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The Many Faces of Pulmonary Nontuberculous Mycobacterial Infection

¹ Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.
² Department of Radiology, St. Francis Hospital, Evanston, IL.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —54-year-old man with mild emphysema, cough, and fever. Cultures from sputum and resected surgical specimen showed Mycobacterium avium-intracellulare complex organisms. Chest radiograph coned to left upper lung shows well-circumscribed cavitary left upper lobe mass.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —54-year-old man with mild emphysema, cough, and fever. Cultures from sputum and resected surgical specimen showed Mycobacterium avium-intracellulare complex organisms. Axial CT images (5-mm section, lung window setting) confirm left upper lobe cavity and show adjacent cluster of small nodules (arrows, C).

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —54-year-old man with mild emphysema, cough, and fever. Cultures from sputum and resected surgical specimen showed Mycobacterium avium-intracellulare complex organisms. Axial CT images (5-mm section, lung window setting) confirm left upper lobe cavity and show adjacent cluster of small nodules (arrows, C).

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —36-year-old woman with chronic cough, weight loss, and fatigue. Cultures from sputum showed Mycobacterium avium-intracellulare complex organisms. Frontal chest radiograph shows right upper lobe volume loss and bronchiectasis and poorly defined nodules in right lower lung. Note also left lower lobe volume loss, heterogeneous opacity, and left upper lobe bulla.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —36-year-old woman with chronic cough, weight loss, and fatigue. Cultures from sputum showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (5-mm section, lung window setting) shows small clustered right upper lobe nodules and cavity (arrow). Note left upper lobe bullae (asterisks).

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —36-year-old woman with chronic cough, weight loss, and fatigue. Cultures from sputum showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (5-mm section, lung window setting) obtained at more caudal level shows right lower lobe tree-in-bud opacities (white arrows) consistent with endobronchial spread of infection. Note left lower lobe cavity (asterisk) and bronchiectasis (black arrow).

View larger version (66K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —37-year-old man with chronic cough. Cultures of bronchoalveolar lavage fluid showed Mycobacterium chelonei organisms. Axial CT image (1.25-mm section, lung window setting) shows large cavity in right upper lobe with lobular intracavitary mass. Note ground-glass opacity in left upper lobe, possibly representing additional focus of infection. Histopathologic analysis of resected specimen showed necrotic lung in cavity.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —37-year-old man with chronic cough. Cultures of bronchoalveolar lavage fluid showed Mycobacterium chelonei organisms. Axial CT image (1.25-mm section, lung window setting) obtained at more caudal level shows tree-in-bud opacities (arrows) consistent with endobronchial spread of infection.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —73-year-old woman with chronic productive cough and fatigue. Cultures of bronchoalveolar lavage fluid showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (1.25-mm section, lung window setting) shows cylindric bronchiectasis (arrows) and partial volume loss in right middle lobe and lingula. Note bilateral lower lobe scattered nodules.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —67-year-old woman with chronic cough and weight loss. Sputum cultures showed Mycobacterium avium-intracellulare complex organisms. Frontal chest radiograph shows hyperinflation and subtle opacity in right middle lobe. Note symmetric bilateral apical scarring.

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —67-year-old woman with chronic cough and weight loss. Sputum cultures showed Mycobacterium avium-intracellulare complex organisms. Lateral chest radiograph shows hyperinflation and atelectasis of right middle lobe.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —67-year-old woman with chronic cough and weight loss. Sputum cultures showed Mycobacterium avium-intracellulare complex organisms. Axial CT images (1-mm section, lung window setting) show diffuse mosaic attenuation and bronchiectases. Note atelectasis of right middle lobe and small peripheral foci of consolidation in left upper lobe.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —67-year-old woman with chronic cough and weight loss. Sputum cultures showed Mycobacterium avium-intracellulare complex organisms. Axial CT images (1-mm section, lung window setting) show diffuse mosaic attenuation and bronchiectases. Note atelectasis of right middle lobe and small peripheral foci of consolidation in left upper lobe.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —41-year-old man with AIDS, CD4 count of 166 cells/mL, and viral load of 153,000 cells/mL, with cough and fever. Cultures of sputum and histopathologic material obtained at mediastinal biopsy showed Mycobacterium avium-intracellulare complex organisms. Biopsies were negative for neoplasm. Frontal chest radiograph shows left-sided mediastinal and upper lobe mass (arrow). Note also subtle left upper lobe reticular opacities.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —41-year-old man with AIDS, CD4 count of 166 cells/mL, and viral load of 153,000 cells/mL, with cough and fever. Cultures of sputum and histopathologic material obtained at mediastinal biopsy showed Mycobacterium avium-intracellulare complex organisms. Biopsies were negative for neoplasm. Axial CT image (5-mm section, soft-tissue window setting) shows bilateral paratracheal adenopathy (asterisks) and left upper lobe invading mediastinum (arrows).

