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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 167-174

Clinical presentations of nontuberculous mycobacteria as suspected and drug-resistant tuberculosis: Experience from a tertiary care center in Eastern India


1 Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Pulmonary Medicine and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Ear, Nose and Throat, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission20-Feb-2022
Date of Decision09-May-2022
Date of Acceptance17-May-2022
Date of Web Publication14-Jun-2022
Date of Print Publicaton14-Jun-2022

Correspondence Address:
Baijayantimala Mishra
Department of Microbiology, Academic Block, All India Institute of Medical Sciences, Sijua, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_68_22

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  Abstract 


Background: Nontuberculous mycobacteria (NTM) are on the rise worldwide. The diagnosis and treatment of NTM disease create a dilemma for physicians as their clinical features often overlap with that of tuberculosis (TB). The present study aims to report a series of NTM infections presenting as suspected TB. Methods: It was a prospective observational study starting from December 2018 to January 2022. A total of 1850 suspected TB patients (pulmonary = 522 and extrapulmonary = 1328) were included in this study. Clinical features, radiological findings, microbiological diagnosis, treatment, and outcome were recorded. Clinical specimens were processed for Ziehl–Neelsen staining, GeneXpert MTB/Rif assay by cartridge-based nucleic acid amplification test, and culture. The culture-positive isolates were categorized as Mycobacterium tuberculosis complex or NTM depending on the detection of MPT64 antigen by immunochromatographic test. The NTM isolates were speciated by line probe assay using GenoType® Mycobacterium common mycobacteria kit. The criteria of the American Thoracic Society/Infectious Diseases Society of America were applied to confirm NTM disease. Results: Of 1850 suspected TB patients, NTM disease was diagnosed in 20 patients (pulmonary = 9, nonpulmonary = 11). Eight NTM cases presented as suspected drug-resistant-TB with a history of antitubercular therapy. Among pulmonary NTM cases, Mycobacterium scrofulaceum (n = 7) was the most common species followed by Mycobacterium kansasii (n = 1) and Mycobacterium intracellulare (n = 1). In nonpulmonary cases, Mycobacterium abscessus (n = 8) was involved in majority of cases followed by Mycobacterium fortuitum (n = 3). Cavitary lung disease and laparoscopic port site infections were most frequent pulmonary and non-pulmonary manifestations respectively. Conclusion: Hence, there is an urgent need for better diagnostic and drug susceptibility testing facility along with standardized treatment protocol for NTM disease.

Keywords: Nonpulmonary, nontuberculous mycobacteria, pulmonary


How to cite this article:
Das S, Mishra B, Mohapatra PR, Preetam C, Rath S. Clinical presentations of nontuberculous mycobacteria as suspected and drug-resistant tuberculosis: Experience from a tertiary care center in Eastern India. Int J Mycobacteriol 2022;11:167-74

How to cite this URL:
Das S, Mishra B, Mohapatra PR, Preetam C, Rath S. Clinical presentations of nontuberculous mycobacteria as suspected and drug-resistant tuberculosis: Experience from a tertiary care center in Eastern India. Int J Mycobacteriol [serial online] 2022 [cited 2022 Jul 6];11:167-74. Available from: https://www.ijmyco.org/text.asp?2022/11/2/167/347525




  Introduction Top


The genus Mycobacterium comprises a diverse group of species which includes the most pathogenic Mycobacterium tuberculosis complex (MTBC) and Mycobacterium leprae. Apart from these two groups, the remaining species of Mycobacterium are collectively referred to as nontuberculous mycobacteria (NTM).[1] The species belonging to NTM form a large and distinct group that is ubiquitous, prevailing in both natural environments and human dwellings, including hospital setups.[2] Their pathogenic potential had long been underestimated. Moreover, the diagnosis and treatment of NTM diseases create a dilemma for physicians as their clinical features often overlap with that of MTBC. NTM diseases are difficult to treat as most of them are resistant to first-line anti-tubercular drugs. They are often misdiagnosed as tuberculosis (TB) or drug-resistant TB (DR-TB) based on acid-fast bacilli (AFB) finding in TB endemic settings.[3] The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have developed guidelines for NTM disease diagnosis, including clinical symptoms, radiographic findings, and microbiologic criteria.[4]

