Detection of nontuberculous mycobacteria from water buffalo raw milk in Brazil

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

When and how to treat pulmonary non-tuberculous mycobacterial diseases

Nontuberculous mycobacteria are ubiquitous environmental organisms that have been recognised as a cause of pulmonary infection for over 50 years. Traditionally patients have had underlying risk factors for development of disease; however the proportion of apparently immunocompetent patients involved appears to be rising. Not all patients culture-positive for mycobacteria will have progressive disease, making the diagnosis difficult, though criteria to aid in this process are available. The two main forms of disease are cavitary disease (usually involving the upper lobes) and fibronodular bronchiectasis (predominantly middle and lingular lobes). For patients with disease, combination antibiotic therapy for 12-24 months is generally required for successful treatment, and this may be accompanied by drug intolerances and side effects. Published success rates range from 30-82%. As the progression of disease is variable, for some patients, attention to pulmonary hygiene and underlying diseases without immediate antimycobacterial therapy may be more appropriate. Surgery can be a useful adjunct, though is associated with risks. Randomised controlled trials in well described patients would provide stronger evidence-based data to guide therapy of NTM lung diseases, and thus are much needed.

Characteristics of nontuberculous mycobacteria from a municipal water distribution system and their relevance to human infections

This thesis documented pathogenic species of nontuberculous mycobacteria in the Brisbane water distribution system. When water and shower aerosol strains were compared with human strains of mycobacteria, the study found that the likelihood of acquiring infection from municipal water was specific for four main species. The method for isolation of mycobacteria from water was refined, followed by sampling from 220 sites across Brisbane. A variety of species (incl 15 pathogens) were identified and genotypically compared to human strains. For M. abscessus and M. lentiflavum, water strains clustered with human strains. Pathogenic strains of M. kansasii were found, though non-pathogenic strains dominated. Waterborne strains of M. fortuitum differed to human strains. Extensive home sampling of 20 patients with NTM disease, supported the theory that the risk of acquiring NTM from water or shower aerosols appears species specific for M. avium, M. kansasii, M. lentiflavum and M. abscessus.

Factors associated with the isolation of Nontuberculous mycobacteria (NTM) from a large municipal water system in Brisbane, Australia

Background Nontuberculous mycobacteria (NTM) are normal inhabitants of a variety of environmental reservoirs including natural and municipal water. The aim of this study was to document the variety of species of NTM in potable water in Brisbane, QLD, with a specific interest in the main pathogens responsible for disease in this region and to explore factors associated with the isolation of NTM. One-litre water samples were collected from 189 routine collection sites in summer and 195 sites in winter. Samples were split, with half decontaminated with CPC 0.005%, then concentrated by filtration and cultured on 7H11 plates in MGIT tubes (winter only). Results Mycobacteria were grown from 40.21% sites in Summer (76/189) and 82.05% sites in winter (160/195). The winter samples yielded the greatest number and variety of mycobacteria as there was a high degree of subculture overgrowth and contamination in summer. Of those samples that did yield mycobacteria in summer, the variety of species differed from those isolated in winter. The inclusion of liquid media increased the yield for some species of NTM. Species that have been documented to cause disease in humans residing in Brisbane that were also found in water include M. gordonae, M. kansasii, M. abscessus, M. chelonae, M. fortuitum complex, M. intracellulare, M. avium complex, M. flavescens, M. interjectum, M. lentiflavum, M. mucogenicum, M. simiae, M. szulgai, M. terrae. M. kansasii was frequently isolated, but M. avium and M. intracellulare (the main pathogens responsible for disease is QLD) were isolated infrequently. Distance of sampling site from treatment plant in summer was associated with isolation of NTM. Pathogenic NTM (defined as those known to cause disease in QLD) were more likely to be identified from sites with narrower diameter pipes, predominantly distribution sample points, and from sites with asbestos cement or modified PVC pipes. Conclusions NTM responsible for human disease can be found in large urban water distribution systems in Australia. Based on our findings, additional point chlorination, maintenance of more constant pressure gradients in the system, and the utilisation of particular pipe materials should be considered.

