Tubercle
THE PATHOGENICITY
OF
MYCOBACTERlUM
AND MYCOBACTERIUM A REPORT
CHELONEI OF SEVEN
Robert B. Dreisin, Charles Scoggin,* Department of
Medicine. National Jewish Division of Pulmonary Medicine,
(1976),
57,49-57
FORTUITUM IN
MAN
:
CASES
and Paul T. Davidson**
Hospital and Research Center, 3800 E. Colfax, Denver, Colorado 80206 University of Colorado Medical Center, Denver, Colorado 80220.**
and
Summary The clinical records of 7 patients referred to the National Jewish Hospital and Research Center over a 6-year period for evaluation of an abnormal chest x-ray and repeated sputum isolates of rapidly growing mycobacteria (Runyon’s Group IV) were reviewed to determine the potential pathogenicity of these organisms. Mycobacterium fort&urn was isolated from 5 patients and Mycobacterium chelonei from 2. Haemoptysis, cough and weight loss were prominent in 6. Three had rheumatoid arthritis. Although two demonstrated cutaneous anergy, lymphocyte responsiveness to PHA was normal. PPD-F was not useful in skin testing or in the in vitro evaluation of lymphocyte function. Histologic examination of the lungs of 2 patients demonstrated caseating granulomata. One patient died of massive pulmonary haemorrhage soon after initiation of therapy. Multi-drug treatment regimens generally resulted in progressive sterilization of the sputum and improvement in the appearance of the chest x-ray. We conclude that some rapidly growing mycobacteria cavitary lung disease and that intensive anti-tuberculosis alter its course.
can cause potentially fatal therapy may successfully
R&urn6 En vue d’btudier la pathogrZnicit6 potentielle des mycobact&ies 2 croissance rapide (Groupe IV de Runyon), les auteurs ont revu les dossiers cliniques de 7 malades adress& au National Jewish Hospital and Research Center pour y etre Bvalues 3 la suite de la p&sence d’un cliche radiologique anormal et de I’isolement rep&+ de ces mycobact&ies a partir de I’expectoration. Mycobacterium fortuitum a 6th isole chez 5 malades et Mycobact&ium chelanei chez 2. Hhmoptysie, toux et perte de poids 6taient les facteurs les plus marquants chez 6 sujets. Trois malades pr&entaient une arthrite rhumatoide. Deux malades qui presentaient une anergie cutanee, avaient neanmoins une rr.+ponse lymphocytaire normale au PHA. Le PPD-F ne s’est This investigation
was supported by Grants 5TOl
HE05933-05
and 5T32 HL07085-01.
* Teaching
and Research Scholar of the American College of Physicians.
**Requests
for reprints should be addressed
to P. T. Davidson,
M.D.,
National Jewish
Hospital
and Research
Center.
50
Dreisin and others pas revele utile pour les tests cutanes ni pour I’btude in vitro de la fonction lymphocytaire. L’examen histologique des poumons de 2 malades a montre des granulomes en tours de caseification. Un malade est mort a la suite d’une hemorragie pulmonaire massive survenue peu de temps apt& le debut de la chimiotherapie. Les regimes therapeutiques associant de nombreuses drogues ont generalement entrain& la sterilisation progressive de I’expectoration et I’amelioration de I’aspect radiologique pulmonaire. Les auteurs concluent que certaines mycobacteries a croissance rapide sont capables de provoquer une affection pulmonaire cavitaire fatale et qu’une therapeutique intensive antituberculeuse peut modifier cette evolution de facon favorable.
Resumen Se examinaron las historias clinicas de 7 pacientes, derivados al Hospital National Judio y al Centro de Investigation durante un period0 de 6 afios, para evaluar una radiografia de t&ax patologica y repetidos examenes de esputos con mycobacterias de crecimiento rapid0 (grupo IV de Runyon) para determinar la virulencia potential de esos germenes. Se aislo Mycobacterium fortuitum en 5 pacientes y Mycobacterium chelonei en 2. Habia hemoptisis, tos y perdida de peso en 6 cases. Tres tenian artritis reumatoidea. Aunque dos de ellos tenian anergia cutanea la respuesta de 10s Iinfocitos a PHA fue normal. La PPD-F no fue util para el test cutaneo ni para la evaluation in vitro de la funcion linfocitaria. El estudio histologico del pulmon en 2 pacientes demostro granulomas con caseosis. Un paciente murio de una hemorragia pulmonar masiva inmediatamente despues de iniciar el tratamiento. Los esquemas terapeuticos con varias drogas produjeron una esterilizacion del esputo y una mejoria radiologica. Se concluye que algunas micobacterias de crecimiento rapid0 pueden producir lesiones pulmonares cavitarias potencialmente fatales y que un tratamiento antituberculoso intensivo puede modificar favorablemente esa evolution.
Introduction The mycobacteria classified in Runyon’s Group IV (Runyon, 1954) are rapidly growing, acid-fast organisms, worldwide in distribution, that are commonly found in the soil (Wolinsky Et Rynearson, 1968). These organisms are not infrequently isolated from the sputum of apparently healthy persons (Edwards Et Palmer, 1959; Hartwig, Cacciatore 8 Dunbar, 1962; Awe, Gangadharam 8 Jenkins, 1973; Warring, 1968), and from at least one group of patients with stable pneumoconioses (Jenkins & Marks, 1971). Although these mycobacteria have been demonstrated to cause subcutaneous infection (Hand & Sanford, 1970; Offer, Karlson & Spittel, 1971), their aetiologic role in pulmonary disease remains open to question (Awe, Gangadharam Et Jenkins, 1973). Numerous reports (Warring, 1968; Offer, Karlson & Spittel, 1971 ; Radenbach, 1972; Corpe, Smith Et Stergus, 1961 ; Phillips Et Larkin, 1964; Pust and others, 1973 ; Dross and others, 1964 ; Foote & Pol, 1974 ; Gacad & Massaro, 1974 ; Beck, 1959, Nicholson & Sevier, 1971 ; Bates, 1966) have documented the repeated isolation of M. fort&urn and M. chelonei from the sputum of patients with pulmonary disorders clinically indistinguishable from tuberculosis. However, common to these cases has been the difficulty in substantiating these mycobacteria as the cause for the patient’s disease. The problem of diagnosis and treatment of the patient with objective evidence of pulmonary
Rapidly Growing disease and concomitant subject of this report.
