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Nontuberculous Mycobacteria and Chronic Cough in Children: An Underappreciated Entity?
Description
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A1956 - Nontuberculous Mycobacteria and Chronic Cough in Children: An Underappreciated Entity?
Author Block: M. Januska, C. Spencer, A. Vicencio; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
Rationale:
Pulmonary nontuberculous mycobacterial (NTM) disease is rarely encountered in children. The isolation of NTM from respiratory samples in children is fraught with clinical uncertainty, and pediatric treatment protocols are not well established. We describe four children with chronic cough who were subsequently found to have bronchoalveolar lavage (BAL) cultures positive for Mycobacterium avium complex (MAC). All responded dramatically to directed therapy.
Methods:
Retrospective case series of four children with chronic cough and positive BAL cultures for MAC.
Results:
Patient 1: A 5-year-old female presented with two years of chronic cough and wheezing, unresponsive to bronchodilator and inhaled corticosteroid therapies. Chest computerized tomography (CT) demonstrated segmental bronchiectasis. Bronchoscopy revealed normal anatomy. MAC grew in BAL culture. Therapy was initiated with azithromycin, ethambutol, and rifampin. Symptoms resolved within the first month of therapy. Treatment was discontinued after one year without symptom return. Repeat imaging showed bronchiectasis resolution.
Patient 2: An 11-year-old female presented with five years of chronic cough, unresponsive to antibiotic, bronchodilator, and inhaled and oral corticosteroid therapies. Chest CT demonstrated segmental bronchiectasis. Bronchoscopy revealed tracheal cobblestoning. MAC grew in BAL culture. Therapy was initiated with clarithromycin. Symptoms improved in the first month of therapy; asymptomatic after one year of therapy.
Patient 3: An 11-year-old male presented with three months of chronic cough and exertional dyspnea, unresponsive to antibiotic, inhaled and oral corticosteroid, leukotriene receptor antagonist, and antihistamine therapies. Pulmonary function tests (PFTs) revealed fixed obstruction. Chest CT demonstrated diffuse ground glass opacities. Transbronchial biopsy revealed non-caseating granulomas. MAC grew in BAL culture. Further history revealed frequent hot tub use, but symptoms, PFTs, and radiographic findings progressed despite avoidance. Therapy was initiated with azithromycin, ethambutol, and rifampin. Symptoms resolved; PFTs and radiographic findings normalized.
Patient 4: A 12-year-old male presented with one year of chronic cough, unresponsive to inhaled corticosteroid and long-acting beta-adrenoceptor agonist therapies. Chest CT demonstrated segmental bronchiectasis. Bronchoscopy revealed pulmonary hemorrhage. MAC grew in BAL culture. Therapy was initiated with clarithromycin. Symptoms resolved. Treatment was discontinued after four months without symptom return. Repeat imaging showed bronchiectasis resolution.
Conclusion:
We describe four children with chronic cough and positive BAL cultures for MAC. All had abnormal radiographic findings without an identifiable etiology on extensive evaluation. All met adult criteria for pulmonary NTM disease and were treated accordingly. These findings suggest that pulmonary NTM disease should be considered in children presenting with chronic cough and positive respiratory cultures for NTM.
Author Block: M. Januska, C. Spencer, A. Vicencio; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
Rationale:
Pulmonary nontuberculous mycobacterial (NTM) disease is rarely encountered in children. The isolation of NTM from respiratory samples in children is fraught with clinical uncertainty, and pediatric treatment protocols are not well established. We describe four children with chronic cough who were subsequently found to have bronchoalveolar lavage (BAL) cultures positive for Mycobacterium avium complex (MAC). All responded dramatically to directed therapy.
Methods:
Retrospective case series of four children with chronic cough and positive BAL cultures for MAC.
Results:
Patient 1: A 5-year-old female presented with two years of chronic cough and wheezing, unresponsive to bronchodilator and inhaled corticosteroid therapies. Chest computerized tomography (CT) demonstrated segmental bronchiectasis. Bronchoscopy revealed normal anatomy. MAC grew in BAL culture. Therapy was initiated with azithromycin, ethambutol, and rifampin. Symptoms resolved within the first month of therapy. Treatment was discontinued after one year without symptom return. Repeat imaging showed bronchiectasis resolution.
Patient 2: An 11-year-old female presented with five years of chronic cough, unresponsive to antibiotic, bronchodilator, and inhaled and oral corticosteroid therapies. Chest CT demonstrated segmental bronchiectasis. Bronchoscopy revealed tracheal cobblestoning. MAC grew in BAL culture. Therapy was initiated with clarithromycin. Symptoms improved in the first month of therapy; asymptomatic after one year of therapy.
Patient 3: An 11-year-old male presented with three months of chronic cough and exertional dyspnea, unresponsive to antibiotic, inhaled and oral corticosteroid, leukotriene receptor antagonist, and antihistamine therapies. Pulmonary function tests (PFTs) revealed fixed obstruction. Chest CT demonstrated diffuse ground glass opacities. Transbronchial biopsy revealed non-caseating granulomas. MAC grew in BAL culture. Further history revealed frequent hot tub use, but symptoms, PFTs, and radiographic findings progressed despite avoidance. Therapy was initiated with azithromycin, ethambutol, and rifampin. Symptoms resolved; PFTs and radiographic findings normalized.
Patient 4: A 12-year-old male presented with one year of chronic cough, unresponsive to inhaled corticosteroid and long-acting beta-adrenoceptor agonist therapies. Chest CT demonstrated segmental bronchiectasis. Bronchoscopy revealed pulmonary hemorrhage. MAC grew in BAL culture. Therapy was initiated with clarithromycin. Symptoms resolved. Treatment was discontinued after four months without symptom return. Repeat imaging showed bronchiectasis resolution.
Conclusion:
We describe four children with chronic cough and positive BAL cultures for MAC. All had abnormal radiographic findings without an identifiable etiology on extensive evaluation. All met adult criteria for pulmonary NTM disease and were treated accordingly. These findings suggest that pulmonary NTM disease should be considered in children presenting with chronic cough and positive respiratory cultures for NTM.
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