Clinical characteristics and prognostic factors of non-tuberculous mycobacterial disease in patients with rheumatoid arthritis.

BACKGROUND/AIMS: This study aimed to identify the clinical characteristics of patients with concurrent rheumatoid arthritis (RA) and suspected non-tuberculous mycobacterial (NTM) infections as well as determine their prognostic factors. METHODS: We retrospectively reviewed the medical records of 91 patients with RA whose computed tomography (CT) findings suggested NTM infection. Subsequently, we compared the clinical characteristics between patients with and without clinical or radiological exacerbation of NTM-pulmonary disease (PD) and investigated the risk factors for the exacerbation and associated mortality. RESULTS: The mean age of patients with RA and suspected NTM-PD was 65.0 ± 10.2 years. The nodular/bronchiectatic (NB) form of NTM-PD was the predominant radiographic feature (78.0%). During follow-up, 36 patients (41.9%) experienced a radiological or clinical exacerbation of NTM-PD, whereas 12 patients (13.2%) died. Combined interstitial lung disease (ILD), microbiologically confirmed NTM-PD, and NB with the fibrocavitary (FC) form on chest CT were identified as risk factors for the clinical or radiological exacerbation of NTM-PD. Hydroxychloroquine use was identified as a good prognostic factor. Conversely, history of tuberculosis, ILD, smoking, microbiologically confirmed NTM-PD, and NB with the FC form on chest CT were identified as poor prognostic factors for mortality in suspected NTM-PD. CONCLUSION: ILD and NB with the FC form on chest CT were associated with NTM-PD exacerbation and mortality. Hydroxychloroquine use may lower the risk of NTM-PD exacerbation. Therefore, radiographic features and presence of ILD should be considered when predicting the prognosis of patients with RA and suspected NTM-PD.

Building a model for the differential diagnosis of non-tuberculous mycobacterial lung disease and pulmonary tuberculosis: A case-control study based on immunological and radiological features.

BACKGROUND: Although the incidence of non-tuberculous mycobacterial pulmonary disease (NTM-PD) is increasing annually, it is easily misdiagnosed as pulmonary tuberculosis (PTB). This study aimed to screen and identify the immunological and radiological characteristics that differentiate NTM-PD from PTB and to construct a discriminatory diagnostic model for NTM-PD, providing new tools for its differential diagnosis. METHODS: Hospitalised patients diagnosed with NTM-PD or PTB between January 2019 and June 2023 were included in the study. Immunological and radiological characteristics were compared between the two groups. Based on the selected differential features, a logistic regression algorithm was used to construct a discriminatory diagnostic model for NTM-PD, and its diagnostic performance was preliminarily analysed. RESULTS: Patients with NTM-PD were significantly older than those with PTB and the tuberculosis-specific interferon-gamma release assay (TB-IGRA) positivity rate was significantly lower in the NTM-PD group. Moreover, the absolute counts of total T lymphocytes, CD4+ T lymphocytes, CD8+ T lymphocytes, NK cells, and B lymphocytes were significantly lower in patients with NTM-PD and PTB than in healthy controls. Additionally, patients with NTM-PD had a significantly lower absolute count of B lymphocytes than the PTB group. Radiological analysis revealed significant differences between patients with NTM-PD and PTB in terms of cavity wall thickness, bronchial dilation, lung consolidation, pulmonary nodule size, pulmonary emphysema, lung bullae, lymph node calcification, pleural effusion, mediastinal and hilar lymphadenopathy, and the tree-in-bud sign. Bronchial dilation was identified as the predominant risk factor of NTM-PD, whereas TB-IGRA positivity, lymph node calcification, pleural effusion, and mediastinal and hilar lymphadenopathies were protective factors. Based on this, we constructed a discriminatory diagnostic model for NTM-PD. Its receiver operating characteristic curve demonstrated good diagnostic performance, with an area under the curve of 0.938. At the maximum Youden index of 0.746, the sensitivity and specificity were 0.835 and 0.911, respectively. CONCLUSIONS: Patients with NTM-PD and PTB exhibited impaired humoral and cellular immune functions as well as significant differences in radiological features. The constructed NTM-PD diagnostic model demonstrated good diagnostic performance. This study provides a new tool for the differential diagnosis of NTM-PD.

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.

Healthcare-Associated nontuberculous mycobacterial endocarditis following coronary artery angiography.