NTMs are emerging as an important pathogen capable of causing disease in both immunocompetent and immunocompromised individuals. NTM infections have become more relevant due to a growing population with different immunocompromised conditions such as HIV/AIDS, diabetes, renal failure, transplant recipients and immunosuppressive therapy. The incidence and prevalence of NTM lung disease (LD) continue to increase worldwide.[5],[6],[7] The exact prevalence of NTM is not known as it is not a reportable disease in most countries including India. Available data from laboratory-based studies revealed the prevalence of NTM and isolation rate in pulmonary diseases varied from 0.7% to 34% in India.[3] The prevalence and species spectrum of NTM varies widely in different study populations and at different geographic locations of the world.[8] It is presumed that NTM infections are under-reported in TB-endemic countries like India due to several factors such as lack of awareness among physicians and microbiologists, lack of laboratory infrastructure for culture and identification of NTM, and lack of a definite diagnosis and treatment protocol.[9] There are few reports of case series of clinical cases of NTM infections with follow-up. The present study aims to report a series of NTM infections presenting as suspected TB.


  Methods Top


It was a prospective observational study conducted in the Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India. A total of 1850 suspected TB patients (pulmonary = 522 and extrapulmonary = 1328) were included during the study starting from December 2018 to January 2022 based on the availability of adequate amount of clinical specimens. Out of them, 110 patients presented as suspected DR-TB with a history of anti-tubercular therapy (ATT). Clinical features, radiological findings, microbiological diagnosis, treatment, and outcome were recorded after taking the informed consent of the patients. The past medical and treatment history (including ATT) was noted. The demographic profile, occupation of patients, and exposure to known risk factors were also recorded for comparison.

The clinical specimens of patients with suspected TB were processed for Ziehl–Neelsen (ZN) staining, GeneXpert MTB/Rif assay by cartridge-based nucleic acid amplification test (CBNAAT), and culture in Lowenstein–Jensen medium (solid) and liquid culture in Mycobacterium Growth Indicator Tube (Becton Dickinson, Sparks, MD). The culture-positive isolates were categorized as MTBC or NTM depending on the detection of MPT64 antigen by rapid immunochromatographic test (ICT) (SD BIOLINE). The NTM isolates were then subjected to speciation by line probe assay (LPA) using GenoType® Mycobacterium common mycobacteria kit (Hain Lifescience, Nehren, Germany).

The criteria of ATS/IDSA were applied to confirm NTM disease.[4] The clinical and radiological criteria included pulmonary symptoms and nodular or cavitary opacities on chest radiograph or high-resolution computed tomography (HRCT) scan showing multifocal bronchiectasis with multiple small nodules, after appropriate exclusion of other diagnoses. The microbiologic criterion included positive culture results from at least two separately expectorated sputum samples or positive culture results from at least one bronchial wash or lavage.[4] A positive culture from one aseptically collected extrapulmonary specimen was considered diagnostic. Specimen in the swab was not acceptable.[4] [Figure 1] depicts the test algorithm to diagnose NTM.
Figure 1: Test algorithm for confirmation of NTM. NTM: Nontuberculous mycobacteria

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  Results Top


Of 1850 suspected TB patients, 107 were diagnosed positive for MTBC by either CBNAAT or culture. NTM disease was diagnosed in 20 cases which included 9 pulmonary and 11 nonpulmonary cases. Eight patients with NTM disease presented as suspected DR-TB with a history of ATT.

Of 20 NTM cases, 14 were female and 6 were male. The mean age of NTM patients was 43.8 (±17.17) years. All the patients were from the eastern part of India. The clinical presentation, radiological features, microbiologic diagnosis, and response to the treatment of 20 NTM cases are as follows.

Pulmonary nontuberculous mycobacteria cases

Case 1

A 55-year-old woman, nonsmoker, nondiabetic presented with intermittent fever, weight loss, shortness of breath, and hemoptysis for 18 months. She was suspected to have a drug-resistant TB case as the patient had a history of ATT for 8 months. CBNAAT was negative for MTB and AFB were seen on ZN stain. The culture revealed Mycobacterium scrofulaceum. Bilateral fibrocavitary lesions were seen on the chest radiograph. A specific drug regimen including rifampicin (R), isoniazid (H), ethambutol (E), and clarithromycin (Cl) was instituted after which clinical improvement was observed. After 1 year, there was a relapse, and the patient is continuing treatment.

