Semin Respir Crit Care Med 2010; 31(5): 575-586
DOI: 10.1055/s-0030-1265898
© Thieme Medical Publishers

Mycobacterial Infections in the Elderly

Carlos Pérez-Guzmán1 , 2 , Mario H. Vargas3 , 4
  • 1Coordinación de Investigación, Instituto de Salud del Estado de Aguascalientes, Aguascalientes, México
  • 2Unidad de Medicina de Atención Ambulatoria, Instituto Mexicano del Seguro Social, Aguascalientes, Mexico
  • 3Unidad de Investigación, Instituto Nacional de Enfermedades Respiratorias, México DF, México
  • 4Unidad de Investigación Médica en Enfermedades Respiratorias, Instituto Mexicano del Seguro Social, México DF, México
Further Information

Publication History

Publication Date:
12 October 2010 (online)

ABSTRACT

In 2008, elderly subjects accounted for more than 262,000 cases of smear-positive tuberculosis worldwide, reaching the highest age-adjusted rates in some regions. Elders are at a greater risk for reactivation of latent tuberculosis or acquisition of new infection, especially if they live in long-term care facilities or are smokers. Once overt clinical tuberculosis appears, they are at increased risk of hospitalization and death. Pulmonary tuberculosis presentation may be atypical in elderly people, as they tend to have lower prevalence of fever, sweating, or hemoptysis, and their chest x-rays show less cavities and more lower lung field involvement. Compared with younger patients, tuberculous elders seem to have lower frequency of positive PPD, but differences in sputum smear positivity are not clear. Regimen recommended for treating new cases of pulmonary tuberculosis is not different from other age groups: a two-month bactericidal phase with daily oral administration of isoniazid, rifampin, pyrazinamide, and ethambutol, and a continuation phase with isoniazid and rifampin daily during four months, though some variations are allowed. Directly observed strategy is highly recommended in the initial phase. Elders with pulmonary tuberculosis may require longer time to become smear negative and seem to have worse outcomes than younger patients.

