Conly, JM

Shafran, SD

PubMed

SD Shafran

JM Conly

Crossref

Infectious disease notes ADULT INFECTIOUS DISEASE NOTES 'Big MAC' attack TN THIS EDITION OF ADULT JNF'ECTIOUS DISEA 'E NOTES. WE lou lli ne som e of lhe recen t deve lopmen ts in our u n-de rstanding of Mycobacler ium auium com plex (MAC) in -fection in pa ti en ts wilh lhe acq uired im mune de fi c iency syndrome (AIDS). Incidence: MAC is U1 e AIDS- defi n ing even l in fewe r lha n 5% of /\IDS cases (Federal Cen lre for AIDS a nd Cen lers for Disease Con trol da la ). bul has been reported in 53% of a u tops ies . 1 RccenUy. a pros pec tive s ludy of 1006 AIDS patien ts has clemons lraled lha l lhc incidence of MAC bacle rem ia is a boul 20% per yea r fo llowing a n AIDS d iagnos is and reaches 50% a l 30 monU1s.2 Mosl pa-tie n ts wilh MAC in fection have CD4 lymphocyte coun ls below 50x 106 I L. 2---1 The organism: MAC re fe rs lo U1 e 28 serolypes of M auium a nd M inlracellula re. Som e taxo nomis ts a lso class ify M scrofulaceum as a m ember of MAC. However. nearly a ll MAC iso lates from AIDS pa ti ents arc M auium. in conlrasl to pulmonary MAC infection. wh ich is more evenly s pli l between M au ium a nd M intracellu la re. 5 Furthermore . lh e majori ty of M auium s t ra ins from AIDS pa lienls has a s im ila r reslric lion fragm ent length po lymorphis m pal-lem .6 Fina lly . mac rophages fro m /\IDS pa lienls a rc s ig-n ifi canUy more s usceptib le lo in vilro infec tion with M auium lhan wi lh M in l racellu lare. 7 76 How does MAC infection occur? MAC organ isms a re widely d is lribuled in the envi ronment. especia lly in wale r sources. a nd in a vari ety of birds a nd ma mmals. Bolh lhe gas troinles lina l lract and respiratory tracl a re recognized porta ls of enlry fo r MAC in AIDS pa lien ls: however . lhe gastrointes tina l tracl a ppears lo be U1e more common of U1e two routes of entry. ll is not unus u a l for MJ\C bacte rem ia lo occur wiU1oul docu-mented prio r gastro inleslina l or respira tory tracl colo-ni za tion. like ly becau se s u ch colon ization m ay be lrans ienl. Impact of MAC infection in AIDS patients: ll has long been recognized lha l MAC infec tion may cause fever. n ight swea ts, weight loss a nd a nem ia . Altho ugh U1e role of MAC infec tion in AIDS morta li ty was previou s ly ques-Lio ned, 8 il is now clear U1a t MAC infection is a n inde-pendent ris k fac tor for morta li ty in AIDS pa tients . even a fle r a djus ting fo r CD4 lymphocyte count. 4 ·9 The mean s urviva l of AIDS pa tients with MAC infection who a re t reated vvilh a nlimycobac te ria l therapy is a pproxi-ma te ly double tha l of untrea ted patienls . 3· 10 Diagnosis : The m osl rapid diagnos tic technique is lhe u se of acid -fast s ta ins of a ppropriate body tissues and secre tions . with s ubsequent confim1a tion by culture. The prefe rred cu lture technique is rad iom etri c (BACTEC) CAN J INFECT DIS VOL 4 No 2 MARCH/ APRIL 1993 with rapid speciation by DNA probing. 11 The rad iomel-ric technique permits clirect inoculation of media with the patient's blood al the bedside. The recenUy released Roche Septi-Check AFB also appears lo an excellenl culture technique, 12 but its use for cultu ring blood is not well documented. In the absence of a radiometric system , blood may be trealed using U1e Dupont isolator (lysis-centrifugation) system or collected into sod ium polyanetholesulfona le, lysed wilil sodium desoxycho-late and suspended in bovine serum albumin prior to inocula tion in mycobacterial m edia. 13 Bone marrow cu lture is more sensitive than blood culture and s hould be considered when blood cultures a re negative and MAC infection is strongly s u spected. Furlilermore, acid-fast smears of bone marrow may be positive a nd thus provide a rap id diagnosis , wh ereas acid-fasl smears of blood a re invari a bly negalive and a re not indi -cated. Prevention: Recently, two identically designed pros pec-tive randomized double-blind clinical trials conducted in adu lt AIDS paLients. with mean CD4 lymphocyte counts of approximately 60xl06/L al enrollment. have demonstrated U1al rifabutin. given orally in a dosage of 300 mg daily. reduces ilie risk of MAC bacleremia by a factor of about 2.5. 