Thank you to Luis for presenting a case of an elderly woman with history of bronchiectasis and MAC presenting with fevers, cough and chest pain. We were joined by Bhavika Kaul from pulmonary!
- Ditty pearl: Use ABCD2 score (age > 60, BP >140, clinical features, duration > 60 min & DM) to decide whom to admit after TIA. For a score > 2 hospitalization recommended given higher risk (> 4 %) of 2 day CVA.
- Faget sign (sphygmothermic dissociation) is described as a temperature-pulse dissociation and is often a sign intracellular organisms with typhoid fever being a common boards question. MOST common cause of fever, HR dissociation… beta-blockade.
- Diagnosis of MAC requires BOTH microbiology and the appropriate clinical context (more details below).
Diagnosis of MAC in the Non-HIV Patient
- Induced sputum with at least 2 positive cultures Or
- At least 1 bronchial lavage Or
- Transbronchial biopsy with mycobacterium
- Clinical Context:
- Pulmonary symptoms, nodular or cavitary opacities on CXR or CT scan with multiple nodules and bronchiectasis AND
- Exclusion of other diagnoses
Treatment of MAC
- Remember that macrolides are the cornerstone of therapy and you DO NOT want to use Azithromycin as a single agent given risk for resistance and partial treatment.
- Hence, avoid azithro as single drug coverage or part of treatment for superimposed CAP in patient with possible MAC
- For most patients being treated for MAC pulmonary disease require a three-drug combination regimen
- Selection depends, in part, on susceptibility to macrolides; most MAC isolates are macrolide susceptible.
- Antimycobacterial treatment is difficult to tolerate (weight benefits & risks) & continued until sputum cultures are consecutively negative for at least 12 months.
50% of patients with advanced HIV patient (CD4 <50) with a positive sputum culture for MAC who are NOT TAKING MAC ppx will get disseminated infection (fevers, weight loss, rising LFTs and cytopenias).
- Chronic infections
- Chronic aspiration
- History of childhood infections
- Cystic fibrosis
- Cigarette smoking
- Inflammatory – Rheumatoid Arthritis and Sjogren’s Syndrome
- Allergic bronchopulmonary aspergillosis (ABPA)
- Ciliary dyskinesia