isolation
of rapidly growing
mycobacteria
Mycobacteria
from the sputum
51 is the
Methods We reviewed the clinical records of all patients referred to the National Jewish Hospital for the evaluation of suspected pulmonary infection with M. fortuitum or n/l. chelonei. Criteria for consideration of the possibility of pulmonary infection were the presence of roentgenographic evidence of cavitary pulmonary disease and the isolation on at least 2 occasions of Group IV organisms from the sputum. Records were reviewed to answer the following questions: 1) what was the clinical presentation ? 2) did the pulmonary disorders occur in otherwise healthy individuals? 3) was there evidence for other pulmonary pathology which could account for the patient’s disability? 4) was histopathologic confirmation obtained to support the diagnosis of mycobacterial infection ? 5) what was the clinical response in cases in which therapy was given ? Results Clinical presentation
From August 1969 to July 1975, 6 men and 3 women aged from 36 to 78 years were referred to the National Jewish Hospital for evaluation of possible infection with rapidly growing mycobacteria. One patient was black, the others white. Two patients did not meet the criteria for inclusion in our review. The first patient had M. fort&urn isolated on only 1 occasion and on further evaluation was found to have an M. tuberculosis infection. In the second patient M. cheloneiwas repeatedly cultured from both the sputum and a draining sinus of the left flank. However, a chest film showed no evidence of active pulmonary disease and a biopsy of the involved twelfth rib yielded only M. tuberculosis. Treatment with isoniazid, ethambutol and streptomycin lead to an uneventful recovery with no further evidence of mycobacterial disease during the next 3 years. Of the remaining 7 patients (Table I), all but 1 presented with haemoptysis, cough, and weight loss. All were white; 4 smoked cigarettes. One patient (case 7) had a previous diagnosis of chronic airways obstruction and was alcoholic. Three had rheumatoid arthritis; none had received corticosteroid therapy before the development of mycobacterial disease. All 7 patients had received some anti-tuberculosis chemotherapy before referral to our hospital. Admission
laboratory
data
Admission laboratory data were non-diagnostic. Anaemia and leukocytosis occurred in 1 patient (case 7). The erythrocyte sedimentation rates were usually mildly elevated and the albumin-to-globulin ratio was reversed in 3 patients. One patient demonstrated ventilatory obstruction on spirometry. The 3 patients with clinical histories and findings of rheumatoid arthritis had positive serum rheumatoid latex agglutination tests. Chest x-rays
In all 7 patients, the chest film was consistent with pulmonary tuberculosis, demonstrating apical or generalized fibrocavitary disease. In the three patients with rheumatoid arthritis, nodular rheumatoid lung disease (Petty 8 Wilkins, 1966; Walker Et Wright, 1968) could not be excluded with certainty by chest roentgenograph alone. Skin tests
Skin testing
to a variety of antigens
was performed
in all 7 patients
(Table
II). Only
3
52
Dreisin and others
Table I. - -
Clinical features of 7 patients from whom rapid growing mycobacteria were isolated -
Sex
Patien
4’s
Race
Symptoms
Duration of symptoms
Cigarette use
Underlying disease*
10 yr.
Yes
Kyphosis
‘Atypical’ mycobacteria isolated x 1Oyrs. Granulomatous hepatitis
0
No
None
Lung and mediastinal node biopsy demonstrated caseating and non-caseating granulomas. Lung biopsy culture + for M. fortuitum M. fortuitom cultured in sputum For 1 year preceding admission
Comment
1
M
58
W
Haemoptysis Chest pain Cough Weight loss
2
M
46
W
None
3
F
78
W
Haemoptysis Weight loss Fatigue Cough
1 yr.
No
RA CHF
4
M
36
W
Haemoptysis Cough Weight loss
1 yr.
Yes
None
-
5
M
61
W
Haemoptysis Cough Fever Weight loss
8 mo.
No
Lipoid pneumonia RA
-
6
M
38
W
Haemoptysis Cough Weight loss
6 yr.
Yes
Previous M. kansasri RA infection
+ AFB smears without cultures ior 6 yr. M. kansasii cultured I yr. prior to admission
7
F
53
W
Haemoptysis Cough Weight loss
2 yr.
Yes
Alcoholism CA0
Abnormal chest film x 4 yr. for which patient refused evaluation
*RA
-
rheumatoid
arthritis, CHF -
congestive
heart failure, CA0 -
chronic airways obstruction.
patients demonstrated a positive reaction to 5 tuberculin units (TU) purified protein derivative - standard PPD-S. Of the 5 patients tested with 5 TU of M. fortuitum PPD-F, only 2 (cases 5 and 6) demonstrated a degree of reactivity. Both patients showed greater reactions to PPD-S than to PPD-F. Patient 6 had a strongly positive reaction to PPD-Y. Immunologic
data
Serum immunoglobulin levels were normal in all 6 patients tested. Patient 1 demonstrated normal immediate hypersensitivity skin reactions to freeze-dried dusts. Cutaneous anergy was present in 2 patients (cases 1 and 3). T-lymphocyte responsiveness to PHA was normal in all 3 patients in whom it was tested. No lymphocyte transformation was observed upon exposure to PPD-F or PPD-S. Migration inhibitory factor production in response to PPD-F
Rapidly Growing
Mycobacteria
53
Table II. Skin test results Patient
PPD-S*
PPD-Y*
PPD-G*
PPD.B*
(mm)
(mm)
(mm)
(mm)
__ 1 2 3 4 5 6 7 * S-
0 0 0 24 9 12 0
A-0
0
0
0 0
0 0
0
0
0
0
6
0
0
0
0 0 13 12
0 0
12
0 7 8
0
9 5
10 18
Standard tuberculin 5TU. Y -
M. kansasii, B -
was negative in 1 case investigated. patients tested. Bacteriology
-’
