A 44 y/o woman was referred to me for possible atypical mycobacterium. Several years ago, she was diagnosed with MAC and treated for 6 months with Rifampin, Ethambutol, and Biaxin. Her therapy was stopped because of optic neuritis. Over the following several years, she remained stable, but in poor general health. Recently, she has developed recurrent sinusitis, and has had several complicated sinus surgeries. She was referred because of persistent cough.
The remainder of her history is unremarkable, with the exception that she continues smoking regularly (1ppd x 20+ years).
On exam, she is thin, but in no distress. Her general exam is unremarkable, although she has some scattered wheezes and rales bilaterally.
Her pulmonary function shows mild obstruction, with normal gas exchange.
A high resolution CT scan shows mild bilateral bronchiectasis, primarily in the upper lobes, middle lobe, and lingula.
How would you approach this patient? I'll post some follow-up as we go...
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Here are a couple ideas: how real was the MAC? She may have ABPM so I would check the usual IgE, CBC with Diff and Aspergillus preciptins. A1AT-deficiency has been associated with bronchiectasis as well and might be worth checking in a young smoker.
The sinus disease may suggest a reservoir for infections (e.g. Aspergillus) and the coexisiting reactive airways and sinus disease raise the possibility of ASA-induced asthma. CF and ciliary dysmotilities could have the same presentation but it would be very surprising to pick it up now at age 44...
any clues from Hx that collagen-vascular disease (chronic poor health, etc.) may be the cause of the bronchiectasis?
All good thoughts. The history of MAC was from several years before her current presentation, and was in a different state. I did not have (and she could not provide) the old records.
IgE was normal, as were other quantitative immunoglubulins. Aspergillus titers were negative. There was no emphysema on her HRCT, so A1AT was not checked. Nothing in her history was suggestive of collagen-vascular disease.
Her history was not suggestive of asthma (bronchodilator reversibility was not checked), and she did not use asthma.
There was no known family history of CF, and this was not further evaluated.
I will bring A1AT again (though it's not the answer since it wasn't checked): one of its pulm. presentations is of predominant bronchiectatic changes without emphysema.
kDoesn't seem to be much interest in this case, so I'll wrap it up. I was concerned that her original atypical mycobacterium was never adaquately treated, so I obtained several sputum samples.
After several weeks, the cultures were growing Mycobacterium terrae. I'd never heard of it, but it is is pathogen and there are sevearl case reports in the literature. (Smith DS et al. Clin Infec Dis 2000).
Very little literature available to guide treatment, but the reports suggest that standard therapy for MAC should be sufficient. Given her prior optic neuritis, we could not use ethambutol, and there is scant literature about alternative regimens for this particular bug.
So, my plan was to use an alternative regimen for MAC (in consultation with ID). Unfortunately, the patient moved out of state and we can not contact her...
Jeff, I thought this was an interesting case. The terrae complex is also a mix of species similar to MAC and they are also slow growers so it may have been a mix of species from the first time she presented...
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