14· 15 Treatment: MAC isola tes are characteris Lica1ly resistant REFERENCES I. Hawkins CC. Gold 1WM. Whim bey E, cl a l. Mycobacleriwn avium complex infecUons in palienls wilh acqu ired immunodefi cien cy syndrome. Ann Intern Med 1986: I 05: 184-8. 2. Nighlingale SD. Byrd LT. Southern PM. Jockusch JD. Cal SX. Wynne BA. Incidence of Mycobaclerium avium-inlracellula re complex bactcrcmia in human immunodefi ciency virus-posilive patients. J Irifecl Dis 1992: 165: 1082-5. 3. Kerlikowskc KM . Katz MH. Chan AK. Perez-Stable EJ. Anlimycobacteria l th erapy fo r disseminated Mycobacleriwn avium complex infection in paUcnts with acquired immunodefi ciency syndrome. Arch lnlem Med 1992: 152 :8 13-7. 4. Jacobson MA. Hopewell PC. Yajko OM. cl a l. Natural history of d isseminated Mycobacteriwn avium complex infection in AIDS. J Infect Dis 199 1:1 64:994-8. 5. Gutherlz LS. Damsker B. Bollonc EJ. Ford EG. Midura TF'. Janela JM. Mycobaclerium avium and Mycobaclerium inlracellula re infeclions in patients wiU1 and wilhoul AJDS. J Irifecl Dis 1989: 160: 1037-4 1. 6. Hamp on SJ. Porlaels F. Thompson J. cl a l. DNA probes demonslralc a si ngle highly conse rved str ain o f Mycobaclerium avium infecling AJDS pa lien ls. Lancel 1989:i:65-8 . 7. Crowle AJ. Ross ER. Cohn DL. Gilden J. May MI-I. Comparison of the abilities of Mycobaclerium aviwn and Mycobaclerium inlracellulare l o infect and multiply in cultured human macrophages from normal and human immunocleficicncy virus-infected subjects. InJecl lmmunol 1992:60:369-703 . 8. Chai son RE. Hopewell PC. Mycobactci-ia and AIDS morlality. Am Rev Respir Dis 1989: 139 : 1-3. (Edit) 9. Chaisson RE. Moore RD. Richman DD. Kcruly J. Creagh T and the Ziclovudi ne Epidemiology Study Group. Incidence and natural histo,y of Mycobacleriwn cwium complex infcclion in patients wiU1 aclvancccl human CAN J INFECT D1s V OL 4 No 2 M ARCH/ APRIL 1993 Infectious disease notes lo most standard antituberculous drugs . 16 However. the oulcome of treatment of pulmonary MAC infection in non -AIDS paLients has been demonstrated to correlate wiU1 U1e number of drugs used which a re active against the infecting strain in vitro. 16 Preliminary evidence s uggests tha t Uie same holds true in AIDS-associa ted MAC infection . 17 A number of newer drugs including cla riU1romycin, azithromycin . rifabutin and Duoroqui-nolones. as well as ilie traditional a ntileprosy drug clofazirnine . have grealer in vitro activity against MAC Ulan trad itional antituberculous drugs . Favourable re -sults wilil combinations of these agents (usually with e U1 a mbulol) have been reported in several uncontrolled series . 18 -2 1 Of these agents. clariU1romycin appea rs lo be Lhe mosl promising . based on a pilot study of cla riUlromycin monolilera py.22 However, clariilirorny-cin monotherapy h as been associa led wiU1 a substantial rale of acquired antibiotic resislance, 22 as would be expecled lo occur when any s low growing mycobaclerial infection is treated with a s ingle agent. AIU1ough U1e optimal trealmenl for MAC infection is far from clear. il is evidenl Ula l combination lreatmenl is required . The 'ideal' combi.naLion is not cw-renUy estab-lished. bul s ignillcant advances can be expected in the nexl two years as U1e results of several current rnulticen-lre conlrolled comparative trials become !mown . immunodefi c iency vinis di sease treated with zidovud ine. Am Rev Respir Dis 1992: 146:285-9. 