Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.

gov/books/NBK551583/

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Lung Nontuberculous Mycobacterial Infections

Arian Bethencourt Mirabal; Gustavo Ferrer.

Author Information

Authors

Arian Bethencourt Mirabal1; Gustavo Ferrer2.

Affiliations
1 Aventura Hospital and Medical Center
2
Nova Southeastern University
Last Update: July 2, 2020.

Introduction
Following the discovery of mycobacterium tuberculosis by Robert Koch in 1882, several other
mycobacteria were identified as well. However, they were not recognized as causing disease in
humans until the 1980s. Non-tuberculosis mycobacteria (NTM) are ubiquitous in the
environment. They are responsible for opportunistic infections that affect not only the
immunocompromised host but also an immunocompetent individual. The incidence of the
disease from NTM has been gradually increasing worldwide, becoming, in recent years, an
emerging public health problem.[1][2][3] In 2007, the American Thoracic Society [ATS]
published a clinical guideline for the diagnosis and treatment of non-tuberculous
mycobacteria.[4] This was chiefly due to previous controversial experts’ opinions on how to
establish the diagnosis and treatment of the disease. Therefore, current guidelines continue to be
based on both experts’ opinions, and some new guidelines; but no universal recommendations
exist. With new medical advances based on molecular microbiology, the diagnosis of most NTM
is not only more precise but much faster than before. In this activity, we provide an in-depth look
at how NTM present, the clinical features and methods to make a rapid diagnosis and
identification of NTM. An interprofessional team approach based on the most up-to-date
literature on the topic is vital if one wants to improve outcomes.

Etiology
M. tuberculosis, M. leprae, and NTM are all related to the genus mycobacteria. Runyon
identified the non-tuberculous mycobacteria in the 1980s. He was able to identify the other
mycobacterial species based on their pigmentation changes in the presence or absence of light
(photochromogens, scotochromogens, non-chromogenic) and growth characteristics (slow versus
rapid).[5] One particular characteristic of the mycobacteria is their slow rate of growth. However,
NTM further sub-classifies into rapidly-growing or slow-growing organisms. The former usually
grows in seven days, whereas the latter usually takes up to three weeks.

During the last decade, the use of more advanced molecular and genetic methods for
microorganism identification has resulted in the previous Runyon classification getting replaced.
Today, the number of identified NTM species has reached more than a hundred, with around fifty

1 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

that correlate with a lung infection.[4] However, the most commonly occurring NTM that affects
humans includes Mycobacteria avium, M. ansasii, and M. abcessus.

Epidemiology
The epidemiology of NTM lung infections has been challenging to determine, due to the
following:

1. In many countries, it is not mandatory to report the condition to the public health
departments

2. The differentiation between infection and disease is often difficult.

3. The diagnosis tests are not always available in all institutions

4. Follow up is not precise

In the 1980s, U.S. laboratories reported an estimated prevalence of NTM infection of 1 to 2 cases
per 100000 population[6]. The annual prevalence increased among men and women in Florida
(by 3.2% per year and 6.5% per year, respectively), and among women in New York (by 4.6%
per year), but there was no significant increase seen in California. The annual prevalence of
NTM pulmonary diseases in U.S. Medicare beneficiaries (all persons 65 years of age and older)
increased from 20 per 100000 in 1997 to 47 per 100000 in 2007.[7]

Studies since the 1950s from Czechoslovakia, Wales, Ireland, Australia, and the United States
have reported increases in the incidence and prevalence of NTM lung infections. In Queensland,
Australia, where NTM is reportable, the incidence of clinically significant pulmonary disease
rose from 2.2 per 100000 in 1999 to 3.2 per 100000 in 2005.[8]

Finally, while the prevalence and incidence of NTM pulmonary disease have been increasing
through the years, not only in the U.S. but also around the world, this epidemiological variation
has not been explained. New radiological advances, especially resolution chest computed
tomography (CT) scanning, improved diagnosis, and an increase in chest screening may be
important factors responsible for these epidemiological observations.

