2. NTM pulmonary disease
The most common clinical manifestation of NTM disease
Incidence: 7.94 per 100,000
Most common pathogen in taiwan
M. avium complex (MAC), rapidly growing species (especially M.
abscessus), M. kansasii
Susceptibility to NTM disease
Preexisting structural lung diseases
− Prior pulmonary tuberculosis, cystic fibrosis, bronchiectasis, COPD,
silicosis, pneumoconiosis
Conditions that might alter local or systemic host immune status
− Alcoholism and smoking, esophageal reflux (especially with M.
fortuitum /abscessus ), sinus disease, IFN-γ production or receptor
abnormalities, HIV/AIDS, immune suppressing drugs and organ
transplantation
2
Expert Rev Respir Med. 2012 Dec;6(6):597-612
Emerg Infect Dis. 2011 Mar;17(3):343-9.
3. Clinical
Pulmonary symptoms (Cough, fatigue, weight loss. Fever and hemoptysis are
less common and suggest advance/extensive disease)
Exclusion of other disease (Such as TB, malignancy)
Chest imaging
Radiograph: nodular or cavitary lesion on chest radiograph
HRCT: multifocal bronchiectasis with multiple small nodules
Microbiologic
Positive cultures from two separate sputum specimens
Positive culture from >1 bronchial wash or BAL
Lung biopsy with histopathologic changes of granulomatous inflammation or
AFB plus positive NTM culture
3
Am J Respir Crit Care Med. 2007;175:367–416.
HRCT: high resolution computed tomography
Diagnostic Criteria of NTM pulmonary disease
Clinical, radiological, and microbiological all required
and
or
or
or
4. Image Findings of NTM Lung Disease
Usually nonspecific and variable, depending in part upon the
species
Two common radiographic pattern
Cavitary tuberculosis-like
Nodular bronchiectasis
4
Clin Radiol. 2002 Aug;57(8):661-9.
Expert Rev Respir Med. 2012 Dec;6(6):597-613.
Comparison of radiographic features of NTM infection and TB
5. Seen in approximately 90% of M. kansasii infection, and 50% of
MAC infection
Often in the upper lobes
Tends to occur among male smokers with underlying COPD, prior TB
Characteristics compare with TB
Smaller, thinner walled cavities with less surrounding parenchymal opacity
More pleural involvement
− Pleural thickening is common and probably more marked than in
tuberculosis but pleural effusions are uncommon
→ insufficiently specific to exclude TB
5
Am J Respir Crit Care Med. 2007;175:367–416.
Radiographic Findings of NTM Lung Disease
Cavitary tuberculosis-like
6. 50% of MAC lung disease, also be seen with other NTM pathogens
including M. abscessus, M. simiae, and M. kansasii
Right middle lobe and lingula are particularly affected
The nodules and bronchiectasis are usually present within the
same lobe
Most prevalent in nonsmoking middle-aged or elderly women, no
previous lung disease, tall and lean body habitus
→ “Lady Windemere’s Syndrome”
6
Clin Chest Med. 2002;23(3):603.
Am J Respir Crit Care Med. 2007;175:367–416.
Radiographic Findings of NTM Lung Disease
Nodular bronchiectasis
7. High-resolution chest CT (HRCT) scan
Regardless of NTM species, the most common HRCT findings were
Small bilateral nodules
Branching centrilobular nodules, (ie, tree-in-bud pattern)
Bronchial wall thickening and cylindrical bronchiectasis
7
Radiology. 1995;194 (2): 413-7.
Chest. 2004;126 (2): 566-81.
Radiology 2004; 231, 880-886
22 y/old male, non-smoker, with cystic
fibrosis and M. abscessus lung disease.
Patient with diffuse nodular and
reticulonodular densities including “tree-
in-bud” appearance of densities in lung
periphery.
(順著支氣管散佈的病灶像是樹枝發芽一樣)
圓柱型支氣管擴張
樹芽狀散佈
8. 66 y/o man, smoker with MAC lung disease
associated with large right upper lobe
cavity and bilateral reticulonodular
densities.
41 y/o female, smoker, with MAC lung
disease associated with left apical
confluent density with cavitation.
(兩側網狀病灶) (左肺尖病灶匯集 density增加並有空洞之病灶形成)
9. 73 y/o non-smoking female with MAC lung disease
demonstrating bilateral nodular densities and
bronchiectasis.
9
10. 79 y/o non-smoking female with MAC lung disease
CXR: primarily mid-lung nodular and reticulonodular densities and cavitation
HRCT: nodules, bronchiectasis and cavitation
10
11. 42 y/o man, smoker, with M. kansasii disease
associated with bilateral upper lobe
reticulonodular densities
77 y/o man, smoker, with M. kansasii disease
associated with bilateral mid and upper lung
field reticulonodular densities with cavitation
11
(網狀病灶 左肺的比較淡)
12. 30 y/old male, non-smoker, with hypersensitivity-like lung disease following
hot-tub exposure
CXR: diffuse reticular densities
HRCT: diffuse “ground glass” appearance of lung parenchyma
12
整個肺呈現”毛玻璃狀”的病灶(出現在肺組織
且瀰漫性分布的病灶)
(兩邊肺看起來有網狀的結構病灶)
14. A much rarer pattern
Present with bilateral diffuse ground-glass infiltrates,
nodules, reticulation, or mosaic attenuation consistent
with patchy air trapping
Radiographic Findings of NTM Lung Disease
Hypersensitivity pneumonitis
14
15. 55 y/o non-smoking female with MAC lung disease
CXR: cavitary right middle lobe (RML) density
HRCT: destruction of the RML with bronchiectasis, and nodules in the lower lobes
15
16. 70 y/o female, non-smoker, with M. abscessus disease
CXR: bilateral reticulonodular densities and cavitation
HRCT: nodules and bronchiectasis in right middle lobe, lingula and lower lobes,
and cavitation
16
17. 54-year-old man with mild emphysema, cough, and fever
MAC infection
A. left upper lung shows well-circumscribed cavitary left upper lobe mass
B, C. left upper lobe cavity and show adjacent cluster of small nodules
17
18. Chest CT scans
patient with MAC infection
Show nodules and multifocal bronchiectasis in the
middle lobe and lingula
18
19. Chest CT scans
Patient with mycobacterium kansasii infection
Shows cavitation and fibrosis in the right upper lobe
19
20. 50 y/o male with COPD and a worsening cough, and a low-grade
fever of 3 months' duration
Mycobacterium kansasii infection
show cavitating consolidation and volume loss, the primary
pattern associated with nontuberculous mycobacterial infections.
20
26. TB
Micronodules and tree-in-bud appearance were the most common
characteristic features of HRCT scans in patients with newly
diagnosed pulmonary TB
These lesions are not seen on chest radiographs, HRCT may
provide valuable information on the diagnosis of active TB
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