0
0 9 0
0
‘Battey’ (M. intracellulare
Serum complement
-
avium complex),
levels were
F -
normal
M. fort&urn.
in the 3
and pathology (Table I I I)
Rapid growers were repeatedly isolated from the sputum of all 7 patients. One patient (6) had had /VI. kansasii isolated from his sputum 1 year previously, and was treated for M. kansasii infection prior to recovery of M. fort&urn from his sputum. In no other patient had mycobacteria other than the rapid-growers been isolated. Patient 5 had lipoid pneumonia and cavitary lung disease and repeatedly yielded Staph aureus as well as M. fort&urn from his sputum. Pathological examination was obtained on the lungs of 2 patients. Open lung biopsy in case 2 revealed granulomas. Ziehl-Nielsen stain was negative for acid-fast organisms, but culture yielded M. fortuitum. No other mycobacteria or fungi were found. Patient 7 died with massive pulmonary hemorrhage. At necropsy extensive caseating granulomatous disease was present in the lungs and the Ziehl-Nielsen strain was positive; the lungs were formaldehydefixed and no cultures were obtained. A suggestion of disseminated disease was present only in case 1. Hepatosplenomegaly and abnormal liver function tests were present. Liver biopsy revealed granulomatous hepatitis. Acid-fast stain and culture of the liver were negative. No other evidence of hematogenous spread was found. Drug susceptibility studies Susceptibility to all anti-tuberculosis drugs was assessed; susceptibility to ethionamide was demonstrated in 4 patients. In no case were the rapid growers sensitive to any other anti-tuberculosis drug at the concentrations commonly tested.* Cultures from 2 patients * Mycobacteria were routinely tested against isoniazid (0.2, 1 .O and 5.0 mcg/ml) ; rifampicin (1 .O and 10.0 mcg/ml) ; ethionamide (10.0 and 15.0 mcg/ml) ; ethambutol (7.5 and 15.0 mcg/ml) ; para-amino salicylic acid (8.0 mcg/ml) ; cycloserine (20.0 and 30.0 mcg/ml); streptomycin (2.0 and 10.0 mcg/ml); kanamycin (6.0 and 12.0 mcg/ml); viomycin (10.0 and 15.0 mcg/ml); and capreomycin (10.0 and 20.0 mcg/ml). Pyrazinamide susceptibilities were determined chromatographically. In isolated instances growth inhibition was noted at higher concentrations of some drugs. Further details concerning the techniques and results of these studies are available from the authors.
54
Dreisin and others Table III. Patient
Organism *
Bacteriology
Total
Total
smears
cultures
M. fort&urn
M. fort&urn
>I0
and pathology
Wumber of specimens submitted
Dathology and comment
>lO
>I0
Liver biopsy showed granulomas, negative for AFB by smear and culture
>I0
>I0
Lung and node biopsy showed caseating and non-caseating granulomas. M. fortuitum cultured from lung biopsy
M. fortuitum
11
14
None
M. fortuitum
9
18
None
M. fortuitum
33
33
Brush biopsy of cavity grew S. aureus as well as M. fortuitum Refused
M. chelonei
2
11
15
M. chelonei
2
4
4
* Identifications
were confirmed
serologically
biopsy
Caseating granulomas positive for AFB at necropsy
by Dr. Werner Schaefer.
were susceptible to tetracycline at concentrations growers to tetracycline has been reported previously and others, 1964).
of 50 mcg/ml. Susceptibility of rapid (Corpe, Smith & Stergus, 1961 ; Brosbe
Treatment and follow-up One of the 7 patients received no anti-tuberculosis treatment because of co-existing cardiac disease. Of the 6 who received anti-tuberculosis drugs, 1 (case 6) was lost to follow-up and another (case 7) died within 2 weeks of initiation of therapy. In the remaining 4 patients, follow-up ranged from 6 to 16 months. Regimens consisting of 4 to 6 anti-tuberculosis drugs were employed including, when possible, drugs to which the organisms were shown to be susceptible in vitro. The rationale for this multiple-drug approach is based on past favourable experience at National Jewish Hospital in the treatment of Runyon Group III (AI intracellulare-avium) infections which also show a great deal of in vitro drug resistance (Lester and others, 1968; Lester and others, 1969; Yeager Et Raleigh, 1973). In case 5, 6 months of chemotherapy resulted in no change in sputum smear and cultures for acid-fast organisms or change in the appearance of the chest x-ray. However, this patient tolerated medications poorly and thus had only sporadic treatment. Sputum culture conversion occurred in case 2 after 5 months of chemotherapy and the chest x-rays showed significant resolution. Patients 1 and 4 had a marked reduction in the number of organisms found in their sputa but continued to have sporadically positive cultures containing small numbers of
Rapidly Growing organisms following discharge. The radiographic of case 1 remains unchanged.
appearances
Mycobacteria
in case 4 improved
55
but those
Discussion There was strong evidence implicating M. fortuitum and M. chelonei as pulmonary pathogens in theseven patients reviewed. All patients presented with a subacute or chronic disease process clinically indistinguishable from pulmonary tuberculosis. All but 1 patient had symptoms including haemoptysis, cough and weight loss. Routine laboratory studies, chest x-rays, and skin tests were not helpful in identifying any unique characteristics of these patients nor did they help determine or not the rapidly growing mycobacteria were pathogens in the individual patient. None of the patients had a previous history of pulmonary tuberculosis although cases 4 and 6 had positive skin tests to PPD-S. Patient 6 had a past history of isolation of M. kansasiifrom his sputum and had been treated for that infection. However, multiple sputum culture specimens while in hospital at National Jewish Hospital yielded only &I. chelonei. He remained ill during one and one-half months of treatment and left against medical advice after refusing lung biopsy. He was subsequently lost to further follow-up. It is of interest that 3 patients had active rheumatoid arthritis. This association has been noted by Bates (1966). A similar association with ankylosing spondylitis has been suggested (Gacad & Massaro, 1974). All 3 patients had haemoptysis and weight loss. These complaints have not been associated with rheumatoid lung disease (Brosbe and others, 1964) and were interpreted as evidence of mycobacterial infection in these patients. The presence of haemoptysis and weight loss in patients with rheumatoid arthritis and cavitary lung disease should alert one to the possible presence of mycobacterial disease. One patient had a previous diagnosis of basilar lipoid pneumonia as well as haemoptysis, cough, fever and weight loss. Beck has related Group IV infection to the presence of lipoid pneumonia (Beck, 1959). This patient developed extensive pulmonary cavitation while M. fortuitum was repeatedly cultured from his sputum. Brush biopsy of the cavitary lesion was positive for both M. fortuitum and Staph. aureus. Although histopathological confirmation of mycobacterial infection was not obtained, the patient failed to respond to specific therapy directed at the staphylococcus. A pathological role for /VI. fort&urn was strongly suspected. No consistent immunologic abnormality was identified although 2 patients demonstrated apparent cutaneous anergy. Three patients (cases 1, 2 and 3), in whom there was strong evidence of infection with rapid growers had lymphocyte blastogenesis demonstrated in response to stimulation with phytohemoglutinin (PHA). However, PPD-F failed to stimulate lymphocyte blastogenesis in the three patients tested and failed to induce migration inhibition in the 1 case attempted. The immunogenicity of PDP-F (Marmorstein Et Scheinhorn, 1975) and its value in tests of immunological competence is doubtful; in none of our patients was it of diagnostic help. Histopathological examination of the lung was done in only 2 patients. Patient 2 underwent open lung biopsy and Patient 7 necropsy. Both patients had caseating pulmonary granulomas. In the setting of repeated isolation of rapidly growing mycobacteria from the sputum and lack of evidence for other processes to explain their findings, it was concluded that these mycobacteria were etiologic in the patients’ pulmonary disease. Treatment directed toward M. fortuitum in case 2 led to partial clearing of the microorganism from the sputum and moderate improvement in the appearance of the chest roentgenogram. Patient 1 from whose sputum M. fort&urn has been isolated for years had granulomas seen in a liver biopsy specimen. Granulomatous hepatitis has been associated with mycobacterial
56
Dreisin and others
disease (Sahn & Neff, 1974), but does not necessarily imply dissemination. In the setting of cavitary lung disease, granulomatous hepatitis, repeated isolation of M. fort&urn from the sputum, and lack of other suitable explanations for the patient’s disability, we felt that there was a strong suggestion of a pathologic role of M. fort&urn in this patient. In the 3 patients in whom treatment directed at the rapidly growing organisms was sustained and adequate follow-up was obtained, there was definite bacteriologic improvement in all, and improvement in the appearance of the chest x-ray in 2. We conclude that rapidly man. However, their relative and frequently ambiguous should be considered with firmation of active infection tuberculosis therapy.
