Atypical Tuberculous Spondylitis and NTM

Atypical mycobacterial spondylitis as a challenging differential diagnosis to metastatic disease of the spine: a case report
“Disseminated Mycobacterium avium complex (MAC) infection is rarely seen in patients without acquired immune deficiency syndrome. A disseminated MAC infection presenting with symptoms that mimic tumor metastasis had not previously been reported. Few disseminated MAC infections have been reported, and all image patterns in these cases indicated destructive lesions. We present a case involving a tumor-like disseminated MAC infection with spondylitis in a 68-year-old man whose symptoms started with severe lower back pain and fever. Treatment for malignancy was performed initially but soon stopped after tissue proving MAC infection. Symptoms then improved dramatically after a four-drug combined anti-nontuberculous mycobacteria treatment.”

Non tuberculous mycobacteria related spondylodiscitis: a case report and systematic literature review
Spinal infections are severe conditions that require accurate procedures to reach diagnosis, often long-lasting antibiotic therapy and, sometimes, surgical treatment [1, 2]. Non Tuberculous Mycobacteria (NTM) infections are quite uncommon especially in healthy patients …
This review highlights the rarity of spinal infections due to NTM and the difficulty of their management. We suggest that, when clinical suspicion of NTMSDs occur, as any for any SD, spinal MRI is mandatory to confirm diagnosis and to identify the possible presence of spinal abscess and consequently plan the biopsy, which should be studied with microbiological techniques mentioned above. The literature provides only a few studies regarding the potential usefulness of PET/CT as a diagnostic tool in spondylodiscitis, however, its potential role in functional assessment of inflammatory and infectious diseases including mycobacteria is gaining interest. The preliminary studies suggest a potential alternative role for PET/CT in the evolution, and follow-up assessment in patients in witch MRI was contraindicated [95]”

Multi-stage surgery for a multiple-level spondylodiscitis caused by multidrug-resistant Mycobacterium avium complex

“The objective of this article is to report a rare case of atypical mycobacterial spinal spondylodiscitis with multiple-level involvement and the successful treatment by multi-stage surgical intervention. Reports on the surgical management of atypical mycobacterial spondylodiscitis are lacking. A 71-year-old woman with a confirmed diagnosis of multiple-level spondylodiscitis of L2-L3 and L5-S1 caused by Mycobacterium avium complex (MAC). The patient underwent a two-stage surgical treatment (first: posterior instrumentation; second: anterior debridement with anterior lumbar interbody fusion). At 1 year after surgery, the patient suffered a proximal junctional failure secondary to a vertebral fracture that was solved with a proximal extension of the fusion using a percutaneous technique. The patient was successfully discharged with good pain control, satisfactory correction, no neurologic complications and an overall satisfactory outcome. A rare case of antibiotic-resistant multi-level spondylodiscitis due to MAC was treated successfully with multi-stage surgical treatment. Surgery in this patient group remains challenging due to the technical complexities and the difficulty of choosing the instrumentation levels.”

Epidemiology, clinical manifestations, and diagnosis of osteomyelitis due to nontuberculous mycobacteria “Nontuberculous mycobacteria (NTM) are a large group of organisms that are widespread in the environment. They have been isolated from numerous environmental sources, including water and soil. NTM can cause a broad range of infections that vary depending on the particular NTM species and on the host’s immune status. In immunocompetent individuals, disease can present as pneumonia, lymphadenitis, or skin, soft tissue, and/or bone infection. Immunocompromised individuals can also present with any of these findings, but disease in such patients may also manifest as disseminated infection. Since NTM are seldom considered as a possible etiology in infections of the soft tissues and/or bones, delays in diagnosis are common.

The epidemiology, pathogenesis, clinical manifestations, and diagnosis of osteomyelitis due to NTM will be reviewed here. The treatment of osteomyelitis due to NTM is discussed separately. (See ”Treatment of osteomyelitis due to nontuberculous mycobacteria in adults”.)

Other manifestations of NTM infections, as well as osteomyelitis due to bacteria and Mycobacterium tuberculosis are also discussed separately. (See ”Epidemiology of nontuberculous mycobacterial infections” and ”Microbiology of nontuberculous mycobacteria” and ”Overview of nontuberculous mycobacteria (excluding MAC) in patients with HIV” and ”Mycobacterium avium complex (MAC) infections in persons with HIV” and ”Rapidly growing mycobacterial infections: Mycobacteria abscessus, chelonae, and fortuitum” and ”Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis” and ”Pathogenesis of osteomyelitis” and ”Approach to imaging modalities in the setting of suspected nonvertebral osteomyelitis” and ”Hematogenous osteomyelitis in children: Epidemiology, pathogenesis, and microbiology” and ”Vertebral osteomyelitis and discitis in adults” and ”Bone and joint tuberculosis”.)”

Vertebral osteomyelitis caused by non-tuberculous mycobacteria: Predisposing conditions and clinical characteristics of six cases and a review of 63 cases in the literature “Several case series have reported on clinical and radiographic characteristics of patients with vertebral osteomyelitis (VO) caused by non-tuberculous mycobacteria (NTM).”