Pathophysiology
All the relevant NTM become acquired via inhalation of infected aerosolized droplets. Living in
close quarters, coughing, and not using a facial mask are risk factors for transmission. Advanced
age, immunosuppression, and use of corticosteroids are all risk factors for acquiring these
organisms. Once the organisms enter the individual, they usually settle in the lower airways; in
some cases, the bacteria incite an inflammatory reaction with an influx of lymphocytes. The
resulting release of cytokines and other mediators can lead to an infectious process that presents
as pneumonia.

History and Physical

NTM isolation has always been controversial among physicians; this is because the bacteria lives
in the ambient, making it very difficult to differentiate colonization versus infection in sterile
sputum. So, it is indispensable to achieve the diagnosis of NTM by integrating clinical,
radiological, and microbiological aspects. Non-tuberculosis mycobacteria have a slow growth

2 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

process, resulting in a considerable time to infect the lungs. Sometimes, this particular factor,
along with a low index of clinical suspiciousness, could result in either misdiagnosis or delayed
diagnosis. Clinical manifestations are similar to tuberculosis lung infection. These could include
respiratory symptoms such as cough, dyspnea, increased sputum production, and systemic
manifestations such as low-grade fever, malaise, and weight loss. The duration of symptoms may
vary from a few days to a few weeks. The physical features are not specific and can mimic any
infectious process of the lungs.

Evaluation
Radiological findings

As with other lung infections, radiological images are crucial for the correct diagnosis of the
disease. However, unlike other lung diseases, non-tuberculosis mycobacteria have characteristic
lung presentations. The two major radiological patterns of NTM lung infection are fibro-cavitary
and nodular bronchiectatic pattern.[1] The fibro-cavitary radiological pattern resembles
tuberculosis lung infection. It presents with cavities with areas of increased opacity, mostly
located in the upper lung. On the other hand, the nodular bronchiectatic pattern characteristically
shows multilobar bronchiectasis, primarily located in the middle and lower lung fields, with
small nodules seen on images. This pattern predominantly presents in women smokers without
previous lung conditions. Finally, there is a high prevalence of patients with bronchiectasis in
patients with NTM lung infection. A recent study demonstrated that the prevalence of NTM
infection in patients with bronchiectasis was 9.3%.[2] Clinicians must be aware that NTM lung
infection could present with bronchiectasis on radiological images.

Laboratory diagnosis

The isolation of non-tuberculosis mycobacteria in human specimens can be challenging. Since

the bacteria can is present in the environment, especially in water sources, a positive test in a
sputum specimen could produce a false-positive result. Also, the NTM species from the
environment that have colonized in the airway could lead to contaminant specimens, contributing
to a falsely positive test result with a poor positive predictive value. Hence, current guidelines
recommend that a collection of three early morning sputum specimens be obtained on three
different days to achieve an accurate diagnosis of non-tuberculosis mycobacteria lung
infection.[1] The methods used for acid-fast bacilli stain require the carbol fuchsin stain (Ziehl-
Neelsen or Kinyoun method) and the fluorochrome procedure (auramine O alone or in
combination with rhodamine B).[3][4] However, the mentioned stain methods cannot
discriminate between tuberculosis versus non-tuberculosis mycobacteria.

Nuclei-acid amplification (NAA) is the most accurate test for identifying mycobacterial strains.
Culture remains the test of choice for NTM laboratory confirmation. There are two media used
for the culture: solid media or liquid media. Solid media includes either egg-based media, such
as the Löwenstein-Jensen medium, or agar-based media such as Middlebrook 7H10 and 7H11
media. Solid media allows the visualization of morphologic, grown rate, and species
characterization. The liquid media system is more sensitive but is more prone to contamination
by other micro-organisms and bacteria overgrowth.

NTM identification

3 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

The treatment of non-tuberculosis infection is specific and different for every particular NTM
species. Making a correct identification of the species is the main factor of successful treatment.
The most accurate NTM identification method is via gene sequence. Sequencing the 16S rRNA
gene allows for the correct identification and discrimination between species. However, species-
level identification may need several gene sequences and more complex methods. Only
specialized laboratories dedicated to the identification of species-levels by using different gene
sequences can perform this test. The matrix-associated laser desorption/ionization time-of-flight
mass spectrometry (MALDI-TOF MS) method has increasingly employed for the identification
of NTM. This method is identifying target bacteria by comparing mass spectral pattern
molecules specific to NTM.