REFERENCES

  • 1 De Magalhaes J P. What is aging?. Available at http://www.senescence.info/definitions.html Accessed November 12, 2009
  • 2 Orimo H, Ito H, Suzuki T, Araki A, Hosoi T, Sawabe M. Reviewing the definition of “elderly”.  Geriatr Gerontol Int. 2006;  6 149-158
  • 3 Orimo H. Reviewing the definition of elderly [in Japanese].  Nippon Ronen Igakkai Zasshi. 2006;  43 27-34
  • 4 World Health Organization .Definition of an older or elderly person. Proposed working definition of an older person in Africa for the MDS Project. Available at http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html Accessed November 12, 2009
  • 5 Katial R, Zheng W. Allergy and immunology of the aging lung.  Clin Chest Med. 2007;  28 663-672
  • 6 Bovornkitti S, Limlomwongse L. Environment and the ageing lung.  Respirology. 1997;  2 169-172
  • 7 World Health Organization .2009 Tuberculosis facts. http://Available at www.who.int/entity/tb/publications/2009/tbfactsheet_2009update_one_page.pdf Accessed February 10, 2010
  • 8 World Health Organization .Global tuberculosis control: a short update to the 2009 report (supplemental online data). Available at http://www.who.int/tb/publications/global_report/2009/update/en Accessed February 20, 2010
  • 9 World Health Organization .Global Tuberculosis Control: Epidemiology, Strategy, Financing. WHO Report 2009. Publication WHO/HTM/TB/2009. 411. Geneva, Switzerland; World Health Organization 2009
  • 10 World Health Organization .World Health Statistics 2009. Available at http://www.who.int/whosis/en/index.html Accessed February 20, 2010
  • 11 Ohmori M, Ishikawa N, Yoshiyama T, Uchimura K, Aoki M, Mori T. Current epidemiological trend of tuberculosis in Japan.  Int J Tuberc Lung Dis. 2002;  6 415-423
  • 12 Tuberculous infection and prevention [in Japanese].  Kekkaku. 2000;  75 619-623
  • 13 Tam C M, Leung C C, Noertjojo K, Chan S L, Chan-Yeung M. Tuberculosis in Hong Kong: patient characteristics and treatment outcome.  Hong Kong Med J. 2003;  9 83-90
  • 14 García-Fernández C, Vera López I, Jaén Herreros F, Sanz-Gallardo M I, Palenque Mataix E, de Juanes Pardo J R. Tuberculosis en ancianos en un hospital general de la Comunidad de Madrid, 1994–2003.  Med Interna. 2006;  23 161-165
  • 15 Rajagopalan S, Yoshikawa T T. Tuberculosis in long-term-care facilities.  Infect Control Hosp Epidemiol. 2000;  21 611-615
  • 16 Zanni G R, Wick J Y. Treating tuberculosis in older adults.  Consult Pharm. 2008;  23 844-846, 851–858
  • 17 Shimouchi A, Koda S, Ochiai H. Survey on nosocomial infection of tuberculosis in nursing homes for elderly in Osaka City [in Japanese].  Kekkaku. 2007;  82 179-184
  • 18 Gisselbrecht M. Tuberculosis in elderly persons living in institutions [in French].  Rev Mal Respir. 2004;  21 8S106-8S113
  • 19 Bates M N, Khalakdina A, Pai M, Chang L, Lessa F, Smith K R. Risk of tuberculosis from exposure to tobacco smoke: a systematic review and meta-analysis.  Arch Intern Med. 2007;  167 335-342
  • 20 Dhamgaye T M. Tobacco smoking and pulmonary tuberculosis: a case-control study.  J Indian Med Assoc. 2008;  106 216-219
  • 21 Chiang C Y, Slama K, Enarson D A. Associations between tobacco and tuberculosis.  Int J Tuberc Lung Dis. 2007;  11 258-262
  • 22 Hassmiller K M. The association between smoking and tuberculosis.  Salud Publica Mex. 2006;  48(Suppl 1) S201-S216
  • 23 Wang J Y, Hsueh P R, Jan I S et al.. The effect of smoking on tuberculosis: different patterns and poorer outcomes.  Int J Tuberc Lung Dis. 2007;  11 143-149
  • 24 Leung C C, Li T, Lam T H et al.. Smoking and tuberculosis among the elderly in Hong Kong.  Am J Respir Crit Care Med. 2004;  170 1027-1033
  • 25 Sanya E O, Akande T M, Opadijo G, Olarinoye J K, Bojuwoye B J. Pattern and outcome of medical admission of elderly patients seen at University of Ilorin Teaching Hospital, Ilorin.  Afr J Med Med Sci. 2008;  37 375-381
  • 26 Low S, Ang L W, Cutter J et al.. Mortality among tuberculosis patients on treatment in Singapore.  Int J Tuberc Lung Dis. 2009;  13 328-334