Isolation of nontuberculous mycobacteria (NTM) from household water and shower aerosols in patients with pulmonary disease caused by NTM

It has been postulated that susceptible individuals may acquire infection with nontuberculous mycobacteria (NTM) from water and aerosol exposure. This study examined household water and shower aerosols of patients with NTM pulmonary disease. The mycobacteria isolated from clinical samples from 20 patients included M. avium (5 patients), M. intracellulare (12 patients), M. abscessus (7 patients), M. gordonae (1 patient), M. lentiflavum (1 patient), M. fortuitum (1 patient), M. peregrinum (1 patient), M. chelonae (1 patient), M. triplex (1 patient), and M. kansasii (1 patient). One-liter water samples and swabs were collected from all taps, and swimming pools or rainwater tanks. Shower aerosols were sampled using Andersen six-stage cascade impactors. For a subgroup of patients, real-time PCR was performed and high-resolution melt profiles were compared to those of ATCC control strains. Pathogenic mycobacteria were isolated from 19 homes. Species identified in the home matched that found in the patient in seven (35%) cases: M. abscessus (3 cases), M. avium (1 case), M. gordonae (1 case), M. lentiflavum (1 case), and M. kansasii (1 case). In an additional patient with M. abscessus infection, this species was isolated from potable water supplying her home. NTM grown from aerosols included M. abscessus (3 homes), M. gordonae (2 homes), M. kansasii (1 home), M. fortuitum complex (4 homes), M. mucogenicum (1 home), and M. wolinskyi (1 home). NTM causing human disease can be isolated from household water and aerosols. The evidence appears strongest for M. avium, M. kansasii, M. lentiflavum, and M. abscessus. Despite a predominance of disease due to M. intracellulare, we found no evidence for acquisition of infection from household water for this species.

Ecophysiology of nontuberculous Mycobacteria in marine aquaculture ponds

The world demand for fish and fishery products is increasing steadily and it is generally accepted that it will not be possible to meet the heavy demand with resources exploited from capture fishery alone. Now aquaculture is well established and fastdeveloping industry in many countries and is a major focus sector for development. During recent decades, aquaculture has gained momentum, throughout the world especially in developing countries. According to Food and Agricultural Oganisation (FAO, 2000), global aquaculture production was 26.38 tones in 1996 have reached 32.9 million tonnes during 1999. Only marine aquaculture sector has contributed 13.1 million tonnes during 1999.India is a major fish producing country. About one half of lndia’s brackish water lands are currently being utilized for farming in order to reduce the gap between supply and demand for fish. Aquaculture has become a major source of livelihood for people and its role in integrated rural development, generation of employment and earning foreign exchange, thereby alleviating poverty is being greatly appreciated around the world.Among the infectious agents, bacteria are becoming the prime causal organisms for diseases in food fishes and other marine animals. Sindermann, (1970) reported that bacterial fish pathogen most commonly found among marine fishes is species of Pseudomonas, Vibrio and Mycobacterium. These can be categorized into primary pathogens; secondary invaders that may cause systemic disease in immunocompromised hosts; and normal marine flora which are not pathogenic but may occur on body surfaces or even within the tissues of the host. I-Iigh density of animals in hatchery tanks and ponds is conducive to the spread of pathogen and the aquatic environment with regular application of protein rich feed, is ideal for culturing bacteria. Bacteria, which are normally present in seawater or on the surface of fish, can invade and cause pathological effects in fishes, which are injured or subjected to other environmental stresses.Mycobacteria except parasites are known as nontuberculosis mycobacteria (NTM), atypical mycobacteria or mycobacteria other than tuberculosis(MO'l'l"). This group of mycobacteria includes opportunistic pathogens and saprophytes. Environmental mycobacteria are ubiquitous in distribution and the sources may include soil, water, warm-blooded as well as cold-blooded animals. Disease caused by environmental mycobacterial strains in susceptible humans (Goslee & Wolinsky, 1976; Grange, 1987), animals and fishes are increasingly attracting attention. Greatest importance of environmental mycobacteria is believed to be their role in immunological priming of humans and animals, thereby modifying their immune responses to subsequent exposure to pathogenic species.

