Among nontuberculous mycobacteria, Mycobacterium abscessus, and also two closely related species, M. massiliense and M. bolletii, are emergent opportunistic agents in humans, causing respiratory, cutaneo-mucous, bone or disseminated infections. Respiratory infections are the most common infections, frequently severe and usually occurring on underlying lung disease (particularly cystic fibrosis) but can occur without predisposing factor, generally in elderly Caucasian women with specific morphologic features. M. abscessus is resistant to most antibiotics. Treatment of M. abscessus consists of an oral agent, clarithromycin, initially combined with two parenteral agents, cefoxitin and amikacin. Concerning infections with a low bacterial load, like skin and soft tissue infections, treatment is efficient. At the opposite, in respiratory infections (with high bacterial load) prolonged triple therapy is required, eradication of the mycobacteria is often not obtained and side effects are common. (C) 2010 Elsevier Masson SAS. All rights reserved.

Lymph node tuberculosis is the most frequent form of extrapulmonary tuberculosis, especially in immunocompromised patients. We have studied patients with proven lymph node tuberculosis in the Department of Infectious Diseases at Pitié-Salpêtrière Hospital, Paris, between January 1997 and January 2002. Clinical presentation, microbiological diagnosis and treatment were analyzed in 13 HIV infected and 19 non-HIV infected patients. A risk factor for tuberculosis was present in all cases (HIV infection, immigration, life in community, poverty, past history of tuberculosis and IVDU). The median duration between the onset of symptoms and diagnosis was longer for HIV infected (2 months) compared with non-HIV infected patients (1 month). At the time of the diagnosis, general symptoms were present in >50% of patients of both groups. In HIV infected patients, abdominal lymph node involvement was more frequent (P < 0.05). All the non-HIV infected and 85% of HIV infected patients had peripheral adenopathies. A pulmonary tuberculosis was noted in more than half of the cases (53% non-HIV and 69% HIV patients). Inflammatory parameters and liver function tests were frequently abnormal in both groups. Hyponatremia was more frequent in HIV patients (P < 0.05). TB skin testing was more frequently positive and phlyctenular in non-HIV infected patients (P < 0.05). In this study, direct examination of the needle aspirate from infected lymph nodes was rarely positive; cultures were more frequently positive after biopsy compared to needle-aspiration. The median duration of treatment was 9 months for the two groups (6-24 months). Three HIV infected patients were infected by mycobacteria resistant to at least one antibiotic (isoniazid, 1; rifampicin, 1; isoniazid, streptomycin, etambutool, 1). All the patients recovered.

Lymph node tuberculosis is the most frequent form of extrapulmonary tuberculosis especially in immunocompromised patients. We have studied patients with proven lymph node tuberculosis in the Department of Infectious Diseases at Pitie-Salpetriere Hospital, Paris, between January 1997 and January 2002. Clinical presentation, microbiological diagnosis and treatment were analyzed in 13 HIV infected and 19 non-HIV infected patients. A risk factor for tuberculosis was present in all cases (HIV infection, immigration, life in community, poverty, past history of tuberculosis and IVDU). The median duration between the onset of symptoms and diagnosis was longer for HIV infected months compared with non-HIV infected patients (1 month). At the time of the diagnosis, general symptoms were present in >50% of patients of both groups. In HIV infected patients, abdominal lymph node involvement was more frequent (P < 0.05). All the non-HIV infected and 85% of FlIV infected patients had peripheral adenopathies. A pulmonary tuberculosis was noted in more than half of the cases (53% non-HIV and 69% HIV patients). Inflammatory parameters and liver function tests were frequently abnormal in both groups. Hyponatremia was more frequent in HIV patients (P < 0.05). TB skin testing was more frequently positive and phlyctenular in non-HIV infected patients (P < 0.05). In this study, direct examination of the needle aspirate from infected lymph nodes was rarely positive; cultures were more frequently positive after biopsy compared to needle-aspiration. The median duration of treatment was 9 months for the two groups (6-24 months). Three HIV infected patients were infected by mycobacteria resistant to at least one antibiotic (isoniazid, 1; rifampicin, 1; isoniazid, streptomycin, etambutool, 1). All the patients recovered. (C) 2003 Editions scientifiques et medicales Elsevier SAS. Tous droits reserves.