Infective endocarditis in a patient with structural heart disease following coronary artery angiography is a rare complication. We report a rare case of Mycobacterium chelonae infective endocarditis following coronary artery angiography in a young male with congenital heart disease. This case illustrates the diagnostic as well as therapeutic challenges we faced when managing this rare infectious entity.

Clinical Impact of Chronic Pulmonary Aspergillosis in Patients with Nontuberculous Mycobacterial Pulmonary Disease and Role of Computed Tomography in the Diagnosis.

Objective Chronic pulmonary aspergillosis (CPA) is an important complication of nontuberculous mycobacterial pulmonary disease (NTM-PD). However, its diagnosis is challenging, as both CPA and NTM-PD present as chronic cavitary disease. The present study evaluated the impact of CPA on the survival of patients with NTM-PD and revealed the key computed tomography findings for a prompt diagnosis. Methods We retrospectively reviewed patients newly diagnosed with NTM-PD in Tenri Hospital (Tenri City, Nara Prefecture, Japan) between January 2009 and March 2018; the patients were followed up until May 2021. Clinical and radiological characteristics were assessed, and patients with CPA were identified. Results A total of 611 patients were diagnosed with NTM-PD. Among them, 38 (6.2%), 102 (17%), and 471 (77%) patients were diagnosed with NTM-PD with CPA, cavitary NTM-PD without CPA, and non-cavitary NTM-PD without CPA, respectively. The 5-year survival rate of the NTM-PD with CPA group (42.8%; 95% confidence interval: 28.7-64.0%) was lower than that of the cavitary NTM-PD without CPA group (74.4%; 95% confidence interval: 65.4-84.6%). A multivariate analysis revealed that fungal balls and cavities with adjacent extrapleural fat were significant predictive factors for NTM-PD with CPA. Conclusion NTM-PD with CPA patients exhibited a worse prognosis than cavitary NTM-PD without CPA patients. Therefore, an unerring diagnosis of CPA is essential for managing patients with NTM-PD. Computed tomography findings, such as fungal balls and cavities with adjacent extrapleural fat, may be valuable diagnostic clues when CPA is suspected in patients with NTM-PD.

Dermoscopy in Mycobacterium marinum infection and its correlation with clinical and histopathological features: a prospective observational study.

BACKGROUND: Mycobacterium marinum is a nontuberculous mycobacterium and a conditional pathogen to humans, which can be inoculated directly and cause chronic skin granulomas. Dermoscopy has been applied to other granulomatous skin diseases, but not to M. marinum infection. AIM: To explore the dermoscopic features of M. marinum infection, and its correlation with clinical and histopathological features. METHODS: In total, 27 lesions from 27 patients (19 women, 8 men, age range 28-71 years) diagnosed with M. marinum infection were identified by clinical examination, histopathological results, PCR sequencing and mycobacterial culture in the dermatology outpatient department of our hospital from March 2020 to February 2022. The dermoscopy images and pathological characteristics were analysed. RESULTS: Lesions were located on the hands, forearms and upper arms. The following dermoscopic features were observed: yellowish-orange structureless areas (85·2%), white striped structures (59·3%), follicular plugs (29·6%), yellowish oval clods (14·8%) and reddish or pinkish areas (14·8%). Vessel structures were visible in all cases: long hairpin vessels (81·5%), corkscrew vessels (25·9%), comma-shaped vessels (22·2%) and linear vessels (22·2%). CONCLUSION: Yellowish-orange structureless areas, white striped structures and long hairpin vessels are the most common dermoscopic features of M. marinum infection. Thus, dermoscopy could be used as a noninvasive auxiliary diagnostic method to provide a diagnostic basis for this disease.

The usefulness of change in CT score for evaluating the activity of Mycobacterium abscessus (Mab) pulmonary disease (Mab-PD).

