cases from January 2014 to March 2015 were analyzed. Results : Of the 20% (142/706) positive growths, 70% (99) were Mtb and 10% NTM. The remainde was of inadequate clinical samples, not allowing the identification of even the suspected NTM. The most frequent clinical form was pulmonary with TB patients younger than those infected with NTM (p = 0.001), the majority living in Teresina (52%). NTMs identified were M. abscessus (36%), M. avium, M. intracellulare, Mycobacterium sp. (14% each) and M. asiaticum, M. szulgai, M. kansasii 7% (each). Mtb drug resistance (7.8%) and TB co-infection with the human immunodeficiency virus (HIV-TB) found to be high (49%, 19/39). Conclusion: The frequencies of Mtb infection, drug resistance and HIV-TB co-infection are still underestimated and failures in the identification of NTM may decrease the actual frequency of these infections. Therefore, there is a need for improvements in TB control and in the diagnosis of NTMs in Piauí.(AU)

Justificativa e Objetivos: O conhecimento da diversidade de espécies de micobactérias não tuberculosas (MNT ) e a frequência da tuberculose (TB) é uma questão importante em regiões rurais-urbanas como o Piauí (nordeste do Brasil), com baixa incidência de TB, pode ajudar a melhorar o diagnóstico e estratégias de prevenção. O objetivo deste estudo é examinar alguns aspectos epidemiológicos e a frequência de Mycobacterium tuberculosis (Mtb) e MNT isolados, no Laboratório Central de Referência em Saúde Pública, Dr. Costa Alvarenga, Piauí (LACEN-PI). Métodos: Dados de todo s os casos de micobacterioses e tuberculose de janeiro de 2014 a março de 2015 foram analisados. Resultados: Dos 20% (142/706), de amostras com crescimento positivo 70% (99) foram Mtb e 10% MNT . O restante era de amostras clínicas inadequadas, não permitindo a identificação inclusive de MNT suspeitos. A forma clínica mais frequente foi pulmonar com pacientes TB mais jovens do que os infectados com MNT (p = 0,001), a maioria morando em Teresina (52%). As MNT s identificadas foram M. abscessus (36%), M. avium , M. intracellulare , M. sp. (14%, cada) e M. asiaticum, M. szulgai , M. kansasii 7% (cada). A droga resistência de Mtb (7,8%) e a co-infecção TB e vírus da imunodeficiência humana (HIV-TB) mostraram-se altas (49%, 19/39).Conclusão: As frequências de infecção por Mtb, de resistência a medicamentos e co-infecção HIV-TB ainda são subestimadas e as falhas na identificação de MNT podem diminuir a real frequência destas infecções . Portanto, há necessidade de melhorias no controle da TB e no diagnóstico de MNT s no Piauí.(AU)

Justificacion y objetivos: Conocer la diversidad de especies de micobacterias no tuberculosas (MNT) y la frecuencia de tuberculosis (TB) es tema importante en regiones rurales-urbanas como Piauí (noreste de Brasil) con baja tasa de incidencia de TB, y puede ayudar a mejorar el diagnóstico y las estrategias de prevenció. El objetivo de este estudio es examinar algunos aspectos epidemiológicos y la frecuencia de Mycobacterium tuberculosis (Mtb) y MNT aislado, en el laboratorio central de referencia de salud pública, Dr. Costa Alvarenga, Piauí (LACEN-PI). Métodos: Se analizaron los datos de todos los casos de micobacteriosis de enero de 2014 a marzo de 2015. Resultados: Del 20% (142/706), de las muestras con crecimiento positivo el 70% (99) fueron Mtb y el 10% MNT. El resto fue de muestras clínicas inadecuadas, no permitiendo la identificación de MNT incluso sospechosas. La forma clínica más frecuente fue la pulmonar y los pacientes con TB eran más jóvenes que los infectados con MNT (p = 0.001), la mayoría viviendo en Teresina (52%).Los MNT identificados fueron M.abscessus (36%), M.avium, M.intracellulare, Mycobacterium sp. (14% cada) y M.asiaticum, M.szulgai, M.kansasii 7% (cada ). La resistencia a los medicamentos de Mtb (7,8%) y la coinfección de TB y el virus de la inmunodeficiencia humana (VIH-TB) fueron altas (49%, 19/39 )Conclusión: Las frecuencias aún subestimadas de resistencia a los medicamentos, coinfección por VIH-TB y fallas de identificaciónidentificación de MNT pueden disminuir la frecuencia real de estas infecciones. Consecuentemente, es necesario mejorar el control y diagnóstico de TB y MNT en Piauí.(AU)