Case 2

A 45-year-old female non-smoker presented with weight loss, loss of appetite, shortness of breath, intermittent fever, cough, and hemoptysis for 12 months. She was suspected of having DR-TB due to the history of ATT for 6 months. CBNAAT did not detect MTB in both sputum and bronchoalveolar lavage (BAL) samples. Both the samples were negative for AFB on ZN stain. M. scrofulaceum was isolated from both sputum and BAL samples. A bilateral fibrocavitary lesion was seen on a chest radiograph. The patient improved clinically after the initiation of rifampicin, isoniazid, ethambutol, and clarithromycin. No relapse of symptoms was noted till 1 year of treatment.

Case 3:

A 74-year-old non-smoker, nondiabetic nonhypertensive male presented with intermittent fever, weight loss, loss of appetite, shortness of breath, and cough for 2 years. The patient had a history of pulmonary TB with ATT for 8 months. Hence, it was a presumptive DR-TB. The patient sample was negative for MTB by CBNAAT, and no AFB was seen on ZN stain, but it was culture positive for M. scrofulaceum. A nodular lesion was on his chest radiograph. The patient died before the final diagnosis of NTM LD and initiation of a specific therapy.

Case 4

A 42-year-old female presented with complaints of intermittent fever, weight loss, shortness of breath, cough, and hemoptysis for around 1 year. The patient had a history of ATT for 8 months. MTB was not detected by CBNAAT and no AFB was seen on ZN staining. M. scrofulaceum was isolated from the patient sample. Fibrocavitary lesions were found in the right lung on the chest radiograph. A specific drug regimen was instituted. The patient improved clinically after initiation of rifampicin, isoniazid, ethambutol, and clarithromycin, and no relapse of symptoms was noted till 1 year of treatment.

Case 5

A 61-year-old female presented with constitutional symptoms such as intermittent fever, weight loss, loss of appetite, shortness of breath and cough for 1 year. The patient had a history of ATT for 6 months. The BAL sample was negative for MTB by CBNAAT. No AFB was seen on ZN stain. The culture was positive for Mycobacterium intracellulare. Fibrocavitary changes and tree-in-bud lesions were seen in HRCT lungs [Figure 2]a. The patient improved clinically after the initiation of amikacin, rifampicin, ethambutol, and clarithromycin. There was no relapse of symptoms till 1 year of treatment.
Figure 2: (a) CT thorax showing fibrocavitary changes and bronchiectasis on right side of hemithorax and tree-in-bud on left hemithorax, (b) Pus discharge from laparoscopic port site near umbilical region due to Mycobacterium abscessus infection, (c) Skin ulcer over leg due to Mycobacterium abscessus infection. CT: Computed tomography

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Case 6

A 52-year-old female complained of intermittent fever, weight loss, shortness of breath, cough, and hemoptysis for 2 years. The patient had taken ATT for 6 months' duration. BAL sample was negative for MTB by CBNAAT, no AFB was seen on ZN stain, and it was culture positive for M. scrofulaceum. Nonhomogeneous coarse nodular opacities of varying density were detected on the chest radiograph. The patient improved clinically after initiation of rifampicin, isoniazid, ethambutol, and clarithromycin and there was no relapse of symptoms was noted till 1 year of treatment.

Case 7

A 41-year-old male presented with complaints of shortness of breath and cough for 1 month. There was no history of ATT. BAL sample was negative for MTB by CBNAAT, and no AFB was seen on ZN stain. Fibroproliferative and cavitary lesions were seen in the right lung on the chest radiograph. Empirical treatment therapy including antibiotics and bronchodilators was started before the isolation of Mycobacterium kansasii on culture. Specific therapy could not be instituted as the patient was lost to follow-up.

Case 8

A 52-year-old female presented with intermittent cough and hemoptysis for 8 months. There was significant weight loss and loss of appetite. It was presumed to be a case of DRTB as there was a history of ATT for 6 months' duration. BAL sample was culture positive for M. scrofulaceum. It was negative for MTB by CBNAAT, and no AFB was seen on ZN stain. On the chest radiograph, cavities with multiple coarse nodules were present. A combined four-drug regimen including injectable amikacin, rifampicin, clarithromycin, and ethambutol was started, following which patient improved clinically.