Mycobacterium intracellulare and Mycobacterium avium (MAC) require specialized culture and identification procedures. To simplify the diagnosis, we inoculated reference strains, and 85 M. avium and 12 M. intracellulare clinical isolates, on egg-based and sheep blood agar. After 5 days of culture, there were significantly more colonies on sheep blood than on egg-based agar for M. avium (ratio: 250.5 +/- 209) but not for M. intracellulare (ratio: 0.44 +/-0.11). Using a ratio > or = 20, the sensitivity of the identification of an MAC isolate as M. avium was 97.65%, the specificity was 100%, and the positive predictive value was 100%. Differential growth on egg-based and blood agar is an aid to the identification of MAC isolates.

Purpose. - Multidrug resistant tuberculosis (MDR-Tb) is a threat to tuberculosis control programmes. Data from MDR-Tb surveillance in France since 1992 are reported.Design. - Annual surveys were performed to collect all culture-positive cases of tuberculosis in France. Information on MDR-Tb cases included age, sex, country of birth, site of Tb, HIV co-infection, date of first diagnosis of Tb and drug susceptibility.Results. - The annual prevalence of MDR-Tb cases was 0.6% on average and remained stable during the study period. A majority of MDR-Tb cases were male (70%), foreign-born (56%), and previously treated (66%). HIV co-infection, present in 21% of patients, was associated with primary MDR-Tb. Among MDR-Tb cases, 16% have been notified at least two different years suggesting they remained sources of MDR infection for long.Conclusion. - The low and stable prevalence rate of MDR-Tb reflects the adequate treatment of new cases of tuberculosis in France. However, because 16% of notified MDR-Tb cases remained culture-positive for years, there is room for improved treatment of these cases.(C) 2003 Editions scientifiques et medicales Elsevier SAS. All rights reserved.

We retrospectively studied outcomes for patients infected with human immunodeficiency virus who received highly active antiretroviral therapy (HAART) and had stopped receiving secondary prophylaxis against toxoplasmic encephalitis (TE) or disseminated Mycobacterium avium complex (MAC) infection. Nineteen patients had a history of TE, and 26 had a history of disseminated MAC infection. The median duration of secondary prophylaxis was 27 months, and the median duration of HAART before discontinuation of secondary prophylaxis was 22 months. Median CD4(+) cell counts at the time of cessation of secondary prophylaxis against TE or disseminated MAC infection were 404 and 105 cells/mm(3), respectively. Plasma virus load was undetectable in 68% of the patients who had a history of TE and in 31% of patients who had a history of disseminated MAC infection. Patients were followed up for a median of 29 months after discontinuation of secondary prophylaxis; no relapses occurred in patients with a history of TE, and 3 relapses occurred in patients with a history of disseminated MAC infection (incidence, 4 relapses per 100 person-years).

Analysis of restriction fragment length polymorphism (RFLP), using a DNA probe directed against the insertion sequence IS6110, was applied to strains of Mycobacterium tuberculosis successively isolated from four patients. In order to determine the cause of recurrence in these patients, the RFLP patterns of the corresponding isolated were analyzed. The profils obtained from the strains isolated from each of the patients were identical, thus suggesting that a relapse, rather than an exogenous reinfection with a new strain, was the cause of recurrence. The RFLP patterns of successive isolated remained unchanged during periods of time ranging from 5 months to 7 years, and were not modified after development of rifampin resistance. These results demonstrate the stability of the polymorphism detected by the IS6110 probe. Therefore, RFLP analysis is a powerfull epidemiologic tool to distinguish relapse from exogenous reinfection.

Analysis of restriction fragment length polymorphism (RFLP), using a DNA probe directed against the insertion sequence IS6110, was applied to strains of Mycobacterium tuberculosis successively isolated from four patients. In order to determine the cause of recurrence in these patients, the RFLP patterns of the corresponding isolates were analyzed. The profils obtained from the strains isolated from each of the patients were identical, thus suggesting that a relapse, rather than an exogenous reinfection with a new strain, was the cause of recurrence. The RFLP patterns of successive isolates remained unchanged during periods of time ranging from 5 months to 7 years, and were not modified after development of rifampin resistance. These results demonstrate the stability of the polymorphism detected by the IS6110 probe. Therefore, RFLP analysis is a powerfull epidemiologic tool to distinguish relapse from exogenous reinfection.