Enfermedad pulmonar por Mycobacterium intracellulare en una paciente inmunocompetente: reporte de un caso en el Perú / Pulmonary disease by mycobacterium intracellulare in an immunocompetent patient: Report of a case in Peru

RESUMEN Presentamos una paciente inmunocompetente cuya enfermedad comenzó a los 49 años con tos, seguida de esputo purulento y hemoptoico, por lo que se diagnosticó bronquiectasias. Tres años después, luego de hemoptisis, le practicaron segmentectomía medial del lóbulo medio y quedó asintomática por meses. Al encontrarse tuberculosis en el informe de patología fue tratada con 4HREZ2R2H2. Cinco años después su BK fue 2+ recibiendo un nuevo esquema de 4HREZ2R2H2, con lo que no logro negativizar declarándose el fracaso al tratamiento. Al hallar en la genotipificación de su cultivo Mycobacterium intracellulare, la paciente recibió azitromicina, moxifloxacina y etambutol, hubo mejoría, pero abandonó el tratamiento a los ocho meses; lo reinició 18 meses después, junto con tratamiento para la depresión y el reflujo gastroesofágico. Al mes la paciente estuvo asintomática, pero hizo reacción dérmica a la moxifloxacina y se la reemplazó por amikacina. Salió de alta y al año estuvo curada, a los 64 años de edad.

ABSTRACT We present the case of an immunocompetent patient whose illness began at age 49 with a cough, followed by purulent and hemoptoic sputum; bronchiectasis was diagnosed. Three years later, after hemoptysis, she underwent medial segmentectomy of the middle lobe and was asymptomatic for months. When tuberculosis was found in the pathology report, she was treated with 4HREZ2R2H2. Five years later her BK was 2+, thus receiving a new scheme of 4HREZ2R2H2, which did not succeed in obtaining negative results and the treatment was declared as a failure. After genotyping her Mycobacterium intracellulare culture, the patient received azithromycin, moxifloxacin and ethambutol. There was improvement, but she abandoned the treatment at 8 months; she restarted it 18 months later, along with treatment for depression and gastroesophageal reflux. After one month the patient was asymptomatic, but she had a dermal reaction to moxifloxacin which was replaced with amikacin. One year later, she was cured and discharged, at the age of 64.

Diversidad de especies de micobacterias no tuberculosas aisladas en ambientes acuáticos de la ciudad de General Pico, La Pampa, Argentina / Species diversity of non-tuberculous mycobacteria isolated from aquatic environments of General Pico city, Province of La Pampa (Argentina)

Las micobacterias no tuberculosas (MNT) no solo se estudian por su importancia como patógenos oportunistas, sino también por sus aplicaciones en biotecnología y biorremediación. Nuestro objetivo fue determinar la presencia de micobacterias en los distintos hábitats acuáticos de la ciudad de General Pico (provincia de La Pampa), así como su diversidad. Los porcentajes de muestras positivas a micobacterias fueron los siguientes: 37,5% en el sistema de distribución de agua de red, 32,6% en el acuífero que abastece dicho sistema, 36,8% en el agua proveniente de las precipitaciones, 53,1% en los humedales del área de influencia, 80% en los natatorios cubiertos y 33,3% en las fuentes decorativas ubicadas en plazas públicas. De los 90 aislamientos de MNT obtenidos el 8,9% no logró ser identificado a nivel de especie con los métodos utilizados, que incluyeron pruebas fenotípicas y métodos moleculares. Las especies más frecuentemente aisladas fueron Mycobacterium fortuitum y Mycobacterium gordonae. Algunas especies identificadas han sido reportadas en casos de micobacteriosis en nuestro país, entre ellas M. fortuitum, M. gordonae, M. intracellulare, M. vaccae, M. lentiflavum y M. nonchromogenicum. No se aislaron MNT en muestras de agua de red con concentraciones de cloro activo residual mayores de 0,8mg/l, mientras que en los natatorios la presencia de hasta 1,5mg/l de cloro activo residual no fue una limitante para la proliferación de estos microorganismos. Se puede considerar que la incidencia de micobacterias en los ambientes acuáticos de General Pico es cercana al 35%, y que la presencia de estos microorganismos y su diversidad se ve afectada por el contacto con el hombre y sus actividades, como así también por la existencia de vida animal.