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —41-year-old man with AIDS, CD4 count of 166 cells/mL, and viral load of 153,000 cells/mL, with cough and fever. Cultures of sputum and histopathologic material obtained at mediastinal biopsy showed Mycobacterium avium-intracellulare complex organisms. Biopsies were negative for neoplasm. Axial CT image (5-mm section, lung window setting) obtained at more caudal level shows tree-in-bud opacities in superior segments of both lower lobes (arrows).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —27-year-old man with AIDS and low CD4 count (< 40 cells/mL) treated with highly active antiretroviral therapy. Despite favorable immune response, patient developed fever and back pain. Cultures of histopathologic material obtained from retroperitoneal lymph node biopsy showed Mycobacterium avium-intracellulare complex organisms. Frontal chest radiograph shows bilateral bulky mediastinal lymphadenopathy. Clinical and imaging findings are consistent in showing immune reconstitution syndrome. Repeat radiographs after treatment (not shown) showed decreased mediastinal adenopathy.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —27-year-old man with AIDS and low CD4 count (< 40 cells/mL) treated with highly active antiretroviral therapy. Despite favorable immune response, patient developed fever and back pain. Cultures of histopathologic material obtained from retroperitoneal lymph node biopsy showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (5-mm section, soft-tissue window setting) obtained in upper abdomen shows extensive retroperitoneal and mesenteric adenopathy (asterisks).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —70-year-old asymptomatic man with pulmonary nodule found on routine chest radiograph (not shown). Histopathologic analysis of resected specimen showed granulomatous inflammation and no evidence of malignancy. Cultures showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (3.75-mm section, lung window setting) (A) and fused axial image from combined 18F-FDG PET/CT (B) show spiculated right upper nodule with significant FDG uptake.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —70-year-old asymptomatic man with pulmonary nodule found on routine chest radiograph (not shown). Histopathologic analysis of resected specimen showed granulomatous inflammation and no evidence of malignancy. Cultures showed Mycobacterium avium-intracellulare complex organisms. Axial CT image (3.75-mm section, lung window setting) (A) and fused axial image from combined 18F-FDG PET/CT (B) show spiculated right upper nodule with significant FDG uptake.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —42-year-old asymptomatic woman with multiple nodules found on routine chest radiograph. Cultures of histopathologic material obtained by fine-needle biopsy showed Mycobacterium xenopi organisms. Frontal chest radiograph shows multiple bilateral pulmonary nodules.

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —42-year-old asymptomatic woman with multiple nodules found on routine chest radiograph. Cultures of histopathologic material obtained by fine-needle biopsy showed Mycobacterium xenopi organisms. Axial CT image (2-mm section, lung window setting) shows bilateral, irregularly marginated nodules in both upper lobes.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —Young man with achalasia, fever, and cough. Culture of bronchoalveolar lavage fluid was positive for Mycobacterium fortuitum. Frontal chest radiograph shows dilated esophagus (white arrows). Note cluster of small nodules in right upper lobe (black arrows).

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —Middle-aged man with cough, fever, and dyspnea who recently purchased indoor hot tub. Histopathologic analysis of lung biopsy specimen showed features of hypersensitivity pneumonitis; cultures of bronchoalveolar lavage fluid showed Mycobacterium avium-intracellulare complex organisms. Axial high-resolution CT image (1.25-mm section, lung window setting) of chest shows diffusely distributed ground-glass nodules. Clinical, imaging, and histopathologic features are consistent with "hot tub lung."

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