OBJECTIVES: Semi-quantitative CT score is generally used for evaluating the disease status of Mycobacterium abscessus (Mab) Pulmonary disease (Mab-PD). However, its accuracy and clinical usefulness are limited, since the CT score is largely affected by coexisting lung disease. Hence, we hypothesized that numerical change in CT score during the observation period may be useful for evaluating disease activity of Mab-PD. METHODS: Patients diagnosed with Mab-PD based on the official ATS/ERS/ESCMID/IDSA statement at Jikei University Hospital and Jikei Daisan Hospital between 2015 January 1 and 2021 July 31 were included (n = 32). We reviewed the medical records, and bacteriological and laboratory data of the patients. Chest CT was performed at diagnosis in all 32 cases. In 18 cases, chest CT images within 4 years before diagnosis were available. The numerical change in CT score between two time points was calculated and the association of the CT scores with sputum Gaffky score and serum CRP was examined. RESULTS: CT score at diagnosis was not correlated with sputum Gaffky score nor serum CRP, while the difference of absolute value and change rate in CT score between at diagnosis and immediate past CT were well correlated with both sputum Gaffky score and serum CRP. CONCLUSIONS: Chronological change in CT score may more precisely reflect the disease activity of airway mycobacterial burden and systemic inflammation in Mab-PD at the timing of diagnosis.

Distinguishing nontuberculous mycobacterial lung disease and Mycobacterium tuberculosis lung disease on X-ray images using deep transfer learning.

BACKGROUND: Nontuberculous mycobacterial lung disease (NTM-LD) and Mycobacterium tuberculosis lung disease (MTB-LD) have similar clinical characteristics. Therefore, NTM-LD is sometimes incorrectly diagnosed with MTB-LD and treated incorrectly. To solve these difficulties, we aimed to distinguish the two diseases in chest X-ray images using deep learning technology, which has been used in various fields recently. METHODS: We retrospectively collected chest X-ray images from 3314 patients infected with Mycobacterium tuberculosis (MTB) or nontuberculosis mycobacterium (NTM). After selecting the data according to the diagnostic criteria, various experiments were conducted to create the optimal deep learning model. A performance comparison was performed with the radiologist. Additionally, the model performance was verified using newly collected MTB-LD and NTM-LD patient data. RESULTS: Among the implemented deep learning models, the ensemble model combining EfficientNet B4 and ResNet 50 performed the best in the test data. Also, the ensemble model outperformed the radiologist on all evaluation metrics. In addition, the accuracy of the ensemble model was 0.85 for MTB-LD and 0.78 for NTM-LD on an additional validation dataset consisting of newly collected patients. CONCLUSIONS: In previous studies, it was known that it was difficult to distinguish between MTB-LD and NTM-LD in chest X-ray images, but we have successfully distinguished the two diseases using deep learning methods. This study has the potential to aid clinical decisions if the two diseases need to be differentiated.

Infection of a venous port - beware of the Mycobacterium.

An 84-year-old female with metastatic left breast cancer underwent a venous port insertion for chemotherapy. The port was inserted using standard techniques with image guidance under local anesthesia. She presented after 36 days with evidence of infection. A limited bedside ultrasound demonstrated free fluid surrounding the port. The port was subsequently removed the same day, at which time pus was expressed from the subcutaneous pocket. The culture from the pus grew Mycobacterium abscessus. She required removal of the port and wound debridement, wound dressings and a prolonged course of antibiotics. Mycobacterium abscessus is a group of rapidly growing, multidrug-resistant, non-tuberculous mycobacteria that are also relatively resistant to standard skin disinfectants. In recent years, this organism has been increasingly reported as the culprit in post-operative or post-procedural infections. Treatment is challenging due to multidrug resistance, and requires an extensive course of intravenous antimicrobial and macrolide-based combination therapy followed by oral antimicrobial therapy. Early treatment is essential as progression may result in disseminated infection. We discuss the peri-operative and post-operative care required in preventing and treating infection with this organism.

Is a radiological score needed to define the severity of Nontuberculous mycobacteria lung disease?

High-resolution CT-scan (HRCT) plays a major role in the diagnosis of Nontuberculous mycobacteria lung disease (NTM-LD), but its role in follow-up is controversial. Our aim was first to conceive a radiological score able to quantify the severity of pulmonary involvement by NTM infection and, second, to check its association with the NTM-LD clinical burden. We also intended, if possible, to verify the potential influence of NTM specific treatment on the radiological score. We retrospectively collected the clinical, microbiological and radiological data of all patients who were admitted to our hospital from 1 January 2012 to 1 January 2020 with a confirmed diagnosis of NTM-LD. A radiological score was applied to evaluate lung involvement on HRCT at diagnosis and at 6-18 months follow-up. Twenty-eight patients with NTM-LD performed follow-up HRCT. No association was found between radiological and clinical score (Spearman R -0.05, 95%CI -0.41 to 0.33). Repeated measures analysis showed a significant increase in radiological score over time (change 1.11, 95%CI 0.10 to 2.11; p-value 0.032), while Mann-Whitney test did not show any difference between treated and untreated patients (p value 0.922). Further studies are needed to assess the usefulness of routine radiological follow-up in patients with NTM-LD.