Non-tuberculous mycobacteria (NTM) are studied not only for their importance as emerging opportunistic pathogens but also for their applications in biotechnology and bioremediation. Our aim was to determine the occurrence and diversity of mycobacteria in different aquatic habitats of General Pico city, Province of La Pampa. The percentage of samples with positive cultures for mycobacteria were the following: 37.5% recovered from the water supply distribution system; 32.6% from the aquifer that supplies water to the distribution system; 36.8% from rain water; 53.1% from the two wetlands in the area of influence; 80% from indoor swimming pools; and 33.3% from water fountains in downtown public squares. Of the 90 NTM isolates, 8.9% could not be identified at the species level with any of the used methods, phenotypic tests and molecular methods. Mycobacterium fortuitum and Mycobacterium gordonae were the most frequently isolated species. Some of the identified species such as, M. fortuitum, M. gordonae, M. intracellulare, M. vaccae, M. lentiflavum and M. nonchromogenicum, have been reported in cases of mycobacteriosis in Argentina. Mycobacteria with values higher than 0.8mg/ml of residual active chlorine were not recovered from the drinking water supply network, whereas in the swimming pools the presence of up to 1.5 mg/l was not a constraint. Based on our results, the presence of mycobacteria in aquatic environments is close to 35% and their occurrence and diversity is affected both by contact with man and his activities as well as by the existence of animal life.

Comparative evaluation of the identification of rapidly growing non-tuberculous mycobacteria by mass spectrometry (MALDI-TOF MS), GenoType Mycobacterium CM/AS assay and partial sequencing of the rpoß gene with phylogenetic analysis as a reference method.

INTRODUCTION: The American Thoracic Society and the Infectious Diseases Society of America recommend that clinically significant non-tuberculous mycobacteria (NTM) should be identified to the species level in order to determine their clinical significance. The aim of this study was to evaluate identification of rapidly growing NTM (RGM) isolated from clinical samples by using MALDI-TOF MS and a commercial molecular system. The results were compared with identification using a reference method. METHODS: We included 46 clinical isolates of RGM and identified them using the commercial molecular system GenoType® CM/AS (Hain, Lifescience, Germany), MALDI-TOF MS (Bruker) and, as reference method, partial rpoß gene sequencing followed by BLAST and phylogenetic analysis with the 1093 sequences available in the GeneBank. RESULTS: The degree of agreement between GenoType® and MALDI-TOF MS and the reference method, partial rpoß sequencing, was 27/43 (62.8%) and 38/43 cases (88.3%) respectively. For all the samples correctly classified by GenoType®, we obtained the same result with MALDI-TOF MS (27/27). However, MALDI-TOF MS also correctly identified 68.75% (11/16) of the samples that GenoType® had misclassified (p=0.005). CONCLUSIONS: MALDI-TOF MS classified significantly better than GenoType®. When a MALDI-TOF MS score >1.85 was achieved, MALDI-TOF MS and partial rpoß gene sequencing were equivalent. GenoType® was not able to distinguish between species belonging to the M. fortuitum complex. MALDI-TOF MS methodology is simple, rapid and associated with lower consumable costs than GenoType®. The partial rpoß sequencing methods with BLAST and phylogenetic analysis were not able to identify some RGM unequivocally. Therefore, sequencing of additional regions would be indicated in these cases.

[Species diversity of non-tuberculous mycobacteria isolated from aquatic environments of General Pico city, Province of La Pampa (Argentina)]. / Diversidad de especies de micobacterias no tuberculosas aisladas en ambientes acuáticos de la ciudad de General Pico, La Pampa, Argentina.

Non-tuberculous mycobacteria (NTM) are studied not only for their importance as emerging opportunistic pathogens but also for their applications in biotechnology and bioremediation. Our aim was to determine the occurrence and diversity of mycobacteria in different aquatic habitats of General Pico city, Province of La Pampa. The percentage of samples with positive cultures for mycobacteria were the following: 37.5% recovered from the water supply distribution system; 32.6% from the aquifer that supplies water to the distribution system; 36.8% from rain water; 53.1% from the two wetlands in the area of influence; 80% from indoor swimming pools; and 33.3% from water fountains in downtown public squares. Of the 90 NTM isolates, 8.9% could not be identified at the species level with any of the used methods, phenotypic tests and molecular methods. Mycobacterium fortuitum and Mycobacterium gordonae were the most frequently isolated species. Some of the identified species such as, M. fortuitum, M. gordonae, M. intracellulare, M. vaccae, M. lentiflavum and M. nonchromogenicum, have been reported in cases of mycobacteriosis in Argentina. Mycobacteria with values higher than 0.8mg/ml of residual active chlorine were not recovered from the drinking water supply network, whereas in the swimming pools the presence of up to 1.5mg/l was not a constraint. Based on our results, the presence of mycobacteria in aquatic environments is close to 35% and their occurrence and diversity is affected both by contact with man and his activities as well as by the existence of animal life.