  • 27 Lefebvre N, Falzon D. Risk factors for death among tuberculosis cases: analysis of European surveillance data.  Eur Respir J. 2008;  31 1256-1260
  • 28 Faustini A, Hall A J, Mantovani J, Sangalli M, Perucci C A. Regional group for the Survey of TB Treatment Outcomes . Treatment outcomes and relapses of pulmonary tuberculosis in Lazio, Italy, 1999-2001: a six-year follow-up study.  Int J Infect Dis. 2008;  12 611-621
  • 29 Lindoso A A, Waldman E A, Komatsu N K, Figueiredo S M, Taniguchi M, Rodrigues L C. Profile of tuberculosis patients progressing to death, city of São Paulo, Brazil, 2002.  Rev Saude Publica. 2008;  42 805-812
  • 30 Wang C S, Chen H C, Yang C J et al.. The impact of age on the demographic, clinical, radiographic characteristics and treatment outcomes of pulmonary tuberculosis patients in Taiwan.  Infection. 2008;  36 335-340
  • 31 Das S K, Mukherjee R S, Ghosh I N, Halder A K, Saha S K. A study of pulmonary tuberculosis in the elderly.  J Indian Med Assoc. 2007;  105 432, 436, 438-439
  • 32 Anyama N, Bracebridge S, Black C, Niggebrugge A, Griffin S J. What happens to people diagnosed with tuberculosis? A population-based cohort.  Epidemiol Infect. 2007;  135 1069-1076
  • 33 Borgdorff M W, Veen J, Kalisvaart N A, Nagelkerke N. Mortality among tuberculosis patients in the Netherlands in the period 1993-1995.  Eur Respir J. 1998;  11 816-820
  • 34 Pérez-Guzmán C, Vargas M H, Torres-Cruz A, Villarreal-Velarde H. Does aging modify pulmonary tuberculosis? A meta-analytical review.  Chest. 1999;  116 961-967
  • 35 Yamagishi F. Tuberculosis in the elderly [in Japanese].  Kekkaku. 2004;  79 481-486
  • 36 Pérez-Guzman C, Torres-Cruz A, Villarreal-Velarde H, Vargas M H. Progressive age-related changes in pulmonary tuberculosis images and the effect of diabetes.  Am J Respir Crit Care Med. 2000;  162 1738-1740
  • 37 Cantalice Filho J P, Sant Anna C C, Bóia M N. Clinical aspects of pulmonary tuberculosis in elderly patients from a university hospital in Rio de Janeiro, Brazil [in Spanish].  J Bras Pneumol. 2007;  33 699-706
  • 38 Rawat J, Sindhwani G, Juyal R. Clinico-radiological profile of new smear positive pulmonary tuberculosis cases among young adult and elderly people in a tertiary care hospital at Deheradun (Uttarakhand).  Indian J Tuberc. 2008;  55 84-90
  • 39 Ismail Y. Pulmonary tuberculosis—a review of clinical features and diagnosis in 232 cases.  Med J Malaysia. 2004;  59 56-64
  • 40 Villarreal-Velarde H, Vargas M H, Torres-Cruz A et al.. Tuberculosis pleuropulmonar en el anciano: estudio comparativo con otras edades.  Rev Inst Nal Enf Respir (Mex). 1998;  11 111-116
  • 41 Rocha M, Pereira S, Barros H, Seabra J. Does pulmonary tuberculosis change with ageing?.  Int J Tuberc Lung Dis. 1997;  1 147-151
  • 42 Craig S E, Bettinson H, Sabin C A, Gillespie S H, Lipman M C. Think TB! Is the diagnosis of pulmonary tuberculosis delayed by the use of antibiotics?.  Int J Tuberc Lung Dis. 2009;  13 208-213
  • 43 Kherad O, Herrmann F R, Zellweger J P, Rochat T, Janssens J P. Clinical presentation, demographics and outcome of tuberculosis (TB) in a low incidence area: a 4-year study in Geneva, Switzerland.  BMC Infect Dis. 2009;  9 217
  • 44 Cavalcanti ZdoR, de Albuquerque MdeF, Campello A R, Ximenes R, Montarroyos U, Verçosa M K. Characteristics of elderly tuberculosis patients in Recife, Brazil: a contribution to the tuberculosis control program.  J Bras Pneumol. 2006;  32 535-543
  • 45 Lee J H, Han D H, Song J W, Chung H S. Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients.  J Korean Med Sci. 2005;  20 784-789
  • 46 Parimon T, Spitters C E, Muangman N, Euathrongchit J, Oren E, Narita M. Unexpected pulmonary involvement in extrapulmonary tuberculosis patients.  Chest. 2008;  134 589-594
  • 47 Fader T, Parks J, Khan N U, Manning R, Stokes S, Nasir N A. Extrapulmonary tuberculosis in Kabul, Afghanistan: a hospital-based retrospective review.  Int J Infect Dis. 2010;  14 e102-e110
  • 48 Kourbatova E V, Leonard Jr M K, Romero J, Kraft C, del Rio C, Blumberg H M. Risk factors for mortality among patients with extrapulmonary tuberculosis at an academic inner-city hospital in the US.  Eur J Epidemiol. 2006;  21 715-721
