Grand Rounds

Non-Tuberculous Mycobacterial Infection in a child operated for Appendectomy

1Seth G S Medical College, Mumbai, India, 2Pediatric Infectious Diseases, Levioza Health Care, Mumbai, India

Address for Correspondence: Lavina Desai, Seth G S Medical College, India.

Clinical Problem :
A 12-year-old boy presented in November 2013 with abdominal pain and vomiting. He was operated for acute appendicitis with a perforation 5 months ago. His current CT scan abdomen showed a short segment stricture in the ileum with moderate dilation of proximal ileum and jejunal loops. He was operated for the same and a lymph node biopsy from the abdomen was taken and sent for histopathology and tuberculosis PCR. Histopathology showed reactive lymph nodes and PCR test was positive for non-tuberculous mycobacterial (NTM) infection. He was referred to us for further management in view of NTM report. On examination, he had no abnormality.

Should this child be given anti-tuberculous therapy?

Discussion :
NTM have emerged as important opportunistic pathogens. (1) NTM exists widely in soil and water and the highest rate of NTM colonization is found in hospitals and hemodialysis with rates ranging from 60%- 100%. Mycobacterium Avium colonization is more likely on recirculating water systems in hospitals. (2) Other important species responsible for outbreaks include M. Fortuitum, M. abscessus and M chelonae. NTM are ubiquitous in the environment and isolation of NTM from a clinical specimen may represent colonization, infection, and pseudo-outbreaks in healthcare settings. (2) Colonization is defined as the establishment of NTM within the patient’s microflora without evidence of disease or tissue invasion. A pseudo-infection is defined as a positive culture result from a patient without evidence of true infection or colonization which is typically caused by contamination during specimen handling. (2) Disease outbreaks usually involve sternal wound infections, plastic surgery wound infections and or postinjection abscesses. Pseudo-outbreaks most commonly relate to contaminated bronchoscopes and endoscopic cleaning machines and contaminated hospital water supplies. (3) An increase in positive acid-fast bacilli smears and cultures obtained from patients without a compatible clinical syndrome, like in our case, should prompt evaluation of pseudo-outbreak. (2) Whereas NTM infection in post-operative wound should be suspected in all post-operative wound infections which occur late and lack local and systemic signs pyogenic infections and have sterile cultures. (1) They usually show delayed healing and do not respond to the antibiotic used for acute pyogenic infections. (4) Analysis of species of NTM and the specimen source may assist in determining the significance of a cluster of isolates. Once an outbreak or pseudo-outbreak is suspected, molecular techniques should be applied promptly to determine the source and identify proper control measures. (2,5) Prevention of nosocomial infections and pseudo-infections due to NTM can be challenging and include disinfectants, strict de-contamination of endoscopes and hospital water systems, single used medical devices and medication vials. (2) A pseudo-outbreak does not need treatment.

References :
  1. Shah AK, Gambhir RPS, Hazra N, Katoch R. Non-Tuberculous mycobacteria in surgical wounds-a rising cause of concern. Indian J Surg. 2010;72:206-210.
  2. Phillip MS, Reyn FV. Nosocomial Infections Due to Nontuberculous Mycobacteria. Clin Infect Dis. 2001;33:1363-1374.
  3. Shiferaw MB, Tulu KT, Zegeye AM, Wubante AA. Liver Enzymes Abnormalities among Highly Active Antiretroviral Therapy-Experienced and HAART Naive HIV-1 Infected Patients at Debre Tabor Hospital, North West Ethiopia: A Comparative Cross-Sectional Study. AIDS Res Treat. 2016;2016:1985452
  4. Kalita JB, Rahman H, Baruah KC. Delayed postoperative wound infections due to non-tuberculous Mycobacterium. Indian J Med Res. 2005;122:535-539.
  5. Shah AK, Gambhir RPS, Hazra N, Katoch R. Non-Tuberculous mycobacteria in surgical wounds -a rising cause of concern. Indian J Surg. 2010;72:206-10.

Correct Answers :  yes 100%
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