Spondylitis following bloodstream dissemination of Mycobacterium chelonae disseminated in an immunocompetent patient: a case report and literature review “Non-tuberculous mycobacterial spondylitis is a rare spinal infection, especially among patients without acquired immunodeficiency syndrome or other immune impairments. Because of its rarity and non-specific clinical manifestations, diagnosis is often delayed or missed. Here, we present a case of Mycobacterium chelonae spondylitis in an immunocompetent patient and review the relevant literature.”

Slowly Growing Nontuberculous Mycobacteria (NTM)
“EVERVIEW: What every practitioner needs to know. Are you sure your patient has disease due to slowly growing nontuberculous mycobacteria? What should you expect to find?
Nontuberculous mycobacteria (NTM) can infect almost any organ in the body, thus, signs and symptoms will vary depending on the site of infection. In general, NTM cause four different clinical syndromes:
* progressive pulmonary disease
* skin and soft-tissue infection
* Lymphadenitis disseminated disease
* Among the slowly growing mycobacteria (SGM), the most clinically relevant species are members of M. avium complex (MAC), M. haemophilum, M. kansasii, M. malmoense, M. marinum, M. simiae, and M. xenopi. M. avium complex includes the common pathogens M. avium, M. chimaera, and M. intracellulare. M. kansasii is the most pathogenic of the slow growers and second only to MAC as a cause of lung disease in some regions.

Pulmonary disease

The symptoms of pulmonary disease due to SGM are variable and nonspecific in nature. It is often difficult to determine if the symptoms are due to mycobacterial infection or the underlying lung disease, such as bronchiectasis, cystic fibrosis, or chronic obstructive pulmonary disease.

Chronic or recurring cough (70-90%), which may be productive, is one of the most common symptoms.

Other symptoms include:
* Fatigue (>80%), malaise, low-grade fevers, night sweats, weight loss (<40%), chest pain, dyspnea (70%), and, occasionally, hemoptysis (<40%)
* Skin, soft-tissue and bone disease
* Patients report drainage or abscess formation at the site of puncture wounds or open traumatic injuries.
* Lymph node disease

Patients present with enlarged, unilateral, non-tender lymph nodes, most commonly in the cervical chain.

  • Disseminated disease

In patients with advanced HIV infection, the clinical manifestations are protean and may be confused with other diseases. SGM can produce disseminated disease in HIV-infected patients with advanced immunosuppression.

Classic symptoms: fever (>80%), night sweats (>35%), and weight loss (>25%)

Additional symptoms: abdominal pain and diarrhea

In non-HIV infected immunocompromised patients, disseminated SGM disease may present as multiple cutaneous nodules or abscesses.

Physical findings

  • Pulmonary Disease

Physical findings are nonspecific and often reflect the underlying pulmonary disease.

Nodular-bronchiectatic NTM disease tends to occur in post-menopausal women, many of whom have a characteristic morphotype with a thin body habitus, kyphoscoliosis, pectus excavatum, and mitral valve prolapse.

Fibro-cavitary disease typically occurs in patients with underlying chronic obstructive pulmonary disease, thus, auscultatory findings include distant breath sounds, wheezes, and rhonchi.

  • Skin, soft-tissue and bone disease

Localized drainage or abscess formation occurs at the site of puncture wounds or open traumatic injuries.

Lesions may be mildly erythematous in appearance, mildly tender, and with serosanguinous drainage.

  • Lymph node disease

Enlarged, unilateral, non-tender lymph nodes, most commonly in the cervical chain occur.

  • Disseminated disease

Physical findings may include cutaneous nodules, abdominal tenderness, hepatosplenomegaly, and lymphadenopathy.

TNF inhibitors increase the risk of nontuberculous mycobacteria in patients with seropositive rheumatoid arthritis in a mycobacterium tuberculosis endemic area “The aim of this study is to examine the impact of tumor necrosis factor inhibitors (TNFI) on nontuberculous mycobacterium (NTM) infection in rheumatoid arthritis (RA) patients in a mycobacterium tuberculosis (MTB) endemic area. We selected 1089 TNFI-treated RA patients and 4356 untreated RA patients using propensity-matching analysis according to age, gender, and Charlson comorbidity index using the Korean National Health Insurance Service database from July 2009 to December 2010. Both groups were followed-up until the end of 2016 to measure the incidence of mycobacterial diseases. The incidence rate of NTM in TNFI-treated RA group was similar to those of MTB (328.1 and 340.9 per 100,000 person-years, respectively). The adjusted hazard ratio (aHR) of NTM for TNFI-treated RA compared to untreated RA was 1.751(95% CI 1.105–2.774). The risk of TNFI-associated NTM in RA was 2.108-fold higher among women than men. The age-stratified effects of TNFI on NTM development were significantly high in RA patients aged 50–65 years (aHR 2.018). RA patients without comorbidities had a higher incidence of NTM following TNFI treatment (aHR 1.742). This real-world, observational study highlights the need to increase awareness of NTM in TNFI-treated RA patients in an MTB endemic area.”

Clinical manifestations of nontuberculous mycobacteria infections “A not negligible portion of cases of spondylodiscitis have a mycobacterial aetiology, with those attributable to NTM being as frequent as those caused by Mycobacterium tuberculosis. Both rapidly and slowly growing species may be involved; among the latter, M. xenopi is one of the leading causes [27].”

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