A comparison of mycolic acid analysis for nontuberculous mycobacteria identification by thin-layer chromatography and molecular methods

The development of fast, inexpensive, and reliable tests to identify nontuberculous mycobacteria (NTM) is needed. Studies have indicated that the conventional identification procedures, including biochemical assays, are imprecise. This study evaluated a proposed alternative identification method in which 83 NTM isolates, previously identified by conventional biochemical testing and in-house M. avium IS1245-PCR amplification, were submitted to the following tests: thin-layer chromatography (TLC) of mycolic acids and PCR-restriction enzyme analysis of hsp65 (PRA). High-performance liquid chromatography (HPLC) analysis of mycolic acids and Southern blot analysis for M. avium IS1245 were performed on the strains that evidenced discrepancies on either of the above tests. Sixty-eight out of 83 (82%) isolates were concordantly identified by the presence of IS1245 and PRA and by TLC mycolic acid analysis. Discrepant results were found between the phenotypic and molecular tests in 12/83 (14.4%) isolates. Most of these strains were isolated from non-sterile body sites and were most probably colonizing in the host tissue. While TLC patterns suggested the presence of polymycobacterial infection in 3/83 (3.6%) cultures, this was the case in only one HPLC-tested culture and in none of those tested by PRA. The results of this study indicated that, as a phenotypic identification procedure, TLC mycolic acid determination could be considered a relatively simple and cost-effective method for routine screening of NTM isolates in mycobacteriology laboratory practice with a potential for use in developing countries. Further positive evidence was that this method demonstrated general agreement on MAC and M. simiae identification, including in the mixed cultures that predominated in the isolates of the disseminated infections in the AIDS patients under study. In view of the fact that the same treatment regimen is recommended for infections caused by these two species, TLC mycolic acid analysis may be a useful identification tool wherever molecular methods are unaffordable.

Isolation and identification of mycobacteria from livestock specimens and milk obtained in Brazil

The prevalence of Mycobacterium bovis and other mycobacterial species in livestock specimens and milk was evaluated. An emphasis was placed upon the distribution of these organisms in milk that is readily available to the public that was either untreated, pasteurized, or treated using ultra high temperature. Twenty-two pathologic specimens from livestock (bovine, swine and bubaline) in five Brazilian states and 128 bovine milk samples from retail markets in the State of São Paulo were examined for mycobacteria. Identification was made by classical biochemical tests, thin layer chromatography of mycolic acids and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. Mycobacteria were isolated from 15 (68.2%) caseous lesions and from 23 (18%) milk samples. Eleven isolates were identified as M. bovis, and the remaining 27 nontuberculous mycobacterial isolates were represented by five species and six unidentified rapidly growing mycobacterial strains. The data demonstrate that animal products in Brazil are frequent reservoirs of mycobacteria and may pose a risk to the public.

Isolation and Identification of Environmental Mycobacteria in the Waters of a Hemodialysis Center

The use of poorly treated water during hemodialysis may lead to contamination with nontuberculous mycobacteria (NTM). This study aimed to isolate and identify NTM species in the water of a Brazilian hemodialysis center. We collected 210 samples of water from the hydric system of the unit (post-osmosis system, hemodialysis rooms, reuse system, and hemodialysis equipment) and from the municipal supply network; we isolated the NTM by a classic microbiological technique and identified them by the PCR restriction enzyme pattern of the hsp65 gene (PRA). Fifty-one (24.3 %) of the collected samples tested positive for NTM; both the municipal supply network (2 samples, 3.2 %) and the hydric system of the hemodialysis center (49 samples, 96.1 %) contained NTM. We isolated and identified potentially pathogenic bacteria such as Mycobacterium lentiflavum (59.0 %) and M. kansasii (5.0 %), as well as rarely pathogenic bacteria like M. gordonae (24.0 %), M. gastri (8.0 %), and M. szulgai (4.0 %). The ability of NTM to cause diseases is well documented in the literature. Therefore, the identification of NTM in the water of a Brazilian hemodialysis center calls for more effective water disinfection procedures in this unit.