10. Horsbu rgh CR Jr. Havlik JA, Ellis DA. et a l. Surviva l of pa lien ts wiU1 acquired immune deficiency syndrome and disseminated Mycobacleriwn aviwn complex infection with and wilhoul antimycobacle1ia l lherapy. Am Rev Respir Dis 199 1:144:557-9. 11 . D rake TA. Hindler JA. Berlin OGW. Bniclrner DA. Rapid idenlifica lion of Mycobacleriwn avium complex in cullure u sing DNA probes. J Clin Microbial 1987:25: 1442-5. 12. Isenberg HD. D'Amato RF. Hcifels L. cl a l. Co llaborative feasibi li ty study of a biphasic syslem (Roche Sepli -Chek AFB) fo r rapid detection and isolation of mycobacte,ia. J Clin Microb ial 1991:29 : 1719-22. 13 . Sa lfingcr M. Slool EW. Plol D. Heifets L. Comparison of U1rcc mcU1ods for recovery o f Mycobaclerium avium comp lex from b lood specimens. J Clin Microbial I 988:26: I 225-6. 14 . Cameron W. Sparli P. Pielroski N. el a l and Lhe Rifabulin Study Group. Rifabulin prevents M aviwn complex (MAC) bacleremia in patients wiU1 A IDS and CD4 <;; 200 . 32nd lnlersciencc Conference on Antimicrobial Agents and Chemolherapy. Anaheim. CA. Oclober 1992 :888. (Abst) 15 . Gordin F. Nighungale S. Wyn ne B. el a l and lhe RIF 087023 Sludy Group. Rifabutin monolherapy prevenls or delay Mycobaclerium aviwn complex (MAC) bacleremia in pa lien ts w iU1 AJDS. 32nd ln terscicnce Conference on Anlim icrobia l Agents and Chemolherapy. Anaheim. CA. October 1992:889 . (Abst) 16 . Horsburgh CR Jr. Mason UG III. Heifels LB. SouU1wick K. Labrecque J. Isem an MD. Response lo therapy of pulmona,y Mycobacleriwn cwium-inlracellulare infection correlates wiU1 resu l ts of in vi tro susceplibili ty lesting. J\m Rev Respir Dis 1987: 135:418-2 1. 17. Horsburgh CR Jr. Havlik JA. Heifets L. Flo1y M. Metchock B, Thom son SE. Response to therapy of Mycobacteriwn aviwn infection in AJDS correlates wilh in vilro su sccpUbilily lcsting. 3 J st lntersciencc Conference on 77 Infectious disease notes Antimicrobial Agents and Chemotherapy. Chicago. October 1991 :671. (Abst) 18. Agins BO. Bennan OS. Spicehand ler D. El -Sadr W. Simberkoff MS. Rahal JJ . Effects of combined therapy wiU1 ansamycin. clofazimine. ethambutol. and isoniazid for Mycobaclerium avium infection in patients w iU1 AIDS. J Inject Dis 1989:159:784-7. 19. HoyJ . Mijch A. Sand land M. Grayson L. Lucas R. Dwyer B. Quadruple-drug therapy of Mycobaclerium avium-inlracellulare bacteremia in AIDS patients. J Infect Dis 1990: 161:801 -5 . 20. Chiu J. Nussbaum J. Bozzetle S. el al. Trealmenl of disseminated Mycobaclerium avium complex infection in AIDS with amikacin. eU1ambutol. ,-ifan1pin. and ciproOoxacin. Ann lnlem Med 1990: 113 :358-6 1. 2 1. Kemper CA. Meng T-C. Nussbaum J. el al and lhe California Collaborative Treatment Group. Treatment of 78 Mycobacterium aviwn complex bacteremia in AIDS with a four-drug ora l regimen. Rifarnpin. eU1ambutol. c lofazimine. and ciproOoxacin. Ann Intern Med 1992 : 116 :466-72. 22 . Chaisson RE. Benson C. Dube M. et al. Clari thromycin therapy for d isseminated Mycobacterium avium complex (MAC) in AJDS. 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy. Anaheim. CA. October 1992 :89 1. (Abst) SD Shafran, MD, FRCPC Edmonton, Alberto JM Conly, MD, FRCPC Toronto, Ontario CAN J INFECT DIS VOL 4 No 2 M ARCH/ APRIL 1993 Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Canadian Journal of Infectious Diseases

‘Big MAC’ Attack

Directory of Open Access Journals

http://downloads.hindawi.com/journals/cjidmm/1993/129613.pdf

‘Big MAC’ Attack

Abstract

Similar works

Full text

Available Versions

Crossref

Directory of Open Access Journals