growing mycobacteria can cause cavitary pulmonary disease in rarity, occasional isolation from the sputum of healthy individuals, clinical presentation make the diagnosis of infection one that caution. We think that, when possible, histopathological conshould be attempted before institution of potentially toxic anti-
Acknowledgements The authors thank Drs. Thomas L. Petty, Steven A. Sahn, Roger S. Mitchell, McClatchy for their helpful suggestions in the preparation of this paper.
and J. K.
References Awe,
Ft. J., Gangadharam, P. FL, Et Jenkins, D. E. (1973). Clinical significance of Mycobaceterium in pulmonary disease. American Review of Respiratory Disease, 108, 1230. Bates, J. H. (1966). Pulmonary infections associated with uncommon mycobacteria, Protocol Research Conference in Pulmonary Diseases, 25.87.
Fortuitum
infections
6. Transactions
of the
Beck, F. (1959). Pulmonary disease due to atypical tubercle bacilli. American Review of Respiratory Disease, 80, 738. Brosbe, E. A., Sugihara, P. T., Smith, C. R., Et Hyde, L. (1964). Experimental drug studies on Mycobacterium fortuitum. AntimicrobialAgents and Chemotherapy, 4,733. Corpe, R. F., Smith, C. E., 8 Stergus, I. (1961). Death due to Mycobacterium fortuitum. Journalof the American Medical Association, 177.78. Dross, I. C., Abbatiello, A. A., Jenney, F. S., Et Cohen, A. C. (1964). Pulmonary infection due to M. fortuitum. American Review of Respiratory Disease, 89.923. Edwards, L. B., & Palmer, C. E. (1959). Isolation of ‘atypical’ mycobacteria from healthy persons. American Review of Respiratory Disease, 50.747. Foote, W. C., 8 Polk, B. F. (1974). Endobronchitis and Mycobacterium fortuitum. Anna/s of internal Medicine, SO, 272. Gacad, G., & Massaro, D. (1974). Pulmonary fibrosis and Group IV mycobacterial infection of the lungs in ankylosing spondylitis. American Review of Respiratory Disease, 109,274. Hand, W. L., 8 Sanford, J. P. (1970). Mycobacterium fortuitum - A human pathogen. Anna/s of internal Medicine. 73,971. Hartwig, E. C., Cacciatore, R., Et Dunbar, F. P. (1962). M. fortuitum: Its identification, incidence and significance in Florida. American Review of Respiratory Disease, 55,84. Jenkins, P. A., 8 Marks, J. (1971). Transient colonization of the respiratory tract by mycobacteria in South Wales. Tubercle. 52,60. Lester, W., Fischer, D. A. Moulding, T. J., Fraser, R. I., 8 McClatchy, J. K. (1968). Evaluation of chemotherapy response in Group III (Battey-type) mycobacterial infections. Transactions of the VA-Armed Forces Pulmonary Disease Research Conference, 27, 20. Lester, W.,‘Moulding, T., Fraser, R. I., McClatchy, J. K., & Fischer, D.A. (1969). Quintuple drug regimens in the treatment of Battey-type infections. Transactions of the VA-Armed Forces Pulmonary Disease Research Conference, 28, 83. Marmorstein, B., b Scheinhorn, D. (1975). The role of non-tuberculous mycobacterial skin test antigens in the diagnosis of mycobacterial infection. Chest, 87,320. Nicholson, D. P., & Sevier, W. R. (1971). Mycobacterium fortuitum as a pathogen. A case report. American Review of Respiratory Disease, 104,747. Offer, R. C., K arlson, A. G., 8 Spitte!l, J. A. (1971). Infection caused by Mycobacterium fortuitum. Mayo Clinic Proceedings, 48,747. Petty, T. L., 8 Wilkins, M. (1966). The five manifestations of rheumatoid lung. Diseases of the Chest, 49,74. Phillips, S., 8 Larkin, J. C. (1964). Atypical pulmonary tuberculosis caused by unclassified mycobacteria. Anna/s of Internal Medicine, 80.491.
Rapidly Growing Pust, R. E., Onubogu, H. 0. N., Egornu, L. I., Et Smithwick. R. (1973). Pulmonary in a Nigerian. American Review of Respiratory Disease, 108.1416.
Mycobacteria
disease due to Mycobacterium
Radenbach, K. L. (1972). Permanently successful chemotherapy in two cases with disease due to Mycobacterium kansasii and fortuitum, respectively. Scandinavian
57
fortuitum
severe pulmonary mycobacterial Journalof Respiratory Diseases,
Supplement, 80,223. Runyon, E. H. (1954). Anonymous mycobacteria in pulmonary disease. Medical Clinics of North America, 43, 273. Sahn, S. A., Et Neff, T. A. (1974). Miliary tuberculosis. American Journalof Medicine, 56, 495. Warring, F. C. (1968). Mycobacteria in New England Hospital. A study of mycobacterial species occurring in the sputum of patients with chronic pulmonary disease. American Review of Respiratory Disease, 98, 965. Walker, W. C., & Wright, V. (1968). Pulmonary lesions and rheumatoid arthritis. Medicine (Baltimore), 47, 501, Wolinsky, E., Et Rynearson, T. K. (1968). Mycobacteria in soil and their relation to disease-associated strains, American Review of Respiratory Disease, 97,1032. Yeager, H., & Raleigh, J. W. (1973). Pulmonary disease due to Mycobacterium intracellulare. American Review of Respiratory Disease. 108. 547.