Occurrence of pathogenic environmental mycobacteria on surfaces in health institutions

The presence of environmental mycobacteria on surfaces in two public health institutions, namely a health center and a hospital in upstate São Paulo (Brazil), was identified by polymerase chain reaction-restriction enzyme analysis (PRA). The possible sources of contamination by these microorganisms were evaluated, contributing to epidemiology studies. Methods: From June 2005 to June 2006, a total of 632 samples were collected from exposed surfaces, such as washbasins, drinking fountains, and other accessible sites, and the mycobacteria present in the samples were isolated and cultured. Results: Sixty-five mycobacteria were isolated from the 632 samples; 47 of which were detected in samples from the health center and 18 in samples collected from the hospital. The isolates were identified by DNA restriction patterns obtained by PRA, and potentially pathogenic species were found to be prevalent among the identified mycobacteria. This study shows that the PRA technique can be employed as a fast and easy method for identification of nontuberculous mycobacteria in public areas. Conclusions: The isolation of environmental mycobacteria from the two health institutions demonstrates that these surfaces are reservoirs of potentially pathogenic mycobacteria and indicates the need for continuous maintenance and monitoring. These data will add to the study of the epidemiology of these microorganisms.

Epidemiology of tuberculosis and nontuberculous mycobacterial infections in Houston children

Background. Nontuberculous mycobacteria (NTM) are environmentally ubiquitous organisms whose epidemiology is poorly understood. Species differ with respect to disease presentation, prognosis, and antimicrobial susceptibility. We reviewed one Texas pediatric hospital's experience with NTM and tuberculosis (TB) disease.^ Methods. This was a retrospective case series of children with culture-confirmed mycobacterial infections seen at a children's hospital from 2003-2008.^ Results. One hundred sixty-two isolates were identified from 150 children; 132 (81.5%) had NTM species isolated, and 30 (18.5%) had M. tuberculosis isolated; 2 children had both NTM and M. tuberculosis isolated. The most common species were Mycobacterium avium complex (MAC) (29%), M. tuberculosis (18.5%), M. abscessus (13%), M. fortuitum (11.7%), and M. chelonae-abscessus (9.9%). TB was the most common organism isolated from respiratory specimens. MAC and M. simiae were significantly more likely to be associated with lymphadenopathy than other NTM species (p < 0.001). Mycobacterium fortuitum was significantly more likely to be associated with soft tissue infections than other NTM species (p < 0.001). Seventy-five children met criteria for NTM disease (30 lymphadenopathy, 17 pulmonary, 17 soft tissue infections, 11 bacteremia). Children with NTM lymphadenopathy were more likely to be Hispanic (OR 24, CI 2.8-1063), younger (3.3 years vs. 10.6 years, p < 0.001), and previously healthy (OR 0.004, CI 0-0.06) than children with NTM pulmonary disease. Children with NTM disease were less likely to be previously healthy (OR 0.30, 95% CI 0.09-0.88) and foreign-born (OR 0.09, CI 0.03-0.29) than children with TB.^ Conclusions. Children with NTM lymphadenopathy were younger and more likely to be healthy than children with NTM pulmonary disease. Tuberculosis comprised a large proportion of mycobacterial disease in this series. Children with NTM pulmonary disease were less likely to be previously healthy and born abroad when compared to children with TB. There was wide variation in antimicrobial susceptibility patterns among NTM species. This, together with the large percentage of disease caused by TB, emphasizes the importance of securing a specific microbiologic diagnosis in children with pulmonary or lymph node disease caused by mycobacteria.^

Clinical significance of Mycobacterium asiaticum isolates in Queensland, Australia