No treatment was established for disseminated M. avium intracellulare (MAC) infection, a common disease of end stage of AIDS. An open study was conducted to assess in 173 AIDS patients, the activity of clarithromycin. Initial bacteriologic eradication from blood was observed in 136/147 evaluable patients (93%). Acquired resistance to clarithromycin associated with relapse appeared to develop after 2 to 7 months of drug treatment in 31/136 patients with initial success. Early bacteriological relapse was associated with clinical deterioration. Side effects of drug treatment were elevated liver enzymes (26%) and impaired hearing (4%). Side effects conducted to stop treatment in 14 cases (8%) to modified treatment in 8 cases (5%). Our study gave new argues for activity of clarithromycin in disseminated MAC infection.

No treatment was established for disseminated M. avium intra-cellulare (MAC) infection, a common disease of end stage of AIDS. An open study was conducted to assess in 173 AIDS patients, the activity of clarithromycin.Initial bacteriologic eradication from blood was observed in 136/147 evaluable patients (93%). Acquired resistance to clarithromycin associated with relapse appeared to develop after 2 to 7 months of drug treatment in 31/136 patients with initial success. Early bacteriological relapse was associated with clinical deterioration.Side effects of drug treatment were elevated liver enzymes (26%) and impaired hearing (4%). Side effects conducted to stop treatment in 14 cases (8%) to modified treatment in 8 cases (5%). Our study gave new argues for activity of clarithromycin in disseminated MAC infection.

A man with AIDS and M. kansasii lung infection received rifampicin and isoniazid for 9 months, combined with ethambutol for four months. The treatment was effective with sputum culture negativation, but relapse occurred. The minimal inhibitory concentration of rifampicin for the M. kansasii strain was respectively 0,2-mu-g/ml at the onset and 128-mu-g/ml after the treatment, giving evidence of acquired resistance. A new treatment was initiated but is was ineffective.

A prospective multicentre open study has been conducted in France in order to assess the efficacy and tolerability of an antimycobacterial regimen including rifabutin in the treatment of patients with pulmonary tuberculosis due to rifampicin and isoniazid resistant bacilli. Patients were treated with daily rifabutin (450-600 mg), associated with companion drugs to which the organisms remained susceptible; in most cases the regimen included a fluoroquinolone. The duration of treatment was initially scheduled for a minimum period of 12 months after sputum culture conversion. Thirty nine patients were enrolled, 23 of whom were treated for at least 12 months. Culture conversion was obtained at the end of the twelfth month in 14 out of 23 patients. Twenty one out of 39 patients experienced adverse events. These were, however, serious enough to discontinue treatment in only four patients. These results suggest that an antimycobacterial combination including rifabutin might contribute to the treatment of multi-resistant pulmonary tuberculosis.

A prospective multicentre open study has been conducted in France in order to assess the efficacy and tolerability of an antimycobacterial regimen including rifabutin in the treatment of patients with pulmonary tuberculosis due to rifampicin and isoniazid resistant bacilli.Patients were treated with daily rifabutin (450-600 mg), associated with companion drugs to which the organisms remained susceptible; in most cases the regimen included a fluoroquinolone. The duration of treatment was initially scheduled for a minimum period of 12 months after sputum culture conversion.Thirty nine patients were enrolled, 23 of whom were treated for at least 12 months. Culture conversion was obtained at the end of the twelfth month in 14 out of 23 patients. Twenty one out of 39 patients experienced adverse events. These were, however, serious enough to discontinue treatment in only four patients.These results suggest that an antimycobacterial combination including rifabutin might contribute to the treatment of multi-resistant pulmonary tuberculosis.

A man with AIDS and M. kansasii lung infection received rifampicin and isoniazid for 9 months, combined with ethambutol for four months. The treatment was effective with sputum culture negativation, but relapse occurred. The minimal inhibitory concentration of rifampicin for the M. kansasii strain was respectively 0.2 microgram/ml at the onset and 128 micrograms/ml after the treatment, giving evidence of acquired resistance. A new treatment was initiated but is was ineffective.