  • 49 Arciniegas W, Orjuela D L. Extrapulmonary tuberculosis: a review of 102 cases in Pereira, Colombia.  Biomedica (Bogota). 2006;  26 71-80
  • 50 te Beek L A, van der Werf M J, Richter C, Borgdorff M W. Increase in extrapulmonary tuberculosis in the Netherlands associated with an increase in the number of residents with non-Dutch nationality; observational study of data from 1993–2001 [iin Dutch].  Ned Tijdschr Geneeskd. 2008;  152 637-642
  • 51 Sreeramareddy C T, Panduru K V, Verma S C, Joshi H S, Bates M N. Comparison of pulmonary and extrapulmonary tuberculosis in Nepal: a hospital-based retrospective study.  BMC Infect Dis. 2008;  8 8
  • 52 Teruel A B, Estornell L H, Rodríguez P C, Espejo A G. [Does age have any bearing on the incidence of extrapulmonary tuberculosis?].  Rev Esp Salud Publica. 2007;  81 57-58
  • 53 Leung C C, Yew W W, Chan C K et al.. Tuberculosis in older people: a retrospective and comparative study from Hong Kong.  J Am Geriatr Soc. 2002;  50 1219-1226
  • 54 Kobashi Y, Mouri K, Fukuda M, Yoshida K, Miyashita N, Oka M. Transitional change in the clinical features of pulmonary tuberculosis.  Respiration. 2008;  75 304-309
  • 55 El-Khushman H, Momani J A, Sharara A M et al.. The pattern of active pulmonary tuberculosis in adults at King Hussein Medical Center, Jordan.  Saudi Med J. 2006;  27 633-636
  • 56 World Health Organization .Treatment of Tuberculosis: Guidelines. 4th ed. Publication WHO/HTM/TB/2009. 420 Geneva, Switzerland; World Health Organization 2009
  • 57 Blumberg H M, Burman W J, Chaisson R E American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America et al. Treatment of tuberculosis.  Am J Respir Crit Care Med. 2003;  167 603-662
  • 58 Domínguez-Castellano A, Muniain M A, Rodriguez-Baño J et al.. Factors associated with time to sputum smear conversion in active pulmonary tuberculosis.  Int J Tuberc Lung Dis. 2003;  7 432-438
  • 59 Telzak E E, Fazal B A, Pollard C L, Turett G S, Justman J E, Blum S. Factors influencing time to sputum conversion among patients with smear-positive pulmonary tuberculosis.  Clin Infect Dis. 1997;  25 666-670
  • 60 Horne D J, Johnson C O, Oren E, Spitters C, Narita M. How soon should patients with smear-positive tuberculosis be released from inpatient isolation?.  Infect Control Hosp Epidemiol. 2010;  31 78-84
  • 61 Banu Rekha V V, Balasubramanian R, Swaminathan S et al.. Sputum conversion at the end of intensive phase of category-1 regimen in the treatment of pulmonary tuberculosis patients with diabetes mellitus or HIV infection: an analysis of risk factors.  Indian J Med Res. 2007;  126 452-458
  • 62 Singla R, Osman M M, Khan N, Al-Sharif N, Al-Sayegh M O, Shaikh M A. Factors predicting persistent sputum smear positivity among pulmonary tuberculosis patients 2 months after treatment.  Int J Tuberc Lung Dis. 2003;  7 58-64
  • 63 Ditah I C, Reacher M, Palmer C et al.. Monitoring tuberculosis treatment outcome: analysis of national surveillance data from a clinical perspective.  Thorax. 2008;  63 440-446
  • 64 Didilescu C, Tigău M, Dediu I, Stoicescu I, Stoicescu I P. Clinical and epidemiological aspects of TB cases registered in persons aged >or  = 65 between 2002–2006, at the TB dispensary of sector 4, Bucharest [in Romanian].  Pneumologia. 2008;  57 148-154
  • 65 Farah M G, Tverdal A, Steen T W, Heldal E, Brantsaeter A B, Bjune G. Treatment outcome of new culture positive pulmonary tuberculosis in Norway.  BMC Public Health. 2005;  5 14
  • 66 Fuse E T, Takeda Y, Toyoda E, Mikami A, Kobayashi N, Kudo K. Predictive factors for treatment incompletion in elderly patients with newly diagnosed pulmonary tuberculosis [in Japanese].  Kekkaku. 2007;  82 803-808
  • 67 American Thoracic Society, Centers for Disease Control and Prevention . Targeted tuberculin testing and treatment of latent tuberculosis infection. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. This is a Joint Statement of the American Thoracic Society (ATS) and the Centers for Disease Control and Prevention (CDC). This statement was endorsed by the Council of the Infectious Diseases Society of America. (IDSA), September 1999, and the sections of this statement.  Am J Respir Crit Care Med. 2000;  161(4 Pt 2) S221-S247
