Pulmonary Mycobacterium szulgai Infection and Treatment in a Patient Receiving Anti-Tumor Necrosis Factor Therapy

Jakko van Ingen; Martin Boeree; Matthijs Janssen; Erik Ullmann; Wiel de Lange; Petra de Haas; Richard Dekhuijzen and Dick van Soolingen

Disclosures

Nat Clin Pract Rheumatol. 2007;3(7):414-419. 

In This Article

Discussion of Treatment Options

Whether or not anti-TNF agents can be safely continued during antimycobacterial treatment remains the subject of debate. Continuation of these agents might be feasible for the following three reasons. Firstly, the disruption of granuloma achieved by anti-TNF agents could increase the exposure of mycobacteria to antimycobacterial drugs, thereby resulting in improved treatment outcome for the infection.[12] Secondly, although an increased risk of paradoxical response to antimycobacterial therapy has been reported in infliximab-treated patients with tuberculosis, which is characterized by clinical deterioration during treatment in patients who initially improve, maintenance of low doses of anti-TNF agents might produce immunologic regulation beneficial to this group.[13] Thirdly, rheumatologic complaints remain well-controlled with anti-TNF therapy. A case reported by Matsumoto et al. showed that antimycobacterial therapy followed by anti-TNF therapy can be safe and effective for the treatment of mycobacterial infection; infliximab therapy was safely restarted after 2 months of antituberculosis treatment.[14] Anti-TNF treatment was not discontinued during antimycobacterial therapy in the patient described here, and his M. szulgai infection improved (Figures 1-3) while his rheumatologic complaints remained minimal and no paradoxical reaction occurred.

Both the American Thoracic Society and the British Thoracic Society have released management guidelines for nontuberculous mycobacterial infections. Although not designed for M. szulgai, both groups specifically mention this species. The American Thoracic Society advises treatment with rifampicin 600 mg, ethambutol hydrochloride 25 mg/kg in the first 2 months, then 15 mg/kg, and streptomycin (dosage depending on weight, age and phase of therapy); the British Thoracic Society advises rifampicin 450 mg for patients who weigh <50 kg and 600 mg for those who weigh >50 kg, ethambutol hydrochloride 15 mg/kg, clarithromycin 500 mg twice daily, and also the option of surgical treatment.[1,15] Previous case series have reported an almost 100% cure rate of M. szulgai infection, with the few failures or relapses resulting from inadequate drug regimens or proven noncompliance.[16] This patient was treated with clarithromycin to avoid the use of drugs that require injection. The optimal duration of therapy has not yet been established in clinical trials; however, both the American Thoracic Society and the British Thoracic Society currently advise 18-24 months of treatment if the patient has a satisfactory clinical and bacteriological response to chemotherapy, as this patient had.

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