Micobacteriosis identificadas en el Laboratorio Nacional de Referencia de Colombia entre 2012 y 2016 / Mycobacterioses identified in the National Reference Laboratory of Colombia from 2012 to 2016

Introducción. En los últimos años se ha observado un aumento en la prevalencia de micobacteriosis ocasionadas por micobacterias no tuberculosas, las cuales hoy se consideran como agentes patógenos emergentes. Su presencia depende de varios factores, como los antecedentes clínicos, el estado de salud de la persona afectada y la presencia de estos microorganismos en el agua, el suelo y los animales, entre otros. Objetivo. Describir las micobacteriosis identificadas en el Laboratorio Nacional de Referencia de Micobacterias del Instituto Nacional de Salud, entre 2012 y 2016. Materiales y métodos. Se hizo un análisis retrospectivo que incluyó 273 pacientes con micobacteriosis. Las variables analizadas fueron el tipo de micobacteriosis, el agente etiológico y los factores de riesgo asociados. Resultados. El 57,1 % de los casos presentó micobacteriosis pulmonar, el 26 %, cutánea, el 10,6 %, diseminada, y el 2,6 %, linfática. La comparación entre la forma pulmonar y la extrapulmonar evidenció que el complejo Mycobacterium avium se presenta con mayor frecuencia en las micobacteriosis pulmonares, en tanto que M. abscessus fue más frecuente en las extrapulmonares. Los pacientes con micobacteriosis pulmonar presentaban antecedentes de tuberculosis con mayor frecuencia que aquellos con las formas extrapulmonares. Conclusión. Estos hallazgos resaltan la importancia del diagnóstico diferencial entre las especies del complejo M. tuberculosis y las micobacterias no tuberculosas, ya que estas últimas son resistentes genéticamente a los fármacos convencionales contra la tuberculosis.

Introduction: In recent years, there has been an increase in the prevalence of mycobacterioses caused by non-tuberculous mycobacteria, which are considered as emerging pathogens. Their presence depends on several factors such as the clinical history, the health status of the affected person, and the presence of these microorganisms in the water, the soil, and the animals, among others. Objective: To describe the mycobacteria and the etiological agent identified in isolates received at the Laboratorio Nacional de Referencia de Micobacterias of the Instituto Nacional de Salud between 2012 and 2016. Materials and methods: We conducted a retrospective analysis of samples from 273 patients with mycobacterioses. We analyzed the following variables: mycobacteriosis type, etiological agent, and associated predisposing factors. Results: 57.1% of the cases presented pulmonary mycobacteriosis; 26%, cutaneous; 10.6%, disseminated, and 2.6%, lymphatic. We found the Mycobacterium avium complex more frequently in pulmonary mycobacteriosis, while M. abscessus was more frequent in the extrapulmonary types of the disease. Patients with pulmonary mycobacteriosis had a history of tuberculosis more frequently than those with extrapulmonary forms. Conclusion: These findings highlight the importance of the differential diagnosis between M. tuberculosis complex species and non-tuberculous mycobacteria since the latter are genetically resistant to conventional antituberculosis drugs.

Aislamiento y caracterización molecular de micobacterias no tuberculosas en el sistema de distribución de agua en un hospital de lima (perú) / Isolation and molecular characterization of nontuberculous mycobacteria in the water distribution system in a hospital of lima (perú)