Drug Susceptibility

When NTM are cultured, drug susceptibility tests are always conducted to assist physicians with
the choice of drug regimens. However, there are difficulties with the drug susceptibility test
because these organisms behave differently in vitro than in vivo.

Treatment / Management
The treatment of NTM requires a holistic and patient-centered approach based on the quality of
life and patient benefits, instead of expecting mycobacteria eradication. An NTM lung infection
differs from a TB lung infection in that it does not require immediate initiation of treatment upon
diagnosis. The treatment of NTM lung infection includes an interprofessional approach and a
discussion of risk and benefits. The therapy should remain in place until 12 months of negative
cultures have been obtained. Bimonthly sputum cultures should also get collected until 12
months of negative cultures have been achieved. During the treatment, the patient requires close
monitoring for drug side effects and medication compliance and adherence.

Treating mycobacterial avium intracellularly complex (MAC) lung disease

The treatment of mycobacterial avium intracellularly complex (MAC) lung disease depends on
clinical presentation, including nodular or bronchiectasis disease, cavitary diseases, and
advanced (severe) or previously treated disease.

Treatment for bronchiectasis or cavitary disease

The first regimen for the treatment of bronchiectasis disease includes clarithromycin [1000 mg
three times per week] or azithromycin [500 to 600 mg three times per week] together with
rifampin [600 mg three times per week]. The primary treatment regimen for cavitary disease is
clarithromycin [500 to 1000 mg per day] or azithromycin [500 to 600 mg three times per week]
together with ethambutol [15 mg per kilogram per day] and rifampin [450–600 mg per day].
Furthermore, streptomycin or amikacin [10 mg per kilogram three times per week] can be an
added therapy.

The treatment of advanced disease

The treatment of advanced (severe) or previously treated disease includes clarithromycin [500 to
1000 mg/day] or azithromycin [250 mg/day] together with rifabutin [150 to 300 mg] or rifampin
[450 to 600 mg once daily], ethambutol [15 mg per kilogram], and streptomycin or amikacin [10
mg per kilogram intramuscular or intravenous three times/week; maximum dose 500 mg for

4 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

age over 50 years for the first 2 to 3 months]. The addition of moxifloxacin [400 mg orally
once/daily] to the previous combination regimen may improve outcomes in refractory diseases or
treatment failing.

Treatment for refractory disease

Refractory pulmonary infection is a failure to achieve negative cultures for more than six
months. The regimen of treatment is the administration of amikacin liposome inhalation
suspension once daily at a dose of 590 mg/8.4 milliliter (one vial) with a specialized nebulizer
system only, along with an optimized multi-drug background regimen.

Duration of therapy

In those achieving three consecutive monthly negative sputum cultures 12 months after last
positive cultures for six months, continue for an additional 12 months. The benefit of extended
therapy in those not achieving three consecutive monthly negative sputum cultures by six months
remains unestablished, although it the subject of an on-going clinical trial.[5]

Treatment of Mycobacterium Kansasii lung disease

Mycobacteria kansasiis lung disease remains a relatively easy treatable pathogen among NTM
lung infection diseases. Usually, the bacteria are sensitive to the tuberculosis regimen, with a
high curative rate. The recommended primary regimens are: Isoniazid [300 mg], Pyridoxine [50
mg], rifampin [600 mg], and ethambutol [15 mg/kg] for 12 months of culture-negative sputum.
Recently it has been demonstrated that adding to the previous treatment a macrolide such as
Streptomycin during the first 2 to 3 months has high effectiveness with a low relapse rate.[6]

Treatment for Mycobacterium abscessus complex lung disease

The treatment of Mycobacterium abscessus complex (MABC) lung infection remains

complicated because of the high treatment failure rate. Therefore, more clinical trials are needed
to establish a successful treatment that results in the eradication and cure of the disease. In
general, the primary regimen consists of a macrolide with two parenteral agents for an extended
period. Also, the treatment divides between the intensive phase that uses imipenem [1000 mg
IV/12 hrs] or cefoxitin [IV, 8 to 12 gm/day, divided into 2 or 3 doses], azithromycin [250 to 500
mg orally once/daily] along with amikacin [IV, 15 mg/kg/once/daily] with adjustable doses until
obtaining peak serum concentration of 20 to 30 ug/ml. This proposed treatment should last 2 or 3
months, depending on the severity of infection, clinical response, tolerability, and toxicity.
Finally, the continuation phase uses azithromycin [250 to 500 mg].

