Bedeutung der lokalen und allgemeinen Risikofaktoren für die Pathogenese der pulmonalen nicht-tuberkulösen Mykobakteriosen bei Nicht-AIDS-Patienten

Zusammenfassung

Hintergrund: Die Entstehung pulmonaler Infektionen mit nichttuberkulösen Mykobakterien (NTM) wird durch vorbestehende bronchopulmonale Grundkrankheiten und durch Beeinträchtigung der Immunabwehr begünstigt, auch wenn diese nicht schwergradig ist. Wir untersuchten daher Charakteristika von Patienten mit NTM und die Assoziation von Risikofaktoren bei Infektionen mit und ohne Krankheitswert.

Methoden: In einer prospektiven Untersuchung zwischen 1992 und 2003 wurden n = 111 Patienten mit bakteriologischem Nachweis nichttuberkulöser Mykobakterien erfasst. Risikofaktoren (allgemein und lokal-pulmonal) für den Erwerb von NTM wurden dokumentiert und Risikoprofile bzw. Risikoscores erstellt.

Ergebnisse: Eine Infektion mit Krankheitswert nach ATS-Kriterien lag in n = 66 Fällen vor. Die häufigsten Spezies unterschieden sich deutlich in den Erkrankungsraten (M. kansasii 100 %, M. xenopi 73 %, M. avium-Komplex 57 %). Ältere Frauen (> 65 Jahre) mit M. avium-Komplex waren selten krank. Risikofaktoren waren bei Infektionen mit und ohne Krankheitswert nahezu gleich häufig, Patienten unter 65 Jahren hatten weniger lokale Risiken als Ältere. Fälle mit M. gordonae wiesen signifikant weniger lokale Risiken auf als solche mit M. avium-Komplex und M. xenopi.

Schlussfolgerungen: Lokale Risikofaktoren begünstigen bereits das Angehen von Infektionen mit nicht-tuberkulösen Mykobakterien und sind nicht erst für die Entstehung von Krankheit nach einer Infektion verantwortlich. Bullöse Lungenveränderungen und Kavernen sowie Bronchiektasen stellen lokale Risikofaktoren dar, können aber auch als Folge einer Mykobakteriose entstehen. Der Begriff der Kolonisation hat neben den Begriffen Infektionen mit und ohne Krankheitswert weiterhin Berechtigung. Bei älteren Frauen mit Nachweis von M. avium-Komplex muss man besonders kritisch abwägen, ob eine Krankheit vorliegt.

Abstract

Background: Pre-existing underlying bronchopulmonary diseases and relative impairments of the immune system are risk factors that predispose to the development of pulmonary infections with non-tuberculous mycobacteria (NTM), even if the impairment is not severe.

Methods: In a prospective study n = 111 patient diagnoses between 1992 and 2004 were included. The criterion for inclusion was laboratory evidence of non-tuberculous mycobacteria. The local risk factors and general risks were recorded for each case and the total number of risks for each patient was counted. Risk profiles were drawn up and risk scores calculated for different groups.

Results: N = 66 patients met the ATS criteria for NTM disease. The disease rates for the most frequent species varied widely (M. avium complex 57 %, M. kansasii 100 %, M. xenopi 73 %). Older women (> 65 years) with M. avium complex were rarely ill. The risk factors were almost equally frequent for patients meeting criteria for disease status and those who did not and patients under 65 years of age had fewer local risk factors than older patients. Patients with M. gordonae showed fewer local risk factors than patients with M. avium complex or M. xenopi.

Conclusions: Even local risk factors predispose towards infections with mycobacteria and do not only lead to disease after infection. Bullous changes of the lungs, cavities and bronchiectasis are local risk factors, but can also develop as sequelae of mycobacteriosis. There is sufficient evidence to support the continued use of the concept of colonisation alongside those of infection with and infection without disease status. In our region, a thorough evaluation is needed to establish whether older women with M. avium complex actually have mycobacteriosis.

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