Case 9

A 47-year-old male presented with fever and cough for 15 days. On the chest radiograph, nodular opacity was marked. The BAL specimen was negative for MTB by CBNAAT. No AFB was seen on ZN stain. It was culture positive for M. scrofulaceum. The patient was lost to follow-up before a definitive diagnosis of NTM LD was made.

Demography, clinical features, diagnosis, treatment, and the response of patients with NTM LD are depicted in [Table 1].
Table 1: Demography, clinical features, diagnosis, treatment, and the response of patients with pulmonary nontuberculous mycobacteria

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Non-pulmonary nontuberculous mycobacteria cases

Case 1

A 65-year-old female presented with complaints of pain and pus discharge from a laparoscopic port site near the umbilical region for the past 6 months [Figure 2]b. She had received ATT for 6 months for a similar presentation about 1 year back on the basis of AFB findings. The patient had a history of laparoscopic surgery for cholecystectomy 2 years back. The curetted tissue sample was negative for Xpert MTB and the culture was positive for Mycobacterium abscessus complex. On ZN stain, no AFB was seen. The patient responded clinically 6 months after the institution of a combined drug regimen including injectable amikacin, levofloxacin, and clarithromycin.

Case 2

A 55-year-old female presented with a swelling over the lower abdomen for the 1 month duration. The aspirated pus sample was negative for MTB by CBNAAT. AFB was seen on ZN stain. Empirical antimicrobial therapy was started with linezolid. It was culture positive for M. abscessus complex. However, specific therapy could not be instituted as the patient was lost to follow-up.

Case 3

A 26-year-old female presented with a non-healing skin ulcer over the right side leg for 6 months [Figure 2]c. The ulcer was not healing with empirical antimicrobial therapy. The pus sample from the site was AFB positive on ZN staining but CBNAAT did not detect MTB. It was culture positive for M. abscessus complex. The ulcer subsided 6 months after the institution of specific therapy, including injectable amikacin, levofloxacin, and clarithromycin.

Case 4

A 38-year-old female presented with complaints of pain over the left iliac region and pus discharge from the laparoscopic port site for the past 3 months. She had a history of laparoscopic myomectomy for fibroid uterus 1 year back. On ultrasonography, a small collection was noted within subcutaneous tissue in the anterior abdominal wall of the lower abdomen. Two sinus tracts were seen coming from left paraumbilical ports and joining the collection. The symptoms did not resolve with empirical antibiotics. USG-guided aspirated pus was culture positive for M. abscessus complex, and CBNAAT was negative for MTB. AFB was seen on ZN stain. Clinical response was present after 1 month of treatment with Cl and Ofloxacin (Ofx). After 6 months, there was a relapse of symptoms.

Case 5

A 42-year-old female presented with pain and pus discharge from a laparoscopic port site for 6 months. She had a history of laparoscopic surgery for cholecystectomy. Pus sample was negative for MTB by CBNAAT. No AFB was seen on ZN stain. Incision and drainage along with empirical antibiotics were instituted before the diagnosis of M. abscessus infection by culture. The patient was lost to follow-up.

Case 6

A 10-year-old girl presented with suspected tubercular lymphadenitis with swelling of cervical lymph nodes for 3 months. The tissue sample was negative for MTB by CBNAAT and culture positive for Mycobacterium fortuitum group. No AFB was seen on ZN stain. Specific therapy could not be instituted as the patient was lost to follow-up.

Case 7

A 52-year-old female presented with pain and pus discharge from laparoscopic port site for the past 3 months. She had a history of laparoscopic surgery for cholecystectomy about 1 year back. MTB was not detected in the pus specimen by CBNAAT. No AFB was seen on ZN stain. It was culture positive for M. abscessus complex. Antimicrobial therapy including clarithromycin and levofloxacin was instituted, but the patient was lost to follow-up.

Case 8

A 60-year-old male presented with pus discharge from the right ear for the last 1 month. It was a suspected TB case, but MTB was not detected in the pus sample by CBNAAT. No AFB was seen on ZN stain. It was culture positive for M. fortuitum. The patient was lost to follow-up before the diagnosis of NTM disease was made.

Case 9

A 29-year-old female complained of pus discharge from a laparoscopic port site for the past 3 months. She had a history of laparoscopic surgery for cholecystectomy about 6 months back. Her pus sample was negative for MTB by CBNAAAT, AFB negative after ZN staining, and culture was positive for M. abscessus. The patient could not receive specific therapy as she was lost to follow-up before a definitive diagnosis of NTM infection was made.