The role for surgery

NTM lung infection can be challenging to manage with antibiotic therapy. In these cases,
adjuvant surgical therapy to remove the most severely destroyed lung can promote treatment
success. In the cases of massive hemoptysis, surgery may be the best choice. Recent studies have
reported successful treatment, with sputum conversion of 80 to 100% in patients after adjuvant
surgical reception[7][8][9]. Surgery requires a comprehensive preoperative evaluation since
recent research has shown that postoperative complications have morbidity of 7% to 25% and a
mortality rate of 0% to 3%.

Medication side effects

5 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

One essential piece of information that is important to include when discussing the medication
regimen with patients has to do with medication side effects, reactions, and interactions.
Physicians and pharmacists must always keep in mind that patients deserve to know as much
information as possible about any new treatment. In the case of treatment with NTM, the most
used medications are macrolides, antituberculosis medications.

In the case of macrolides like azithromycin or erythromycin, the most common side effects are
gastrointestinal symptoms, including nausea, heartburn, etc. Another side effect of this type of
medication is the prolongation of QT, leading to cardiac arrhythmias. It is always essential to
have a baseline EKG when using this medication. Cholestatic hepatitis has been often reported in
patients using this medication. Finally, transient reversible tinnitus or deafness with over 4
gm/day of erythromycin IV has occurred in a patient with renal impairment.

Rifampin is potentially hepatotoxic. It requires caution in a patient with ongoing liver

impairment or excessive use of alcohol. If elevated bilirubin and/or a substantive increase in
liver-associated enzymes occurs, discontinue Rifampin therapy. One of the most known side
effects with rifampin is red-orange discoloration of urine, feces, and saliva. It can stain contact
lenses permanently. There are reports of thrombocytopenia and vasculitis.

Ethambutol is another medication used in the treatment of NTM. One of the most serious adverse
reactions is optic neuritis with decreased visual acuity, central scotoma, loss of ability to see
green, and perception problems; peripheral neuropathy and headache are the most commons side
effects reported.

Differential Diagnosis
Like other lung etiologies, NTM lung infection affects the host in several ways. Clinical
manifestation could mimic other lung infections, such as Mycobacterial tuberculosis, atypical
bacterial infections, and chronic lung diseases. Clinicians should approach the differential
diagnostic of pulmonary pathologies based on the clinical manifestations and radiological
characteristics. Among the differential diagnosis infections, neoplasia, and connective tissue
diseases are the most common that share similarities to NTM lung infections. Mycoplasma,
chlamydia, and viral pneumonia are relevant entities to include in the differential. Others are
fungal lung infections like Aspergillus, Histoplasma, and Coccidiosis, to name a few. Small cell
and non-small cell lung cancer are important to consider, especially in patients with weight loss
and lymphadenopathy. Moreover, disorders of the connective tissue, such as rheumatoid arthritis
lung disease, granulomatosis with polyangiitis, or eosinophilic granulomatosis with polyangiitis,
can represent an essential part in the differential as well. Overall, any entity that presents with
respiratory manifestations, and either cavitary or bronchiectasis radiological lung pictures on
images is part of the differential diagnosis and needs to be ruled out.

Prognosis
The prognosis of NTM lung infection is guarded. Patients who have a fragile immune system are
more prone to worse outcomes when compared with immunocompetent patients. Also, the
prognosis will depend on the type of NTM lung infection. Recent studies have shown that
patients with MAC lung infection have a better prognosis when compared to patients with other
NTM infections.[10] Also, the mortality rate of patients with lung infection with Mycobacterial
abcessus is greater when compared with patients with other NTM lung infections.[11] Finally,

6 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

the main predictor of mortality in NTM lung infection seems to be chronic underlying lung
diseases in combination with the type of non-tuberculosis mycobacterial lung infection,
especially Mycobacterial abcessus.