Mycobacterium asiaticum was first reported as a cause of human disease in 1982, with only a few cases in the literature to date. This study aims to review the clinical significance of M. asiaticum isolates in Queensland, Australia. A retrospective review (1989 to 2008) of patients with M. asiaticum isolates was conducted. Data were collected through the Queensland TB Control Centre database. Disease was defined in accordance with the American Thoracic Society criteria. Twenty-four patients (13 female) had a positive culture of M. asiaticum, many residing around the Tropic of Capricorn. M. asiaticum was responsible for pulmonary disease (n = 2), childhood lymphadenitis (n = 1), olecranon bursitis (n = 1), 6 cases of possible pulmonary disease, and 2 possible wound infections. Chronic lung disease was a risk factor for pulmonary infection, and wounds/lacerations were a risk factor for extrapulmonary disease. Extrapulmonary disease responded to local measures. Pulmonary disease responded to ethambutol-isoniazid-rifampin plus pyrazinamide for the first 2 months in one patient, and amikacin-azithromycin-minocycline in another patient. While M. asiaticum is rare in Queensland, there appears to be an environmental niche. Although often a colonizer, it can be a cause of pulmonary and extrapulmonary disease. Treatment of pulmonary disease remains challenging. Extrapulmonary disease does not mandate specific nontuberculous mycobacterium (NTM) treatment.

Mycobacterium abscessus infection and potable water

Mycobacterium abscessus is a rapidly growing mycobacteria responsible for progressive pulmonary disease, soft tissue and wound infections, and can contaminate clinical specimens. Nontuberculous mycobacteria (NTM) are generally considered environmental organisms though M. abscessus has not featured frequently in environmental studies, particularly those examining potable water. In a study of Brisbane potable water, M. abscessus was isolate from ten different locations. The incidence of disease due to M. abscessus has been increasing in Queensland. Aim: To compare genotypically the M. abscessus isolates obtained from water to those obtained from human clinical specimens. Methods: From a study of Brisbane potable water between 2007 and 2009, ten isolates confirmed as M. abscessus were recovered. In addition, one strain was isolated from a rainwater tank of a patient with disease due to M. avium, and another from the swimming pool of a patient with M. intracellulare disease. A random sample of 74 clinical isolates referred to the QLD Mycobacterial reference laboratory during the same time period was available for comparison using repPCR strain typing (Diversilab). Results: The drinking water isolates formed two distinct strain patterns (A and B) that shared >90% similarity. The tankwater isolate (pattern C) shared >85% similarity with the potable water isolates, but the pool isolate (D) was distinctly different. Fifty-three clinical isolates clustered tightly (>95% similarity) with the Group A potable water isolates, 4 patients with Group B. Thirteen patient isolates clustered with the Rainwater tank isolate. One patient matched the pool isolate. There were a further 3 patient isolates that were unrelated to the water isolates. No differences were found between strain types in terms of geographic origin, gender, age, or site/type of infection. Conclusion: The high degree of similarity between strains of M. abscessus from potable water and strains causing infection in humans from the same area, strengthens the possibility that drinking water may be a source of infection in these patients.

Deoxyribonucleic acid methylation in mycobacteria

Deoxyribonucleic acid modification in six strains of mycobacteria was investigated. The presence of 5-methylcytosine in the virulent strain Mycobacterium tuberculosis H37Rv and its absence in the avirulent strain M. tuberculosis H37Ra and other saprophytic, fast-growing mycobacteria appear to be the salient features. However, deoxyribonucleic acid from M. smegmatis SN2 lysogenized with the temperature phage I3 showed the presence of 5-methylcytosine. All of the strains had N6-methyladenine.

Transduction of Isoniazid Susceptibility-Resistance and Streptomycin Resistance in Mycobacteria

Transduction of resistance to isoniazid and streptomycin as well as susceptibility to isoniazid in Mycobacterium smegmatis SN2 has been demonstrated. A method has been described for the selection of isoniazid-susceptible variants after transduction of susceptibility.