RESUMEN Introducción: Las infecciones por micobacterias pueden causar lesiones cutáneas y pulmonares; las micobacterias pueden hallarse en fuentes de agua intrahospitalarias, pudiendo llegar a los pacientes inmunosuprimidos y provocar enfermedades severas. Objetivo: Aislar y caracterizar micobacterias no tuberculosas en el sistema de distribución de agua en un hospital de Lima. Materiales y métodos: Se aislaron las micobacterias en medios convencionales a base de huevo; y se emplearon pruebas bioquímicas y herramientas moleculares como la reacción en cadena de la polimerasa ―PCR― y secuenciación para su identificación. Para el análisis de secuenciación se empleó el GenBank y para el árbol filogenético se utilizó MEGA 6. Resultados: Fue posible el aislamiento de bacilos ácido alcohol resistentes en muestras de agua potable fría, aunque no en agua caliente del hospital. Se aislaron e identificaron varias especies de micobacterias no tuberculosas en las muestras de agua, siendo el 100 % de crecimiento rápido, estas fueron: Mycobacterium canariasense; M. frederiksbergense; M. mucogenicum; Mycobacterium fortuitum y Mycobacterium chelonae. Conclusiones: Esta es la primera vez que se aíslan micobacterias en agua potable de un hospital en Perú. Se concluye que la existencia de micobacterias en el agua del hospital podría ser fuente potencial de brotes nosocomiales, por lo que debería tenerse en cuenta su estudio periódicamente.

ABSTRACT Introduction: Mycobacterial infections can cause skin and lung lesions. Mycobacteria can be found in intra-hospital water sources which can reach immuno-suppressed patients and cause severe disease. Objective: To isolate and characterize non-tuberculous mycobacteria in the water distribution system in a hospital in Lima. Materials and Methods: Mycobacteria were isolated in conventional culture egg-based media and biochemical tests and molecular tools such as polymerase chain reaction (PCR) and sequencing were used for their identification. The GenBank was used for sequencing analysis and MEGA 6 was used for the phylogenetic tree. Results: Isolation of acid-fast bacilli was possible in samples of cold drinking water, although not in the hospital hot water. Several species of non-tuberculous mycobacteria were isolated and identified in the water samples being a 100% of rapid growth such as Mycobacterium canariasense, M. frederiksbergense, Mycobacterium fortuitum, Mycobacterium chelonae, and M. mucogenicum. Conclusions: This is the first time that mycobacteria are isolated in drinking water at a hospital in Perú. It is concluded that the existence of mycobacteria in hospital water could be a potential source of nosocomial outbreaks and should be analyzed periodically.

Mycobacterium lentiflavum as the main cause of lymphadenitis in pediatric population. / Mycobacterium lentiflavum como causa principal de linfadenitis en población pediátrica.

INTRODUCTION: Cervical lymphadenitis is the most common nontuberculous mycobacteria (NTM) infection in immunocompetent children, mainly in those under 5years. For many years Mycobacterium lentiflavum (M. lentiflavum) has been considered a rare NTM causing lymphadenitis. METHODS: A restrospective study was performed in pediatric patients with microbiologically confirmed NTM cervical lympahdenitis at the Niño Jesús Hospital in Madrid during 2009-2016. RESULTS: During the period studied, 28 cases of cervical lymphadenitis were recorded. In 23 (82.14%) and in 5 (17,85%) cases, M. lentiflavum and Mycobacterium avium were isolated, respectively. In those patients infected with M. lentiflavum, the most frequent location was sub-maxilar (43.47%); 15 (65.21%) were boys, global median age was 30,8 months and all cases showed a satisfactory evolution. CONCLUSION: We propose that M. lentiflavum should be considered an important emergent pathogen cause of cervical lymphadenitis in the pediatric population.

Lady Windermere syndrome in Castile and León. / Síndrome de Lady Windermere en Castilla y León.

INTRODUCTION: Lady Windermere syndrome (LWS) is a pulmonary disease caused by Mycobacterium avium complex (MAC). The objective of this study is to ascertain its frequency and characteristics in the northern area of the autonomous community of Castile and León. METHODS: A retrospective study of patients with MAC isolates in respiratory samples from five public hospitals in the autonomous community over a six-year period, following the ATS/IDSA criteria. The MAC strains were identified by GenoType Mycobacterium reverse hybridisation probes or PCR-RFLP analysis of the hsp65 gene. RESULTS: Of 183 cases of MAC identified, only five women (2.7%) aged 68.8±10.7years met LWS criteria. In three cases, MAC was isolated jointly and intermittently with other pathogens. Only one patient was treated according to ATS/IDSA criteria. DISCUSSION: LWS remains underestimated, with affected patients representing a significant burden on healthcare resources over long periods of time. As a result, greater microbiological and therapeutic knowledge of the syndrome is needed.