Complications
Like other lung etiologies, NTM lung infection affects the host in several ways. Clinical
manifestation could mimic other lung infections, such as Mycobacterial tuberculosis, atypical
bacterial infections, and chronic lung diseases. Clinicians should approach the differential
diagnostic of pulmonary pathologies based on the clinical manifestations and radiological
characteristics. Among the differential diagnosis infections, neoplasias, and connective tissue
diseases most commonly share similarities to NTM lung infections. Mycoplasma, chlamydia,
and viral pneumonia are relevant entities to include in the differential. Others are fungal lung
infections like Aspergillus, Histoplasma, and Coccidiosis, to name a few. Small cell and non-
small-cell lung cancer are important to consider. Moreover, disorders of the connective tissue,
such as rheumatoid arthritis lung diseases, granulomatosis with polyangiitis, or eosinophilic
granulomatosis with polyangiitis, represent an essential part of the differential as well. Overall,
any entity that presents with respiratory manifestations, and either cavitary or bronchiectasis
radiological lung pictures on images, is part of the differential diagnostic, and these conditions
need to be ruled out.

Deterrence and Patient Education

Prevention of NTM is a rather challenging task due to its ubiquitous presence in the
environment. Therefore, it is necessary to discuss with the patient about disease prevention
remains problematic. Also, it is unclear how to assess whether the patient is susceptible to NTM
and if it would be efficacious to educate patients in the avoidance of specific environmental
sources. As an example, it is a known fact that hot showers can be a vector of transmission for
the disease, but it is unclear if educating the patient on avoiding hot showers will decrease the
chances of infection. There is not enough data that support a solid prevention strategy for the
transmission of NTM.

In terms of treatment, the patient should be advised regarding the time-frame of the treatment, as
this could be very lengthy. Patients must be educated with an organized care plan to achieve
better outcomes. The plan must include medication regimens, side effects, preset appointments,
and a timeframe of treatment completeness. Patients must be aware of potential complications.
They also should be aware that only by taking the medication as prescribed can they achieve
disease-free status, as this is only possible if they have negative sputum cultures for NTM after
12 months. It is necessary to build patient rapport and healthy relationships with the patients to
obtain the best results.

Enhancing Healthcare Team Outcomes

The diagnosis and treatment of NTM are complex and best done with an interprofessional team.
Patient-centered care is a practical approach and is the ultimate goal when treating patients.
Research has demonstrated that an integrated interprofessional team is the best method for
achieving excellent outcomes in inpatient care. Health professionals who look at the patient as a
whole person may have more influence on the patient than if they look at him merely as a sick

7 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

individual. The pharmacist should educate the patient on the importance of drug compliance,
while also checking the medication record and verifying dosing and drug interactions. An
infectious disease pharmacist can also go over the latest antibiogram data with the clinician to
optimize antimicrobial effectiveness and prevent antibiotic resistance. Nursing can have
involvement with medication administration as well as verifying compliance, looking for adverse
events, and offering patient counsel, and reporting any concerns to the clinician staff.

In some cases, daily observer therapy may be necessary. The patient should be urged to quit
smoking, as this may exacerbate the symptoms. The pharmacist should work in tandem with the
infectious disease expert and monitor the patient for adverse effects to the medications. A holistic
approach helps determine the patient necessities and strengths that could serve as an essential
component of the treatment plan. Hence, the healthcare invitation to participate in patient-
centered care improves outcomes, patient safety, and enhances interprofessional team
performance. [Level 5]

Questions
To access free multiple choice questions on this topic, click here.

Figure

Mycobacterium kansasii. Image courtesy S Bhimji MD

Figure

MAI pneumonia. Image courtesy S Bhimji MD

Figure

CT Mycobacterium abscessus. Image courtesy S Bhimji MD

References
1. Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, Holland SM,
Horsburgh R, Huitt G, Iademarco MF, Iseman M, Olivier K, Ruoss S, von Reyn CF, Wallace
RJ, Winthrop K., ATS Mycobacterial Diseases Subcommittee. American Thoracic Society.
Infectious Disease Society of America. An official ATS/IDSA statement: diagnosis,
treatment, and prevention of nontuberculous mycobacterial diseases. Am. J. Respir. Crit.
Care Med. 2007 Feb 15;175(4):367-416. [PubMed: 17277290]
2. Chu H, Zhao L, Xiao H, Zhang Z, Zhang J, Gui T, Gong S, Xu L, Sun X. Prevalence of
nontuberculous mycobacteria in patients with bronchiectasis: a meta-analysis. Arch Med Sci.
2014 Aug 29;10(4):661-8. [PMC free article: PMC4175767] [PubMed: 25276148]
3. Kim N, Yi J, Chang CL. Recovery Rates of Non-Tuberculous Mycobacteria from Clinical
Specimens Are Increasing in Korean Tertiary-Care Hospitals. J. Korean Med. Sci. 2017
Aug;32(8):1263-1267. [PMC free article: PMC5494324] [PubMed: 28665061]