Case 10

A 7-year-old boy presented as a suspected case of tubercular lymphadenitis with swelling of the cervical lymph node for 1 month. The aspirated pus sample was negative for MTB by CBNAAT, and no AFB was seen on ZN stain. It was culture positive for M abscessus complex. The patient did not receive specific therapy as he was lost to follow-up before a definitive diagnosis of NTM infection was made.

Case 11

A 23-year-old male presented with a subcutaneous abscess over the left deltoid for 3 months duration. The patient had a history of taking an injection at that site about 1 month prior to this. There was relapse after treatment with incision and drainage and empirical antibiotic (Linezolid). Pus from the site was negative for MTB by CBNAAT and negative for AFB on ZN stain. It was culture positive for M. fortuitum. Specific therapy, including levofloxacin, trimethoprim/sulfamethoxazole (TMP/SMX), and clarithromycin was instituted. There was a clinical improvement after 1 month of initiation of therapy.

Demography, clinical features, diagnosis, treatment, and the response of patients with nonpulmonary NTM infection are depicted in [Table 2].
Table 2: Demography, clinical features, diagnosis, treatment, and the response of patients with nonpulmonary nontuberculous mycobacteria infection

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  Discussions Top


The majority of pulmonary cases in our series presented as presumptive drug-resistant TB with a history of intake of ATT. In resource-limited TB settings like India, the facilities for culture and speciation of mycobacteria are available at fewer centers. Culture and speciation by the conventional biochemical method is time taking and cumbersome. Facilities for speciation by LPA, DNA sequencing, and MALDI-TOF mass spectrometry (Matrix assisted laser disroption/ionisation -Time of flight ) are available only at higher centers.[3],[10] Hence, most NTM cases are presumptively diagnosed as TB based on ZN staining by microscopy, and ATT is instituted. As NTM are resistant to conventional ATT, relapse occurs very frequently after a few months of asymptomatic state.[3],[11] These cases are presented as suspected DR-TB.

Worldwide, pulmonary involvement is the most common form of NTM disease. In a large proportion of pulmonary cases, the NTM disease is diagnosed in patients with previously damaged lung parenchyma, chronic LD, such as bronchiectasis, chronic obstructive pulmonary disease, and cystic fibrosis.[12] Radiological patterns vary from bronchiectasis, fibrocavitary, coarse nodular shadows of varying density to inflammatory infiltrations. In our series, we had broadly two patterns: fibrocavitary and coarse nodular, which is supported by existing literature.[5] The fibrocavitary pattern (n = 6) is more common than the coarse nodular pattern (n = 3) in our series. Mycobacterium avium complex (MAC) is the most common species causing NTM LD worldwide.[8] However, in our series, Mycobacterium scrfulaceum (n = 7) is the most common species isolated from pulmonary specimens followed by M. kansasii (n = 1) and M. intracellulare (n = 1) belonging to MAC. Although M. scrfulaceum rarely causes LD in America and Europe, it is second-most common after MAC in TB endemic countries of Africa.[8] Among African gold miners, M. kansasii and M. scrofulaceum (68%) were the most common agents causing NTM-LD. The majority of patients presented with new cavitation.[13] Our finding is in line with previous studies. In different Indian studies, the common species isolated from pulmonary specimens are M. abscessus, M. fortuitum, M. intracellulare, M. chelonae, M. avium, M. gordonae, M. kansasii, and M. szulgai.[3],[11] Differential geographic distribution and host factors may be the reason for area-wise variation in species spectrum. A large multi-centric study is required to know the species spectrum of NTM.

Rapid growers such as M. abscess, M. chelonae, and M. fortuitum are the most common cause of skin and soft tissue infection (SSTI), a common non-pulmonary manifestation.[3],[11] Our results are in line with the existing literature. M. abscessus (n = 8) is the most common species involved, followed by M. fortuitum (n = 3). SSTI usually occurs due to previous surgical procedures, laparoscopic port site infection, injection site abscesses, and cosmetic surgery.[14]

Specific treatment for NTM disease is guided by ATS/IDSA and British Thoracic Society guidelines.[4],[15] However, in most of the cases, an empirical therapeutic regimen is initiated on the basis of the identification of NTM by a negative MPT64 rapid ICT (which is positive for MTB complex). Moreover, standard drug susceptibility test (DST) is not available everywhere. Hence, strict adherence to ATS/IDSA or BTS guidelines is not always possible in resource constraints countries. Hence, the drug regimen is prescribed on a case-by-case basis.[4]