T-SPOT with CT image analysis based on deep learning for early differential diagnosis of nontuberculous mycobacteria pulmonary disease and pulmonary tuberculosis.

OBJECTIVES: This study aimed to establish a diagnostic algorithm combining T-SPOT with computed tomography image analysis based on deep learning (DL) for early differential diagnosis of nontuberculous mycobacteria pulmonary disease (NTM-PD) and pulmonary tuberculosis (PTB). METHODS: A total of 1049 cases were enrolled, including 467 NTM-PD and 582 PTB cases. A total of 320 cases (160 NTM-PD and 160 PTB) were randomized as the testing set and were analyzed using T-SPOT combined with the DL model. The testing cases were first divided into T-SPOT-positive and -negative groups, and the DL model was then used to separate the cases into four subgroups further. RESULTS: The precision was found to be 91.7% for the subgroup of T-SPOT-negative and DL classified as NTM-PD, and 89.8% for T-SPOT-positive and DL classified as PTB, which covered 66.9% of the total cases, compared with the accuracy rate of 80.3% of T-SPOT alone. In the other two remaining groups, where the T-SPOT prediction was inconsistent with the DL model, the accuracy was 73.0% and 52.2%, separately. CONCLUSION: Our study shows that the new diagnostic system combining T-SPOT with DL based computed tomography image analysis can greatly improve the classification precision of NTM-PD and PTB when the two methods of prediction are consistent.

Deep Learning-Based Prediction Model Using Radiography in Nontuberculous Mycobacterial Pulmonary Disease.

BACKGROUND: Prognostic prediction of nontuberculous mycobacteria pulmonary disease using a deep learning technique has not been attempted. RESEARCH QUESTION: Can a deep learning (DL) model using chest radiography predict the prognosis of nontuberculous mycobacteria pulmonary disease? STUDY DESIGN AND METHODS: Patients who received a diagnosis of nontuberculous mycobacteria pulmonary disease at Seoul National University Hospital (training and validation dataset) between January 2000 and December 2015 and at Seoul Metropolitan Government-Boramae Medical Center (test dataset) between January 2006 and December 2015 were included. We trained DL models to predict the 3-, 5-, and 10-year overall mortality using baseline chest radiographs at diagnosis. We tested the predictability for the corresponding mortality using only DL-driven radiographic scores and using both radiographic scores and clinical information (age, sex, BMI, and mycobacterial species). RESULTS: The datasets comprised 1,638 (training and validation set) and 566 (test set) chest radiographs from 1,034 and 200 patients, respectively. The Dl-driven radiographic score provided areas under the receiver operating characteristic curve (AUC) of 0.844, 0.781, and 0.792 for 10-, 5-, and 3-year mortality, respectively. The logistic regression model using both the radiographic score and clinical information provided AUCs of 0.922, 0.942, and 0.865 for the 10-, 5, and 3-year mortality, respectively. INTERPRETATION: The DL model we developed could predict the mid-term to-long-term mortality of patients with nontuberculous mycobacteria pulmonary disease using a baseline radiograph at diagnosis, and the predictability increased with clinical information.

Nontuberculous Mycobacterial Infections.

Mycobacterial species other than Mycobacterium tuberculosis and Mycobacterium leprae constitute nontuberculous mycobacteria (NTM). NTM infections are on the rise, particularly in the Western world. They cause a wide range of pulmonary and systemic manifestations. The 2 most common types are as follows: classical cavitary type, seen with preexisting lung disease, and the nonclassical bronchiectatic type, seen in elderly women without preexisting lung disease. Disseminated infections by the hematogenous route are common in immunocompromised patients including those with HIV. Imaging plays a key role in the diagnosis and monitoring of NTM infection.

Nontuberculous Mycobacterial Pulmonary Disease: A Clinical and Radiologic Update.

Nontuberculous mycobacterial pulmonary disease (NTM-PD) is increasingly recognized in the U.S. and worldwide as a debilitating disease that is challenging to diagnose and manage. Beyond the principle task of recognizing the protean imaging manifestations of NTM-PD, radiologists will need to appropriately communicate with pulmonology and infectious disease colleagues in multidisciplinary management discussions. This update on nontuberculous mycobacteria (NTM) species, their clinical significance, and imaging features aims to support these roles. Terminology mirrors that laid out by the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) published guidelines on NTM-PD.1.