  • 68 Mack U, Migliori G B, Sester M C. Lange et al. LTBI: latent tuberculosis infection or lasting immune responses to M. tuberculosis? A TBNET consensus statement.  Eur Respir J. 2009;  33 956-973
  • 69 Huebner R E, Schein M F, Bass Jr J B. The tuberculin skin test.  Clin Infect Dis. 1993;  17 968-975
  • 70 Kobashi Y, Mouri K, Yagi S et al.. Clinical utility of the QuantiFERON TB-2G test for elderly patients with active tuberculosis.  Chest. 2008;  133 1196-1202
  • 71 Mori T, Sakatani M, Yamagishi F et al.. Specific detection of tuberculosis infection: an interferon-γ-based assay using new antigens.  Am J Respir Crit Care Med. 2004;  170 59-64
  • 72 Chee C BE, KhinMar K W, Gan S H, Barkham T M, Pushparani M, Wang Y T. Latent tuberculosis infection treatment and T-cell responses to Mycobacterium tuberculosis–specific antigens.  Am J Respir Crit Care Med. 2007;  175 282-287
  • 73 Lalvani A, Pareek M. A 100 year update on diagnosis of tuberculosis infection.  Br Med Bull. 2010;  93 69-84 , 10.1093/bmb/ldp039
  • 74 Menzies D, Pai M, Comstock G. Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research.  Ann Intern Med. 2007;  146 340-354
  • 75 Ferrara G, Losi M, D'Amico R et al.. Interferon-gamma-release assays detect recent tuberculosis re-infection in elderly contacts.  Int J Immunopathol Pharmacol. 2009;  22 669-677
  • 76 Bennett D E, Courval J M, Onorato I et al.. Prevalence of tuberculosis infection in the United States population: the national health and nutrition examination survey, 1999–2000.  Am J Respir Crit Care Med. 2008;  177 348-355
  • 77 Runyon E H. American Thoracic Society . Preventive treatment in tuberculosis: a statement by the Committee on Therapy, American Thoracic Society.  Am Rev Respir Dis. 1965;  91 297-298
  • 78 Ferebee S H. Controlled chemoprophylaxis trials in tuberculosis: a general review.  Bibl Tuberc. 1970;  26 28-106
  • 79 Stead W W. Tuberculosis among elderly persons, as observed among nursing home residents.  Int J Tuberc Lung Dis. 1998;  2(9, Suppl 1) S64-S70
  • 80 Stead W W. Special problems in tuberculosis: tuberculosis in the elderly and in residents of nursing homes, correctional facilities, long-term care hospitals, mental hospitals, shelters for the homeless, and jails.  Clin Chest Med. 1989;  10 397-405
  • 81 Dooley S W, Villarino M E, Lawrence M et al.. Nosocomial transmission of tuberculosis in a hospital unit for HIV-infected patients.  JAMA. 1992;  267 2632-2634
  • 82 Zaza S, Blumberg H M, Beck-Sagué C et al.. Nosocomial transmission of Mycobacterium tuberculosis: role of health care workers in outbreak propagation.  J Infect Dis. 1995;  172 1542-1549
  • 83 Hutton M D, Cauthen G M, Bloch A B. Results of a 29-state survey of tuberculosis in nursing homes and correctional facilities.  Public Health Rep. 1993;  108 305-314
  • 84 Centers for Disease Control and Prevention . Prevention and control of tuberculosis in facilities providing long-term care to the elderly: recommendations of the Advisory Committee for Elimination of Tuberculosis.  MMWR Morb Mortal Wkly Rep. 1990;  39(RR-10) 7-20
  • 85 Ijaz K, Dillaha J A, Yang Z, Cave M D, Bates J H. Unrecognized tuberculosis in a nursing home causing death with spread of tuberculosis to the community.  J Am Geriatr Soc. 2002;  50 1213-1218
  • 86 Centers for Disease Control and Prevention . Tuberculosis elimination revisited: obstacles, opportunities, and a renewed commitment—Advisory Council for the Elimination of Tuberculosis (ACET).  MMWR Morb Mortal Wkly Rep. 1999;  48(RR-9) 1-13
  • 87 Griffith D E, Aksamit T, Brown-Elliott B A ATS Mycobacterial Diseases Subcommittee et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases.  Am J Respir Crit Care Med. 2007;  175 367-416
  • 88 Wayne L G, Sramek H A. Agents of newly recognized or infrequently encountered mycobacterial diseases.  Clin Microbiol Rev. 1992;  5 1-25