THE PATHOGENICITY
OF
MYCOBACTERlUM
AND MYCOBACTERIUM A REPORT
CHELONEI OF SEVEN
Robert B. Dreisin, Charles Scoggin,* Department of
Medicine. National Jewish Division of Pulmonary Medicine,
(1976),
57,49-57
FORTUITUM IN
MAN
:
CASES
and Paul T. Davidson**
Hospital and Research Center, 3800 E. Colfax, Denver, Colorado 80206 University of Colorado Medical Center, Denver, Colorado 80220.**
and
Summary The clinical records of 7 patients referred to the National Jewish Hospital and Research Center over a 6-year period for evaluation of an abnormal chest x-ray and repeated sputum isolates of rapidly growing mycobacteria (Runyon’s Group IV) were reviewed to determine the potential pathogenicity of these organisms. Mycobacterium fort&urn was isolated from 5 patients and Mycobacterium chelonei from 2. Haemoptysis, cough and weight loss were prominent in 6. Three had rheumatoid arthritis. Although two demonstrated cutaneous anergy, lymphocyte responsiveness to PHA was normal. PPD-F was not useful in skin testing or in the in vitro evaluation of lymphocyte function. Histologic examination of the lungs of 2 patients demonstrated caseating granulomata. One patient died of massive pulmonary haemorrhage soon after initiation of therapy. Multi-drug treatment regimens generally resulted in progressive sterilization of the sputum and improvement in the appearance of the chest x-ray. We conclude that some rapidly growing mycobacteria cavitary lung disease and that intensive anti-tuberculosis alter its course.
can cause potentially fatal therapy may successfully
R&urn6 En vue d’btudier la pathogrZnicit6 potentielle des mycobact&ies 2 croissance rapide (Groupe IV de Runyon), les auteurs ont revu les dossiers cliniques de 7 malades adress& au National Jewish Hospital and Research Center pour y etre Bvalues 3 la suite de la p&sence d’un cliche radiologique anormal et de I’isolement rep&+ de ces mycobact&ies a partir de I’expectoration. Mycobacterium fortuitum a 6th isole chez 5 malades et Mycobact&ium chelanei chez 2. Hhmoptysie, toux et perte de poids 6taient les facteurs les plus marquants chez 6 sujets. Trois malades pr&entaient une arthrite rhumatoide. Deux malades qui presentaient une anergie cutanee, avaient neanmoins une rr.+ponse lymphocytaire normale au PHA. Le PPD-F ne s’est This investigation
was supported by Grants 5TOl
HE05933-05
and 5T32 HL07085-01.
* Teaching
and Research Scholar of the American College of Physicians.
**Requests
for reprints should be addressed
to P. T. Davidson,
M.D.,
National Jewish
Hospital
and Research
Center.
50
Dreisin and others pas revele utile pour les tests cutanes ni pour I’btude in vitro de la fonction lymphocytaire. L’examen histologique des poumons de 2 malades a montre des granulomes en tours de caseification. Un malade est mort a la suite d’une hemorragie pulmonaire massive survenue peu de temps apt& le debut de la chimiotherapie. Les regimes therapeutiques associant de nombreuses drogues ont generalement entrain& la sterilisation progressive de I’expectoration et I’amelioration de I’aspect radiologique pulmonaire. Les auteurs concluent que certaines mycobacteries a croissance rapide sont capables de provoquer une affection pulmonaire cavitaire fatale et qu’une therapeutique intensive antituberculeuse peut modifier cette evolution de facon favorable.
Resumen Se examinaron las historias clinicas de 7 pacientes, derivados al Hospital National Judio y al Centro de Investigation durante un period0 de 6 afios, para evaluar una radiografia de t&ax patologica y repetidos examenes de esputos con mycobacterias de crecimiento rapid0 (grupo IV de Runyon) para determinar la virulencia potential de esos germenes. Se aislo Mycobacterium fortuitum en 5 pacientes y Mycobacterium chelonei en 2. Habia hemoptisis, tos y perdida de peso en 6 cases. Tres tenian artritis reumatoidea. Aunque dos de ellos tenian anergia cutanea la respuesta de 10s Iinfocitos a PHA fue normal. La PPD-F no fue util para el test cutaneo ni para la evaluation in vitro de la funcion linfocitaria. El estudio histologico del pulmon en 2 pacientes demostro granulomas con caseosis. Un paciente murio de una hemorragia pulmonar masiva inmediatamente despues de iniciar el tratamiento. Los esquemas terapeuticos con varias drogas produjeron una esterilizacion del esputo y una mejoria radiologica. Se concluye que algunas micobacterias de crecimiento rapid0 pueden producir lesiones pulmonares cavitarias potencialmente fatales y que un tratamiento antituberculoso intensivo puede modificar favorablemente esa evolution.
Introduction The mycobacteria classified in Runyon’s Group IV (Runyon, 1954) are rapidly growing, acid-fast organisms, worldwide in distribution, that are commonly found in the soil (Wolinsky Et Rynearson, 1968). These organisms are not infrequently isolated from the sputum of apparently healthy persons (Edwards Et Palmer, 1959; Hartwig, Cacciatore 8 Dunbar, 1962; Awe, Gangadharam 8 Jenkins, 1973; Warring, 1968), and from at least one group of patients with stable pneumoconioses (Jenkins & Marks, 1971). Although these mycobacteria have been demonstrated to cause subcutaneous infection (Hand & Sanford, 1970; Offer, Karlson & Spittel, 1971), their aetiologic role in pulmonary disease remains open to question (Awe, Gangadharam Et Jenkins, 1973). Numerous reports (Warring, 1968; Offer, Karlson & Spittel, 1971 ; Radenbach, 1972; Corpe, Smith Et Stergus, 1961 ; Phillips Et Larkin, 1964; Pust and others, 1973 ; Dross and others, 1964 ; Foote & Pol, 1974 ; Gacad & Massaro, 1974 ; Beck, 1959, Nicholson & Sevier, 1971 ; Bates, 1966) have documented the repeated isolation of M. fort&urn and M. chelonei from the sputum of patients with pulmonary disorders clinically indistinguishable from tuberculosis. However, common to these cases has been the difficulty in substantiating these mycobacteria as the cause for the patient’s disease. The problem of diagnosis and treatment of the patient with objective evidence of pulmonary
Rapidly Growing disease and concomitant subject of this report.
