Non-cystic fibrosis bronchiectasis
Editor – In their excellent review of non-cystic fibrosis bronchiectasis Murray and Hill (Clin Med April 2009 pp 164–9) failed to mention an important and increasingly prevalent variety of bronchiectasis in older adults. Bronchiectasis associated with nontuberculous mycobacterial (NTM) infection, notably Mycobacterium avium complex (MAC) and Mycobacterium abscessus, is now frequently seen in older patients, notably women who give no history of respiratory disease earlier in life and are often non-smokers. The disease is characterised by bronchiectasis which most often involves the right middle lobe and the lingular segment of the left upper lobe in association with nodules – small nodules in the ‘tree-in-bud’ configuration and larger nodules which are often peripheral in their distribution and may occasionally cavitate although cavitation is not a characteristic feature of this disorder. This disorder which has been labelled nodular bronchiectasis may be detected when investigating an older patient with a history of cough and sputum production associated with recurrent infectious exacerbations and, later in the illness, with progressive weight loss. The chest radiograph is usually characterised by large lungs which may be surprisingly unremarkable although in the later stages peripheral nodules and features of bronchiectasis may become apparent. In the earlier stages of the disease a computed tomography chest X-ray is usually striking for its abnormalities, an example of which is included (Fig 1).
Although the study by Jenkins et al suggested poor results when treating NTM lung disease, the majority of their patients with MAC disease had cavitary disease which is recognised to be poorly responsive to treatment.1gTheir study may thus not be generalisable to patients with nodular bronchiectasis who do seem in case series to respond to treatment.2In our clinic, treatment regimens with azithromycin, ethambutol and clofazimine have been well tolerated and often result in sputum culture conversion and improvement of symptoms. Treatment is also given in the belief that it will arrest the progression of the disease. Azithromycin and clar-ithromycin are thought to be the only medications which are effective against MAC and it would thus be important not to give one of these antibiotics, as suggested by Murray and Hill, without concurrent medication to patients who might have MAC nodular bronchiectasis for fear of creating an untreatable macrolide resistant organism.
- © 2009 Royal College of Physicians
References
Non-cystic fibrosis bronchiectasis
We thank Drs Cowie and Field for highlighting nontuberculous mycobacterial (NTM) infection as an important entity associated with non-cystic fibrosis bronchiectasis. We did not include this originally due to the constraints of the review article. Drs Cowie and Field comment on NTM infection which has been recognised in the 2007 American Thoracic Society/Infectious Diseases Society of America statement on the diagnosis, treatment and prevention of NTM as both an important cause and complication of bronchiectasis.1In 2005, Wickremasinghe et al conducted a prospective study of 100 patients with non cystic-fibrosis bronchiectasis and found the prevalence of NTM to be 2%, with 1% requiring treatment.2Similarly in 2006, Fowler et al‘s study found a 9% prevalence of NTM (7 out of 80 patients with non-cystic fibrosis bronchiectasis) with 2.5% requiring treatment according to ATS guidelines.3The actual prevalence of NTM infection in non-cystic fibrosis bronchiectasis needs further study.
Drs Cowie and Field also raised caution to the use of macrolide therapy in nodular bronchiectasis. At present, randomised controlled trials are needed to decide both whether there is a role for macrolides as a long-term prophylactic therapy in non-cystic fibrosis bronchiectasis, and whether they could affect the resistance pattern if there is concomitant mycobacterial infection. There is currently no evidence that acute usage of macrolide therapy has such an effect and in our opinion it is an important second line treatment for acute exacerbations of non-cystic fibrosis bronchiectasis (see Table 2 of our CME article, Clin Med April 2009 pp 164–9).
- © 2009 Royal College of Physicians
References
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- Wickremasinghe M
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- Fowler SJ
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