Chest radiography is not sensitive enough to detect all lung abnormalities described in NTM pulmonary infection. Chest CT may demonstrate nonspecific findings including bronchiectasis (with right middle lobe and lingular predilection), airway centered nodules, and ground-glass opacities. Nodules may cavitate. On the basis of the 2020 clinical practice guidelines, experts recommend that patients with confirmed NTM pulmonary infection be treated with antimicrobial therapy over monitoring for evidence of progression. Treatment of NTM pulmonary infection typically requires a three-drug regimen with a macrolide for at least 15-18 months.
Unlike pulmonary tuberculosis, NTM pulmonary infections can be refractory and difficult to fully eradicate. For this reason, it is not deemed safe for patients with rheumatoid arthritis and other autoimmune diseases to resume TNF inhibitor therapy during and/or after completion of therapy for NTM infection without risk for reactivation of NTM infection. It is also advisable to limit corticosteroid therapy. Nonbiologic drugs, including hydroxychloroquine, methotrexate, leflunomide, and sulfasalazine, should be considered as alternative treatments to reduce the degree of immunosuppression. Although non–TNF inhibitor biologic drugs may also have a theoretical increased risk for NTM infection similar to that of TNF inhibitors, limited data are available to quantify the risk. Therefore, these other biologic drugs (abatacept, tocilizumab, and rituximab) may be considered as replacement options to treat rheumatoid arthritis if nonbiologic drugs fail. Close monitoring for recurrence of pulmonary symptoms is required when patients resume immunosuppressive therapy.
After pulmonary NTM infection was diagnosed in the patient in this case, her adalimumab therapy was held and methotrexate was continued for treatment of rheumatoid arthritis. For pulmonary NTM infection, she was treated with azithromycin, ethambutol, and rifampin for 24 months. Over the course of her treatment, her micronodular disease continued to wax and wane. Her cough was mild, intermittent, and occasionally associated with yellow sputum. The antimicrobial therapy was discontinued after repeated respiratory samples tested negative for nontuberculous mycobacteria for over 1 year. Given that relapse of NTM pulmonary infection is common, she was advised to continue monitoring her symptoms and to provide respiratory samples every 3 months to evaluate for the presence of nontuberculous mycobacteria.
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