isolation
of rapidly growing
mycobacteria
Mycobacteria
from the sputum
51 is the
Methods We reviewed the clinical records of all patients referred to the National Jewish Hospital for the evaluation of suspected pulmonary infection with M. fortuitum or n/l. chelonei. Criteria for consideration of the possibility of pulmonary infection were the presence of roentgenographic evidence of cavitary pulmonary disease and the isolation on at least 2 occasions of Group IV organisms from the sputum. Records were reviewed to answer the following questions: 1) what was the clinical presentation ? 2) did the pulmonary disorders occur in otherwise healthy individuals? 3) was there evidence for other pulmonary pathology which could account for the patient’s disability? 4) was histopathologic confirmation obtained to support the diagnosis of mycobacterial infection ? 5) what was the clinical response in cases in which therapy was given ? Results Clinical presentation
From August 1969 to July 1975, 6 men and 3 women aged from 36 to 78 years were referred to the National Jewish Hospital for evaluation of possible infection with rapidly growing mycobacteria. One patient was black, the others white. Two patients did not meet the criteria for inclusion in our review. The first patient had M. fort&urn isolated on only 1 occasion and on further evaluation was found to have an M. tuberculosis infection. In the second patient M. cheloneiwas repeatedly cultured from both the sputum and a draining sinus of the left flank. However, a chest film showed no evidence of active pulmonary disease and a biopsy of the involved twelfth rib yielded only M. tuberculosis. Treatment with isoniazid, ethambutol and streptomycin lead to an uneventful recovery with no further evidence of mycobacterial disease during the next 3 years. Of the remaining 7 patients (Table I), all but 1 presented with haemoptysis, cough, and weight loss. All were white; 4 smoked cigarettes. One patient (case 7) had a previous diagnosis of chronic airways obstruction and was alcoholic. Three had rheumatoid arthritis; none had received corticosteroid therapy before the development of mycobacterial disease. All 7 patients had received some anti-tuberculosis chemotherapy before referral to our hospital. Admission
laboratory
data
Admission laboratory data were non-diagnostic. Anaemia and leukocytosis occurred in 1 patient (case 7). The erythrocyte sedimentation rates were usually mildly elevated and the albumin-to-globulin ratio was reversed in 3 patients. One patient demonstrated ventilatory obstruction on spirometry. The 3 patients with clinical histories and findings of rheumatoid arthritis had positive serum rheumatoid latex agglutination tests. Chest x-rays
In all 7 patients, the chest film was consistent with pulmonary tuberculosis, demonstrating apical or generalized fibrocavitary disease. In the three patients with rheumatoid arthritis, nodular rheumatoid lung disease (Petty 8 Wilkins, 1966; Walker Et Wright, 1968) could not be excluded with certainty by chest roentgenograph alone. Skin tests
Skin testing
to a variety of antigens
was performed
in all 7 patients
(Table
II). Only
3
52
Dreisin and others
Table I. - -
Clinical features of 7 patients from whom rapid growing mycobacteria were isolated -
Sex
Patien
4’s
Race
Symptoms
Duration of symptoms
Cigarette use
Underlying disease*
10 yr.
Yes
Kyphosis
‘Atypical’ mycobacteria isolated x 1Oyrs. Granulomatous hepatitis
0
No
None
Lung and mediastinal node biopsy demonstrated caseating and non-caseating granulomas. Lung biopsy culture + for M. fortuitum M. fortuitom cultured in sputum For 1 year preceding admission
Comment
1
M
58
W
Haemoptysis Chest pain Cough Weight loss
2
M
46
W
None
3
F
78
W
Haemoptysis Weight loss Fatigue Cough
1 yr.
No
RA CHF
4
M
36
W
Haemoptysis Cough Weight loss
1 yr.
Yes
None
-
5
M
61
W
Haemoptysis Cough Fever Weight loss
8 mo.
No
Lipoid pneumonia RA
-
6
M
38
W
Haemoptysis Cough Weight loss
6 yr.
Yes
Previous M. kansasri RA infection
+ AFB smears without cultures ior 6 yr. M. kansasii cultured I yr. prior to admission
7
F
53
W
Haemoptysis Cough Weight loss
2 yr.
Yes
Alcoholism CA0
Abnormal chest film x 4 yr. for which patient refused evaluation
*RA
-
rheumatoid
arthritis, CHF -
congestive
heart failure, CA0 -
chronic airways obstruction.
patients demonstrated a positive reaction to 5 tuberculin units (TU) purified protein derivative - standard PPD-S. Of the 5 patients tested with 5 TU of M. fortuitum PPD-F, only 2 (cases 5 and 6) demonstrated a degree of reactivity. Both patients showed greater reactions to PPD-S than to PPD-F. Patient 6 had a strongly positive reaction to PPD-Y. Immunologic
data
Serum immunoglobulin levels were normal in all 6 patients tested. Patient 1 demonstrated normal immediate hypersensitivity skin reactions to freeze-dried dusts. Cutaneous anergy was present in 2 patients (cases 1 and 3). T-lymphocyte responsiveness to PHA was normal in all 3 patients in whom it was tested. No lymphocyte transformation was observed upon exposure to PPD-F or PPD-S. Migration inhibitory factor production in response to PPD-F
Rapidly Growing
Mycobacteria
53
Table II. Skin test results Patient
PPD-S*
PPD-Y*
PPD-G*
PPD.B*
(mm)
(mm)
(mm)
(mm)
__ 1 2 3 4 5 6 7 * S-
0 0 0 24 9 12 0
A-0
0
0
0 0
0 0
0
0
0
0
6
0
0
0
0 0 13 12
0 0
12
0 7 8
0
9 5
10 18
Standard tuberculin 5TU. Y -
M. kansasii, B -
was negative in 1 case investigated. patients tested. Bacteriology
-’