Differentiating nontuberculous mycobacterium pulmonary disease from pulmonary tuberculosis through the analysis of the cavity features in CT images using radiomics.

OBJECTIVE: To differentiate nontuberculous mycobacteria (NTM) pulmonary diseases from pulmonary tuberculosis (PTB) by analyzing the CT radiomics features of their cavity. METHODS: 73 patients of NTM pulmonary diseases and 69 patients of PTB with the cavity in Shandong Province Chest Hospital and Qilu Hospital of Shandong University were retrospectively analyzed. 20 patients of NTM pulmonary diseases and 20 patients of PTB with the cavity in Jinan Infectious Disease Hospitall were collected for external validation of the model. 379 cavities as the region of interesting (ROI) from chest CT images were performed by 2 experienced radiologists. 80% of cavities were allocated to the training set and 20% to the validation set using a random number generated by a computer. 1409 radiomics features extracted from the Huiying Radcloud platform were used to analyze the two kinds of diseases' CT cavity characteristics. Feature selection was performed using analysis of variance (ANOVA) and least absolute shrinkage and selection operator (LASSO) methods, and six supervised learning classifiers (KNN, SVM, XGBoost, RF, LR, and DT models) were used to analyze the features. RESULTS: 29 optimal features were selected by the variance threshold method, K best method, and Lasso algorithm.and the ROC curve values are obtained. In the training set, the AUC values of the six models were all greater than 0.97, 95% CI were 0.95-1.00, the sensitivity was greater than 0.92, and the specificity was greater than 0.92. In the validation set, the AUC values of the six models were all greater than 0.84, 95% CI were 0.76-1.00, the sensitivity was greater than 0.79, and the specificity was greater than 0.79. In the external validation set, The AUC values of the six models were all greater than 0.84, LR classifier has the highest precision, recall and F1-score, which were 0.92, 0.94, 0.93. CONCLUSION: The radiomics features extracted from cavity on CT images can provide effective proof in distinguishing the NTM pulmonary disease from PTB, and the radiomics analysis shows a more accurate diagnosis than the radiologists. Among the six classifiers, LR classifier has the best performance in identifying two diseases.

Chest Computed Tomography Features of Nontuberculous Mycobacterial Pulmonary Disease Versus Asymptomatic Colonization: A Cross-sectional Cohort Study.

BACKGROUND: Asymptomatic colonization by nontuberculous mycobacteria (NTM) found in sputum isolates are commonly encountered and clinicians lack a biomarker for prognosticating the risk of transition asymptomatic colonization to active clinical disease. Chest computed tomography (CT) imaging is commonly obtained in this patient population and may serve a role for this purpose. METHODS: We conducted a single-center, cross-sectional study of patients followed in the NTM clinic at our center between August 2019 and August 2020. All patients had a history of NTM isolated from their airways and were cohorted as either nontuberculous mycobacteria-pulmonary disease (NTM-PD) if they met ATS/IDSA guidelines for treatment or as nontuberculous mycobacteria-colonized (NTM-C) if they did not meet ATS/IDSA criteria for NTM treatment. Patients with a chest CT were included in the analysis and CT scans were assessed for features including bronchiectasis, nodules, and cavities. Bronchiectasis severity was calculated using the modified Reiff scoring system. Univariate analyses were conducted to compare patients with NTM-C and NTM-PD. RESULTS: Eighty-four patients were included in the analysis and 27 were classified as NTM-C and 57 as NTM-PD. NTM-PD patients had a greater median number of lung lobes affected by bronchiectatic airways (6 [1] NTM-PD vs. 5 [3] NTM-C P=0.005) and a greater frequency of cystic bronchiectasis (17.5% NTM-PD vs. 0% NTM-PD, P=0.016). Bronchiectasis severity was higher for NTM-PD patients (7 [9] NTM-PD vs. 5 [1.5] NTM-C, P<0.001). CONCLUSIONS: Patients with NTM-PD have greater bronchiectatic airway involvement and the forms of bronchiectasis present are more severe compared with NTM-C patients. In addition, cavitation of lung parenchyma was a radiographic feature solely associated with NTM-PD. Features identified on chest CT may be useful as a prognostic biomarker for the risk of transition from NTM-C to NTM-PD.