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Challenges in the Diagnosis and Management of Mycobacterium avium Complex Infection in South Africa, a Country with High TB Prevalence
Shookdev L Modi*1,2,3,4, Shookdev L Modi*1,2,3,4, Shookdev L Modi*1,2,3,4, Shookdev L Modi*1,2,3,4, M A John2,3,4,5, M A John2,3,4,5, M A John2,3,4,5, M A John2,3,4,5, C Menezes2,3,4,5, C Menezes2,3,4,5, C Menezes2,3,4,5, C Menezes2,3,4,5, P MacPhail2,3,4,5, P MacPhail2,3,4,5, P MacPhail2,3,4,5, and P MacPhail2,3,4,5
1Themba Lethu Clin, Johannesburg, South Africa; 2Helen Joseph Hosp, Johannesburg, South Africa; 3Johannesburg; 4South Africa; and 5Univ of Witswatersrand, Johannesburg, South Africa
Background: HIV/tuberculosis (TB) co-infection is the leading cause of
morbidity and mortality in Sub-Saharan Africa. The prevalence of HIV/TB
co-infection in South Africa,
which notifies the majority of TB cases in Africa,
is 60%. Mycobacterium avium complex (MAC),
supposedly uncommon in developing countries, is reported to occur in South Africa in
10% of HIV-infected persons with CD4<100. Developed countries have a similar
frequency. We believe that MAC is under-diagnosed in our clinic because of the
high rates of TB in our HIV population, overlapping clinical features and
existing laboratory protocols. Therefore, we wanted to determine the prevalence
of MAC in our HIV-positive patients and to identify clinical and laboratory
features, if any, that could differentiate MAC from TB, and to document
pulmonary MAC infection.
Methods: From a total of 386
Bactec results captured on the hospital and TLC database (Therapy Edge) between
January 2005 and September 2006, we identified
39 adult HIV-infected patients with clinical features suggestive of, or microbiologically
confirmed, MAC.
Results: There was a male predominance of 53% (clinic M:F 1:2.3). The commonest presenting symptoms
were cough (61%), night sweats (54%), and weight loss (51%). Positive cultures
were found from blood, sputum, and skin/soft tissue. Of these patients, 35% had
positive MAC sputum cultures together with clinical and radiological features
of MAC pulmonary disease; 12 (31%) patients met the criteria for MAC IRIS.
During the study period, 8 (20%) patients died (all but 1 of AIDS-related
illnesses), 13 (33%), who are on zithromax, ethambutol, and ciprobay are alive
and responding well, while 17 (43%) were lost to follow-up. On further inquiry,
4 of those lost to follow-up were found to have died.
Conclusions: Clinical and laboratory features were not specific for
MAC because they were also seen in TB. In contrast to other reports, liver abnormalities and bone
marrow suppression were uncommon. Pulmonary MAC infection and MAC IRIS are
common in our patients. A high index of suspicion is
needed to diagnose MAC in areas of high TB prevalence. As many patients receive
empiric TB treatment close follow-up is necessary.
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