0
0 9 0
0
‘Battey’ (M. intracellulare
Serum complement
-
avium complex),
levels were
F -
normal
M. fort&urn.
in the 3
and pathology (Table I I I)
Rapid growers were repeatedly isolated from the sputum of all 7 patients. One patient (6) had had /VI. kansasii isolated from his sputum 1 year previously, and was treated for M. kansasii infection prior to recovery of M. fort&urn from his sputum. In no other patient had mycobacteria other than the rapid-growers been isolated. Patient 5 had lipoid pneumonia and cavitary lung disease and repeatedly yielded Staph aureus as well as M. fort&urn from his sputum. Pathological examination was obtained on the lungs of 2 patients. Open lung biopsy in case 2 revealed granulomas. Ziehl-Nielsen stain was negative for acid-fast organisms, but culture yielded M. fortuitum. No other mycobacteria or fungi were found. Patient 7 died with massive pulmonary hemorrhage. At necropsy extensive caseating granulomatous disease was present in the lungs and the Ziehl-Nielsen strain was positive; the lungs were formaldehydefixed and no cultures were obtained. A suggestion of disseminated disease was present only in case 1. Hepatosplenomegaly and abnormal liver function tests were present. Liver biopsy revealed granulomatous hepatitis. Acid-fast stain and culture of the liver were negative. No other evidence of hematogenous spread was found. Drug susceptibility studies Susceptibility to all anti-tuberculosis drugs was assessed; susceptibility to ethionamide was demonstrated in 4 patients. In no case were the rapid growers sensitive to any other anti-tuberculosis drug at the concentrations commonly tested.* Cultures from 2 patients * Mycobacteria were routinely tested against isoniazid (0.2, 1 .O and 5.0 mcg/ml) ; rifampicin (1 .O and 10.0 mcg/ml) ; ethionamide (10.0 and 15.0 mcg/ml) ; ethambutol (7.5 and 15.0 mcg/ml) ; para-amino salicylic acid (8.0 mcg/ml) ; cycloserine (20.0 and 30.0 mcg/ml); streptomycin (2.0 and 10.0 mcg/ml); kanamycin (6.0 and 12.0 mcg/ml); viomycin (10.0 and 15.0 mcg/ml); and capreomycin (10.0 and 20.0 mcg/ml). Pyrazinamide susceptibilities were determined chromatographically. In isolated instances growth inhibition was noted at higher concentrations of some drugs. Further details concerning the techniques and results of these studies are available from the authors.
54
Dreisin and others Table III. Patient
Organism *
Bacteriology
Total
Total
smears
cultures
M. fort&urn
M. fort&urn
>I0
and pathology
Wumber of specimens submitted
Dathology and comment
>lO
>I0
Liver biopsy showed granulomas, negative for AFB by smear and culture
>I0
>I0
Lung and node biopsy showed caseating and non-caseating granulomas. M. fortuitum cultured from lung biopsy
M. fortuitum
11
14
None
M. fortuitum
9
18
None
M. fortuitum
33
33
Brush biopsy of cavity grew S. aureus as well as M. fortuitum Refused
M. chelonei
2
11
15
M. chelonei
2
4
4
* Identifications
were confirmed
serologically
biopsy
Caseating granulomas positive for AFB at necropsy
by Dr. Werner Schaefer.
were susceptible to tetracycline at concentrations growers to tetracycline has been reported previously and others, 1964).
of 50 mcg/ml. Susceptibility of rapid (Corpe, Smith & Stergus, 1961 ; Brosbe
Treatment and follow-up One of the 7 patients received no anti-tuberculosis treatment because of co-existing cardiac disease. Of the 6 who received anti-tuberculosis drugs, 1 (case 6) was lost to follow-up and another (case 7) died within 2 weeks of initiation of therapy. In the remaining 4 patients, follow-up ranged from 6 to 16 months. Regimens consisting of 4 to 6 anti-tuberculosis drugs were employed including, when possible, drugs to which the organisms were shown to be susceptible in vitro. The rationale for this multiple-drug approach is based on past favourable experience at National Jewish Hospital in the treatment of Runyon Group III (AI intracellulare-avium) infections which also show a great deal of in vitro drug resistance (Lester and others, 1968; Lester and others, 1969; Yeager Et Raleigh, 1973). In case 5, 6 months of chemotherapy resulted in no change in sputum smear and cultures for acid-fast organisms or change in the appearance of the chest x-ray. However, this patient tolerated medications poorly and thus had only sporadic treatment. Sputum culture conversion occurred in case 2 after 5 months of chemotherapy and the chest x-rays showed significant resolution. Patients 1 and 4 had a marked reduction in the number of organisms found in their sputa but continued to have sporadically positive cultures containing small numbers of
Rapidly Growing organisms following discharge. The radiographic of case 1 remains unchanged.
appearances
Mycobacteria
in case 4 improved
55
but those
Discussion There was strong evidence implicating M. fortuitum and M. chelonei as pulmonary pathogens in theseven patients reviewed. All patients presented with a subacute or chronic disease process clinically indistinguishable from pulmonary tuberculosis. All but 1 patient had symptoms including haemoptysis, cough and weight loss. Routine laboratory studies, chest x-rays, and skin tests were not helpful in identifying any unique characteristics of these patients nor did they help determine or not the rapidly growing mycobacteria were pathogens in the individual patient. None of the patients had a previous history of pulmonary tuberculosis although cases 4 and 6 had positive skin tests to PPD-S. Patient 6 had a past history of isolation of M. kansasiifrom his sputum and had been treated for that infection. However, multiple sputum culture specimens while in hospital at National Jewish Hospital yielded only &I. chelonei. He remained ill during one and one-half months of treatment and left against medical advice after refusing lung biopsy. He was subsequently lost to further follow-up. It is of interest that 3 patients had active rheumatoid arthritis. This association has been noted by Bates (1966). A similar association with ankylosing spondylitis has been suggested (Gacad & Massaro, 1974). All 3 patients had haemoptysis and weight loss. These complaints have not been associated with rheumatoid lung disease (Brosbe and others, 1964) and were interpreted as evidence of mycobacterial infection in these patients. The presence of haemoptysis and weight loss in patients with rheumatoid arthritis and cavitary lung disease should alert one to the possible presence of mycobacterial disease. One patient had a previous diagnosis of basilar lipoid pneumonia as well as haemoptysis, cough, fever and weight loss. Beck has related Group IV infection to the presence of lipoid pneumonia (Beck, 1959). This patient developed extensive pulmonary cavitation while M. fortuitum was repeatedly cultured from his sputum. Brush biopsy of the cavitary lesion was positive for both M. fortuitum and Staph. aureus. Although histopathological confirmation of mycobacterial infection was not obtained, the patient failed to respond to specific therapy directed at the staphylococcus. A pathological role for /VI. fort&urn was strongly suspected. No consistent immunologic abnormality was identified although 2 patients demonstrated apparent cutaneous anergy. Three patients (cases 1, 2 and 3), in whom there was strong evidence of infection with rapid growers had lymphocyte blastogenesis demonstrated in response to stimulation with phytohemoglutinin (PHA). However, PPD-F failed to stimulate lymphocyte blastogenesis in the three patients tested and failed to induce migration inhibition in the 1 case attempted. The immunogenicity of PDP-F (Marmorstein Et Scheinhorn, 1975) and its value in tests of immunological competence is doubtful; in none of our patients was it of diagnostic help. Histopathological examination of the lung was done in only 2 patients. Patient 2 underwent open lung biopsy and Patient 7 necropsy. Both patients had caseating pulmonary granulomas. In the setting of repeated isolation of rapidly growing mycobacteria from the sputum and lack of evidence for other processes to explain their findings, it was concluded that these mycobacteria were etiologic in the patients’ pulmonary disease. Treatment directed toward M. fortuitum in case 2 led to partial clearing of the microorganism from the sputum and moderate improvement in the appearance of the chest roentgenogram. Patient 1 from whose sputum M. fort&urn has been isolated for years had granulomas seen in a liver biopsy specimen. Granulomatous hepatitis has been associated with mycobacterial
56
Dreisin and others
disease (Sahn & Neff, 1974), but does not necessarily imply dissemination. In the setting of cavitary lung disease, granulomatous hepatitis, repeated isolation of M. fort&urn from the sputum, and lack of other suitable explanations for the patient’s disability, we felt that there was a strong suggestion of a pathologic role of M. fort&urn in this patient. In the 3 patients in whom treatment directed at the rapidly growing organisms was sustained and adequate follow-up was obtained, there was definite bacteriologic improvement in all, and improvement in the appearance of the chest x-ray in 2. We conclude that rapidly man. However, their relative and frequently ambiguous should be considered with firmation of active infection tuberculosis therapy.
