Nontuberculous Mycobacterial Infection as a Cause of Difficult-to-Control Asthma: A Case-Control Study

doi:10.1378/chest.10-0186

Chest

Volume 139, Issue 1, January 2011, Pages 23-27

https://doi.org/10.1378/chest.10-0186 Get rights and content

Background

Symptomatic disease due to nontuberculous mycobacteria (NTM) is known to occur commonly in the presence of structural lung disease, but is not described in association with asthma.

Methods

This was a case-control study nested in a cohort. We identified 22 patients with difficult asthma referred to a tertiary academic referral center and subsequently found to have infection with NTM. We matched each case with two control subjects (next two consecutive patients referred for asthma management).

Results

It took on average 2.1 years from the onset of new or worsening symptoms to NTM diagnosis. The most common symptoms were worsening cough (77%), sputum production (40.9%), and frequent exacerbations (31.8%). Mycobacterium avium complex accounted for 63.6% of the infections, Mycobacterium xenopi the balance. Case subjects were older (59.8 ± 8.9 vs 42.6 ± 18 years; P < .001) and had more severe airflow obstruction (FEV₁, 57% [40%-74%] vs 89.5% [80%-98%]; P < .001). There was no difference between case and control subjects in the proportion using inhaled corticosteroids (ICS) or the average daily dose at the time of presentation, but case subjects had used ICS for a longer period (17 [6.2-20] vs 4 [0.75-6.0] years; P=.002). Six subjects with NTM were being treated with daily oral steroids, whereas none of the control subjects was. Of the 22 cases, 10 were treated with antibiotics for NTM, seven demonstrating clinical improvement or resolution of the presenting symptoms.

Conclusions

NTM infection can be associated with asthma and should be considered in difficult-to-treat disease, especially in older individuals with more severe airflow obstruction and greater exposure to inhaled or systemic corticosteroids.

Section snippets

Materials and Methods

This is a case-control study nested within a cohort. The cohort involved all subjects being followed in a respiratory tertiary center in Toronto, Ontario, Canada (Asthma and Airways Centre, University Health Network) who had been referred for uncontrolled asthma. Cases were identified among subjects who, as part of assessment for their uncontrolled symptoms, were found to have NTM infection. Each case was matched with two control subjects. Control subjects were chosen as the next two

Clinical Characteristics

Twenty-two subjects met criteria for a previous history of asthma with concomitant pulmonary NTM isolation from 2003 to April 2009. Of these patients, 19 were referred for difficult-to-treat or poorly controlled asthma, and three were referred because of asthma complicated by other factors (two had episodes of hemoptysis and one had an abnormal chest radiograph). The most common symptomatic changes in cases were cough (77%), sputum production (40.9%), and frequent exacerbations (31.8%).

Discussion

We describe a group of patients referred to a tertiary center for perceived worsening of asthma who were found to have concomitant infection with NTM. Overall, patients with difficult-to-control asthma and pulmonary NTM infection were older, had more severe airflow obstruction, and had been taking inhaled or oral steroids for longer than uninfected patients. MAC and M xenopi were the mycobacteria implicated in all patients, with a relative frequency similar to that of all pulmonary NTM isolates

Acknowledgments

Author contributions: Dr L. G. Fritscher: contributed to the development of the protocol, data collection and analyses, and manuscript preparation.

Dr Marras: contributed to the development of the protocol, data collection and analyses, and manuscript preparation.

Ms Bradi: contributed to data collection and manuscript preparation.

Dr C. C. Fritscher: contributed to the development of the protocol, data analyses, and manuscript preparation.

Dr Balter: contributed to data collection and manuscript

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Funding/Support: The study was partially funded by an unrestricted grant from the Imperial Oil Foundation, which provided funds in order to explore new diagnostic methods in asthma and airways diseases.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Original ResearchAsthmaNontuberculous Mycobacterial Infection as a Cause of Difficult-to-Control Asthma: A Case-Control Study

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Clinical Characteristics

Discussion

Acknowledgments

J Allergy Clin Immunol

Chest

Chest

J Allergy Clin Immunol

Respir Med

Vaccine

J Allergy Clin Immunol

Isolation prevalence of pulmonary non-tuberculous mycobacteria in Ontario, 1997-2003

Thorax

An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases

Am J Respir Crit Care Med

Asthma unresponsive to usual therapy

Respiratory tract viral infections in inner-city asthmatic adults

Arch Intern Med

Original Research
Asthma
Nontuberculous Mycobacterial Infection as a Cause of Difficult-to-Control Asthma: A Case-Control Study