8 of 9 7/23/2020, 7:01 PM
Lung Nontuberculous Mycobacterial Infections - StatPearls - NCBI B... https://www.ncbi.nlm.nih.gov/books/NBK551583/

4. Somoskövi A, Hotaling JE, Fitzgerald M, O'Donnell D, Parsons LM, Salfinger M. Lessons

from a proficiency testing event for acid-fast microscopy. Chest. 2001 Jul;120(1):250-7.
[PMC free article: PMC2925666] [PubMed: 11451846]
5. Griffith DE, Eagle G, Thomson R, Aksamit TR, Hasegawa N, Morimoto K, Addrizzo-Harris
DJ, O'Donnell AE, Marras TK, Flume PA, Loebinger MR, Morgan L, Codecasa LR, Hill AT,
Ruoss SJ, Yim JJ, Ringshausen FC, Field SK, Philley JV, Wallace RJ, van Ingen J, Coulter C,
Nezamis J, Winthrop KL., CONVERT Study Group. Amikacin Liposome Inhalation
Suspension for Treatment-Refractory Lung Disease Caused by Mycobacterium avium
Complex (CONVERT). A Prospective, Open-Label, Randomized Study. Am. J. Respir. Crit.
Care Med. 2018 Dec 15;198(12):1559-1569. [PubMed: 30216086]
6. Santin M, Dorca J, Alcaide F, Gonzalez L, Casas S, Lopez M, Guerra MR. Long-term
relapses after 12-month treatment for Mycobacterium kansasii lung disease. Eur. Respir. J.
2009 Jan;33(1):148-52. [PubMed: 19118226]
7. Yu JA, Pomerantz M, Bishop A, Weyant MJ, Mitchell JD. Lady Windermere revisited:
treatment with thoracoscopic lobectomy/segmentectomy for right middle lobe and lingular
bronchiectasis associated with non-tuberculous mycobacterial disease. Eur J Cardiothorac
Surg. 2011 Sep;40(3):671-5. [PubMed: 21324708]
8. Shiraishi Y, Katsuragi N, Kita H, Hyogotani A, Saito MH, Shimoda K. Adjuvant surgical
treatment of nontuberculous mycobacterial lung disease. Ann. Thorac. Surg. 2013
Jul;96(1):287-91. [PubMed: 23618520]
9. Kang HK, Park HY, Kim D, Jeong BH, Jeon K, Cho JH, Kim HK, Choi YS, Kim J, Koh WJ.
Treatment outcomes of adjuvant resectional surgery for nontuberculous mycobacterial lung
disease. BMC Infect. Dis. 2015 Feb 19;15:76. [PMC free article: PMC4342798] [PubMed:
25887191]
10. Kotilainen H, Valtonen V, Tukiainen P, Poussa T, Eskola J, Järvinen A. Clinical findings in
relation to mortality in non-tuberculous mycobacterial infections: patients with
Mycobacterium avium complex have better survival than patients with other mycobacteria.
Eur. J. Clin. Microbiol. Infect. Dis. 2015 Sep;34(9):1909-18. [PMC free article:
PMC4545189] [PubMed: 26155783]
11. Graybill JR, Silva J, Fraser DW, Lordon R, Rogers E. Disseminated mycobacteriosis due to
Mycobacterium abcessus in two recipients of renal homografts. Am. Rev. Respir. Dis. 1974
Jan;109(1):4-10. [PubMed: 4588091]

Copyright © 2020, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution, and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is provided to the
Creative Commons license, and any changes made are indicated.

Bookshelf ID: NBK551583 PMID: 31869064

9 of 9 7/23/2020, 7:01 PM