growing mycobacteria can cause cavitary pulmonary disease in rarity, occasional isolation from the sputum of healthy individuals, clinical presentation make the diagnosis of infection one that caution. We think that, when possible, histopathological conshould be attempted before institution of potentially toxic anti-
Acknowledgements The authors thank Drs. Thomas L. Petty, Steven A. Sahn, Roger S. Mitchell, McClatchy for their helpful suggestions in the preparation of this paper.
and J. K.
References Awe,
Ft. J., Gangadharam, P. FL, Et Jenkins, D. E. (1973). Clinical significance of Mycobaceterium in pulmonary disease. American Review of Respiratory Disease, 108, 1230. Bates, J. H. (1966). Pulmonary infections associated with uncommon mycobacteria, Protocol Research Conference in Pulmonary Diseases, 25.87.
Fortuitum
infections
6. Transactions
of the
Beck, F. (1959). Pulmonary disease due to atypical tubercle bacilli. American Review of Respiratory Disease, 80, 738. Brosbe, E. A., Sugihara, P. T., Smith, C. R., Et Hyde, L. (1964). Experimental drug studies on Mycobacterium fortuitum. AntimicrobialAgents and Chemotherapy, 4,733. Corpe, R. F., Smith, C. E., 8 Stergus, I. (1961). Death due to Mycobacterium fortuitum. Journalof the American Medical Association, 177.78. Dross, I. C., Abbatiello, A. A., Jenney, F. S., Et Cohen, A. C. (1964). Pulmonary infection due to M. fortuitum. American Review of Respiratory Disease, 89.923. Edwards, L. B., & Palmer, C. E. (1959). Isolation of ‘atypical’ mycobacteria from healthy persons. American Review of Respiratory Disease, 50.747. Foote, W. C., 8 Polk, B. F. (1974). Endobronchitis and Mycobacterium fortuitum. Anna/s of internal Medicine, SO, 272. Gacad, G., & Massaro, D. (1974). Pulmonary fibrosis and Group IV mycobacterial infection of the lungs in ankylosing spondylitis. American Review of Respiratory Disease, 109,274. Hand, W. L., 8 Sanford, J. P. (1970). Mycobacterium fortuitum - A human pathogen. Anna/s of internal Medicine. 73,971. Hartwig, E. C., Cacciatore, R., Et Dunbar, F. P. (1962). M. fortuitum: Its identification, incidence and significance in Florida. American Review of Respiratory Disease, 55,84. Jenkins, P. A., 8 Marks, J. (1971). Transient colonization of the respiratory tract by mycobacteria in South Wales. Tubercle. 52,60. Lester, W., Fischer, D. A. Moulding, T. J., Fraser, R. I., 8 McClatchy, J. K. (1968). Evaluation of chemotherapy response in Group III (Battey-type) mycobacterial infections. Transactions of the VA-Armed Forces Pulmonary Disease Research Conference, 27, 20. Lester, W.,‘Moulding, T., Fraser, R. I., McClatchy, J. K., & Fischer, D.A. (1969). Quintuple drug regimens in the treatment of Battey-type infections. Transactions of the VA-Armed Forces Pulmonary Disease Research Conference, 28, 83. Marmorstein, B., b Scheinhorn, D. (1975). The role of non-tuberculous mycobacterial skin test antigens in the diagnosis of mycobacterial infection. Chest, 87,320. Nicholson, D. P., & Sevier, W. R. (1971). Mycobacterium fortuitum as a pathogen. A case report. American Review of Respiratory Disease, 104,747. Offer, R. C., K arlson, A. G., 8 Spitte!l, J. A. (1971). Infection caused by Mycobacterium fortuitum. Mayo Clinic Proceedings, 48,747. Petty, T. L., 8 Wilkins, M. (1966). The five manifestations of rheumatoid lung. Diseases of the Chest, 49,74. Phillips, S., 8 Larkin, J. C. (1964). Atypical pulmonary tuberculosis caused by unclassified mycobacteria. Anna/s of Internal Medicine, 80.491.
Rapidly Growing Pust, R. E., Onubogu, H. 0. N., Egornu, L. I., Et Smithwick. R. (1973). Pulmonary in a Nigerian. American Review of Respiratory Disease, 108.1416.
Mycobacteria
disease due to Mycobacterium
Radenbach, K. L. (1972). Permanently successful chemotherapy in two cases with disease due to Mycobacterium kansasii and fortuitum, respectively. Scandinavian
57
fortuitum
severe pulmonary mycobacterial Journalof Respiratory Diseases,
Supplement, 80,223. Runyon, E. H. (1954). Anonymous mycobacteria in pulmonary disease. Medical Clinics of North America, 43, 273. Sahn, S. A., Et Neff, T. A. (1974). Miliary tuberculosis. American Journalof Medicine, 56, 495. Warring, F. C. (1968). Mycobacteria in New England Hospital. A study of mycobacterial species occurring in the sputum of patients with chronic pulmonary disease. American Review of Respiratory Disease, 98, 965. Walker, W. C., & Wright, V. (1968). Pulmonary lesions and rheumatoid arthritis. Medicine (Baltimore), 47, 501, Wolinsky, E., Et Rynearson, T. K. (1968). Mycobacteria in soil and their relation to disease-associated strains, American Review of Respiratory Disease, 97,1032. Yeager, H., & Raleigh, J. W. (1973). Pulmonary disease due to Mycobacterium intracellulare. American Review of Respiratory Disease. 108. 547.