  • 89 Tortoli E. Impact of genotypic studies on mycobacterial taxonomy: the new mycobacteria of the 1990's.  Clin Microbiol Rev. 2003;  16 319-354
  • 90 Tortoli E. The new mycobacteria: an update.  FEMS Immunol Med Microbiol. 2006;  48 159-178
  • 91 Hoffner S E. Pulmonary infections caused by less frequently encountered slow-growing environmental mycobacteria.  Eur J Clin Microbiol Infect Dis. 1994;  13 937-941
  • 92 Tanaka E, Kimoto T, Matsumoto H et al.. Familial pulmonary Mycobacterium avium complex disease.  Am J Respir Crit Care Med. 2000;  161 1643-1647
  • 93 Haverkort F. Australian Mycobacterium Reference Laboratory Network; Special Interest Group in Mycobacteria within the Australian Society for Microbiology . National atypical mycobacteria survey, 2000.  Commun Dis Intell. 2003;  27 180-189
  • 94 Marinho A, Fernandes G, Carvalho T, Pinheiro D, Gomes I. Nontuberculous mycobacteria in non-AIDS patients.  Rev Port Pneumol. 2008;  14 323-337
  • 95 Marras T K, Daley C L. Epidemiology of human pulmonary infection with nontuberculous mycobacteria.  Clin Chest Med. 2002;  23 553-567
  • 96 Olivier K N, Weber D J, Wallace Jr R J Nontuberculous Mycobacteria in Cystic Fibrosis Study Group et al. Nontuberculous mycobacteria, I: Multicenter prevalence study in cystic fibrosis.  Am J Respir Crit Care Med. 2003;  167 828-834
  • 97 Olivier K N, Weber D J, Lee J H Nontuberculous Mycobacteria in Cystic Fibrosis Study Group et al. Nontuberculous mycobacteria, II: Nested-cohort study of impact on cystic fibrosis lung disease.  Am J Respir Crit Care Med. 2003;  167 835-840
  • 98 Witty L A, Tapson V F, Piantadosi C A. Isolation of mycobacteria in patients with pulmonary alveolar proteinosis.  Medicine (Baltimore). 1994;  73 103-109
  • 99 Horsburgh Jr C R. Epidemiology of Mycobacterium avium complex. In: Korvick JA, Benson CA Mycobacterium avium Complex Infection: Progress in Research and Treatment. New York; Marcel Dekker 1996: 1-22
  • 100 Cassidy P M, Hedberg K, Saulson A, McNelly E, Winthrop K L. Nontuberculous mycobacterial disease prevalence and risk factors: a changing epidemiology.  Clin Infect Dis. 2009;  49 e124-e129
  • 101 Al Jarad N, Demertzis P, Jones D J et al.. Comparison of characteristics of patients and treatment outcome for pulmonary non-tuberculous mycobacterial infection and pulmonary tuberculosis.  Thorax. 1996;  51 137-139
  • 102 Suzuki J, Kataoka R, Sugimoto S, Morio S. An epidemiological study of registered cases positive for atypical mycobacteria in the tuberculosis surveillance system [in Japanese].  Nippon Koshu Eisei Zasshi. 2004;  51 40-47
  • 103 Czajkowska M, Augustynowicz-Kopeć E, Zwolska Z et al.. Pulmonary mycobacterioses—frequency of occurrence, clinical spectrum and predisposing factors [in Polish].  Pneumonol Alergol Pol. 2002;  70 550-560
  • 104 Schluger N W. Tuberculosis and nontuberculous mycobacterial infections in older adults.  Clin Chest Med. 2007;  28 773-781
  • 105 Sugihara E, Dambara T, Aiba M et al.. Clinical study on lung disease caused by non-tuberculous mycobacteriosis in the elderly [in Japanese].  Nippon Ronen Igakkai Zasshi. 2007;  44 503-506
  • 106 Balkis M M, Kattar M M, Araj G F, Kanj S S. Fatal disseminated Mycobacterium simiae infection in a non-HIV patient.  Int J Infect Dis. 2009;  13 e286-e287
  • 107 Shimokawaji T, Kobayashi H, Kanoh S, Motoyoshi K. Disseminated Mycobacterium avium infection in an immunocompetent aged patient [in Japanese].  Nihon Kokyuki Gakkai Zasshi. 2006;  44 464-467
  • 108 The Research Committee of the British Thoracic Society . Pulmonary disease caused by M. malmoense in HIV negative patients: 5-yr follow-up of patients receiving standardised treatment.  Eur Respir J. 2003;  21 478-482
  • 109 Iwata M, Ida M, Takeuchi E, Nakamura Y, Horiguchi T, Sato A. Middle lobe syndrome—incidence and relationship to atypical mycobacterial pulmonary disease [in Japanese].  Nihon Kyobu Shikkan Gakkai Zasshi. 1996;  34 57-62

Mario H VargasM.D. M.S. 

Unidad de Investigación, Instituto Nacional de Enfermedades Respiratorias

Tlalpan 4502, CP 14080, México DF, México

Email: mhvargasb@yahoo.com.mx