In the case of MAC pulmonary disease, a three-drug regimen including rifampicin, ethambutol, and a macrolide is recommended for at least 12 months after culture conversion.[15] However, in case of severe MAC pulmonary disease (radiological evidence of lung cavitation), injectable Amikacin is added to the three-drug regimen for initial 3 months.[15] In our series, injectable Amikacin was prescribed along with a three-drug regimen to one patient with MAC LD with cavitation. Clinical response was present in this case.

In the case of LDs due to M. scrofulaceum, a three-drug or four-drug regimen including one macrolide is recommended depending on the susceptibility of the strain. The duration of therapy depends on response and outcome.[4] In a study, treatment failure occurred in 12% of patients with NTM-LD with M. scrofulaceum infection.[13]

The majority of SSTIs in our studies are due to laparoscopic port site infection and rapid growers were the causative agents in all these cases. These findings are in line with the existing literature.[16],[17] Typically, wound infections due to NTM do not occur as an immediate complication following surgery. There is apparent immediate post-operative healing. Gradually, over a variable period of time, the scar breaks down to a persistent non-healing wound with discharging sinuses. The wound does not heal with empirical antimicrobial therapy used for acute infection. The wounds are often painless and patients do not present with any constitutional symptoms.[14] Hence, in all the SSTIs with a chronic nonhealing wound, particularly the laparoscopic port site wound warrants high suspicion of NTM infection.

The treatment regimen for SSTI due to M. abscessus is based on the susceptibility pattern of the strain. In most cases, a regimen including injectable amikacin, a macrolide and/or fluoroquinolone is chosen.[4] Monotherapy or macrolide with a fluoroquinolone dual therapy should not be used. In this series, the macrolide-based regimen has shown good results. M. fortuitum is usually susceptible to oral antibiotics. The percentage of strains susceptible to different antimicrobials is variable. Isolates are susceptible to amikacin (100%), ciprofloxacin and ofloxacin (100%), sulfonamides (100%), cefoxitin (50%), imipenem (100%), clarithromycin (80%), and doxycycline (50%).[4] In this series, one patient with SSTI due to M. fortuitum was treated with levofloxacin, TMP/SMX, and clarithromycin with good clinical response.

Although treatment outcome after specific therapy is good, relapse is not uncommon. The clinical response to treatment regimen depends on the strain and species of NTM, susceptibility profile, host factors, site of infection and severity of disease.[4],[15] The major limitation of the present study is lack of susceptibility testing of NTM isolates. However, this also underscores the fact that knowledge on susceptibility profile of NTM isolates in India is highly imperative.


  Conclusion Top


In TB endemic settings like that of India, most of the NTM cases are misdiagnosed as TB and hence wrongly treated with antitubercular drugs. Again, after relapse or treatment failure, they are wrongly diagnosed and treated in the line of MDR TB. Any patient with underlying damaged lung parenchyma, nonresponder of ATT without detectable drug resistance, having clinically slow progression or worsening and radiographical progression should be investigated for the diagnosis of NTM. Even after the completion of treatment, a mycobacterial sputum culture is needed as relapse is common. In the case of chronic non-healing SSTIs at the laparoscopic wound, the first suspicion should be NTM. In those cases, empirical anti-microbial therapy leads to relapse. This contributes to significant morbidity, mortality, and increased drug resistance. Hence, there is an urgent need for a better diagnostic and drug susceptibility testing facility and development of a standardized treatment protocol for NTM disease.

Limitations of study

Antimicrobial susceptibility testing of NTM isolates was not performed in this study. Second, a specific therapeutic drug regimen could not be instituted in some cases as those patients were lost to follow-up before diagnosis of NTM disease. Moreover, response to treatment with specific therapy could not be recorded in few cases as they did not turn up for follow-up checkup and repeat testing.

Ethical clearance

The study was approved by the Institutional Ethics Committee of All India Institute of Medical Sciences, Bhubaneswar (Reference Number: IEC/AIIMS BBSR/PG Thesis/2018-19/32, dated December 22, 2018).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patients/guardians of minor patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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  In this article
Abstract
Introduction
Methods
Results
Discussions
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