Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Akciğerde Tüberküloz Dışı Mikobakteri Hastalığı: 42 Vakanın Retrospektif Analizi
Non-Tuberculous Mycobacterial Lung Diseases: Retrospective Analysis of 42 Cases
Zeki KILIÇASLANa, Tülin KUYUCUb, Aylin BABALIKb, Gülcihan ÖZKANc, Züleyha KAYA BİNGÖLa, Emine Nilgün ORDUa, Mualla PARTALd, Kaya KÖKSALANe
aGöğüs Hastalıkları AD, İstanbul Üniversitesi İstanbul Tıp Fakültesi,
bGöğüs Hastalıkları Kliniği,
dMikrobiyoloji Labarotuvarı, Süreyyapaşa Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi,
cYedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi,
eİstanbul Üniversitesi Deneysel Tıp Araştırma Enstitüsü, İstanbul
Turkiye Klinikleri J Med Sci. 2013;33(3):854-67
doi: 10.5336/medsci.2012-32048
Article Language: TR
Full Text
ÖZET
Amaç: Tüberküloz dışı mikobakteri (TDM) enfeksiyonları, özellikle AIDS hastalarında ve immünosüpresif hastalarda olabilir. Bu çalışma, akciğerde TDM enfeksiyonu saptanan 42 hastanın retrospektif olarak incelenmesi amacı ile tasarlanmıştır. Gereç ve Yöntemler: Bu retrospektif tanımlayıcı çalışmaya, 2004-2010 yılları arasında, İstanbul Üniversitesi İstanbul Tıp Fakültesi Göğüs Hastalıkları, Süreyyapaşa Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi ve Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi kliniklerinde TDM enfeksiyonu tanısı ile izlenen 37'si (%88,1) erkek, toplam 42 hasta [yaş (standart sapma-SS) 46,69 (14,57) yıl] dahil edildi. Tiplendirme Hsp65PCRREA yöntemiyle yapıldı. Tedavi protokolleri, radyolojik ve bakteriyolojik bulgular, eşlik eden hastalıklar ve tedavi sonuçlarına ilişkin veriler tıbbi kayıtlardan, hastalar doğrudan aranarak ve tüberküloz (TB) dispanserlerinin verilerinden elde edildi. Bulgular: En sık saptanan TDM tipleri, Mycobacterium abscessus (n=14; %33,3), Mycobacterium avium (n=9; %21,4) ve Mycobacterium kansasii (n=8; %19,0) olarak belirlendi. Toplam 20 (%47,6) hastada eşlik eden hastalık saptandı [11 (%26,2) hastada solunumsal; 9 (%21,4) hastada solunumsal olmayan hastalık). En sık rastlanan radyolojik bulgular, 27 (%64,3) hastada kavite, 23 (%57,8) hastada segmenter veya subsegmenter homojen opasiteler ve 23 (%57,8) hastada fokal asiner, alveoler, mikronodüler opasitelerdi; olguların 27'sinde (%64,3) tutuluş bilateraldi. Birinci sıra ilaçlara duyarlılık testinin hastaların 30'unda (%71,4), ikinci sıra ilaçlara duyarlılık testinin 16 (%38,1) hastada yapıldığı belirlendi. Hastaların 18'inde (%60) izoniyazit + rifampisin direnci saptandı. Hastaların 262sında (%61,9) tam iyileşme, 2'sinde (%4,8) tedavi başarısızlığı, 3'ünde (%7,1) ölüm görüldü. Hastaların 5'inde (%11,9) tedavi devam ederken 5'i (%11,9) tedavisiz takip ve 1'i (%2,4) tedavi terki olarak saptandı. Sonuç: Akciğerde TDM enfeksiyonu olan hastalarda mikobakteri tiplendirmesinin yapılması, doğru tanı ve uygun tedavi kararının alınması ve ülkemizde doğru epidemiyolojik verilerin elde edilmesi açısından önemlidir. Mikobakteri şuşlarında rutin tiplendirme yapılmaması TDM olgularında tanının gecikmesine ve ilaç direncinin ortaya çıkmasına yol açmaktadır. TDM enfeksiyonu saptanan olgularda tedavi kararı ve ilaç seçimi klinik ve bakteriyolojik bulguların birlikte değerlendirilmesi ile yapılmalıdır.

Anahtar Kelimeler: Tüberküloz dışı mikobakteriler; tedavi
ABSTRACT
Objective: Non-tuberculosis mycobacterium (NTM) infections are particularly common in patients with AIDS and also in immuncompromised patients. The present study was designed to analyse retrospectively 42 cases with non-tuberculous mycobacterial lung infection. Material and Methods: A total of 42 patients [mean (standard deviation-SD); age 46.69 (14.57) years, 37 (88.1%) males] diagnosed with NTM lung infection were included in this retrospective descriptive study, during their follow up at the İstanbul University İstanbul Faculty of Medicine, Süreyyapaşa Chest Diseases and Chest Surgery Training and Research Hospital and Yedikule Chest Diseases and Chest Surgery Training and Research Hospital clinics, between 2004 and 2010. Identification was performed with Hsp65PCRREA. Data on therapeutic management, radiological and bacteriological findings, co-morbidities and treatment outcomes were obtained from medical records, direct phone calls to patients and tuberculosis dispensaries. Results: The most frequently identified NTM types were Mycobacterium abscessus, Mycobacterium avium and Mycobacterium kansasii [n=14 (33.3%), 9 (21.4%) and 8 (19.0%), respectively]. Co-morbidities were identified in 20 (47.6%) [respiratory in 11 (26.2%) and non-respiratory in 9 (21.4%)] patients. Chest x-ray revealed cavity in 27 (63.4%), segmental or subsegmental homogenous opacities in 23 (57.8%) and focal acinar, alveolar, micronodular opacities in 23 (57.8%) patients; 27 (64.3%) cases had bilateral involvement. Drug sensitivity testing for first-line drugs performed in 30 (71.4%) patients revealed isoniazide+rifampicin resistance in 18 (60.0%) patients, while drug sensitivity testing for second-line drugs was performed in 16 (38.1%) patients. Treatment outcome was cure in 26 (61.9%) patients, treatment failure in 2 (4.8%), death in 3 (7.1%), ongoing treatment in 5 (11.9%) and follow-up without treatment in 5 (11.9%) patients, while 1 (2.4%) patient stopped treatment. Conclusion: Identification of the mycobacterium type in patients with pulmonary TDM infection is essential for correct diagnosis and best treatment planning in addition to obtaining real-life epidemiologic data in Turkey. Lack of identification of the mycobacterium delays the diagnosis and causes resistance development in TDM patients. In patients with TDM infection, treatment should be planned based on both clinical and bacteriological findings.

Keywords: Nontuberculous mycobacteria; therapy

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