Welcome to Cross-Canada Paediatric - Respiratory Residency Rounds
Page 9/Case04/01

Radiological Findings
Can include any of the following:
– Immunocompromised: hilar or mediastinal nodes**
– Consolidation, fibrosis, nodules, bronchiectasis, adenopathy, cavitation rare
– Usually more indolent, slowly progressive disease
– Bronchiectasis and centrilobular nodules
– Lingula and right middle lobe; apical cavitary disease

ATS criteria for NTM infection (1997)
(Wallace et al. Am J Resp Crit Care Med 1997)

Multiple Specimens and Patient Follow-up
Symptomatic patients with infiltrate, nodular or cavitary disease, or a high resolution CT scan that shows multifocal bronchiectasis and/or multiple small nodules

A. If 3 sputum/bronchial wash results are available from previous 12 months:
1) 3 + cultures with negative AFB smear or
2) 2 + cultures and one + AFB smear

B. If only one bronchial wash available:
1) + culture with 2+ 3+ 4+ AFB smear or growth on solid media.

C. If sputum/bronchial wash evaluations are nondiagnostic or another disease cannot be excluded:
1) Transbronchial or lung biopsy yielding NTM or
2) Biopsy showing mycobacterial histopathological features and one or more sputum/bronchial washings are positive for NTM, even in low numbers

Diagnostic Issues
– PPD test for NTM. Avian sensitin used in Australia, not widely available, >10mm = significant. Double Mantoux test differentiating NTM from MTB: sensitivity 98%, specificity not known (Daley, Peds Infect Dis, 1999) sensitivity of 79%, specificity 69% (Pang, 1992)
– PPD-T commonly weak false positive reactions (<10 mm) (Ginsburg, Peds Infec Dz, 1992)

Literature Review
Pulmonary mycobacterium avium disease - uncommon in children


– Gilbert and Lincoln reported (n=13) from 1930-1969, additional 5 probable cases and 3 possible cases; Fergie reported (n=9) from 1969-1997
– Underlying immunodefiency uncommon, but increasing incidence with HIV
– Incidence unknown, but reported 10% in kids with HIV
– Wide variation in type and duration of therapy (Fergie, Clinical Infectious Disease, 1997)

(Dore et al, Peds Pulmonology, 1998)
Case reports (n=10)
– Pulmonary non-tuberculous mycobacterium infection
– Bronchial obstruction 8/10;
– Endobonchial obstruction 6/10
– One patient had chronic granulomatous disease, the remaining with normal immune function based on currently available tests. Not tested for specific immune mediators such as tumor necrosis factor Clarithromycin and rifabutin used in 4/10, highly variable therapy. Benefit of steroids in decreasing bronchial compression reported. (Piedmonte et al, Ped Pulm, 1997)

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