321.2 🩺 國考版

321.2.1 高頻考點

321.2.1.1 Main Pulmonary NTM

  • MAC (most common): M. avium + M. intracellulare + M. chimaera
  • M. abscessus complex (most difficult)
  • M. kansasii (TB-like)
  • M. xenopi, M. malmoense (Europe)

321.2.1.2 Diagnosis (ATS/IDSA 2020)

  • Clinical: pulmonary symptoms
  • Radiographic: nodular bronchiectasis or fibrocavitary
  • Microbiologic: ≥ 2 sputum OR 1 BAL OR 1 tissue biopsy

321.2.1.3 Lady Windermere Syndrome

  • Tall thin elderly women
  • Right middle lobe + lingula bronchiectasis
  • MAC infection
  • Suppression of cough hypothesis

321.2.1.4 MAC Treatment

  • Azithromycin + ethambutol + rifampin
  • Daily or thrice weekly
  • 12 months after sputum culture conversion
  • Total 18-24 months typically

321.2.1.5 Refractory MAC

  • ALIS (inhaled liposomal amikacin, Arikayce) — CONVERT 2018
  • FDA 2018 approved
  • Add to standard regimen
  • For failed standard ≥ 6 months

321.2.1.6 M. abscessus Subspecies

  • subsp. abscessus: erm(41) inducible macrolide resistance
  • subsp. massiliense: erm(41) inactive, macrolide-susceptible
  • subsp. bolletii: variable

321.2.1.7 M. abscessus Treatment

  • IV intensive: amikacin + imipenem/cefoxitin + macrolide (if susceptible) + tigecycline/linezolid
  • Oral continuation: macrolide + clofazimine + bedaquiline emerging
  • ≥ 12 months after culture conversion
  • Cure 30-50%

321.2.1.8 M. kansasii

  • Most TB-like
  • Rifampin + isoniazid + ethambutol × 9-12 months
  • Macrolide may be added
  • Curable

321.2.1.9 Disseminated MAC (HIV)

  • CD4 < 50
  • Macrolide + ethambutol + rifabutin
  • ART crucial
  • Prophylaxis with azithromycin if CD4 < 50

321.2.1.10 Hot Tub Lung

  • MAC inhalation
  • Hypersensitivity-like
  • Drain + clean hot tub
  • Steroids + antimicrobial

321.2.1.11 Key Trials

  • CONVERT (2018): ALIS for refractory MAC

321.2.2 易混淆比范

NTM Species Pattern Treatment Duration Cure Rate
MAC Nodular bronchiectatic, Lady Windermere 12 mo after conversion 80%
M. abscessus Variable ≥ 12 mo + lifelong supp 30-50%
M. kansasii TB-like fibrocavitary 9-12 mo 95%+
M. xenopi Variable 12 mo after conversion 60-70%

321.2.3 Special Topics

321.2.3.1 Bronchiectasis + NTM Workflow

  1. Confirm NTM diagnosis (ATS/IDSA 2020)
  2. Drug susceptibility testing
  3. Decide treatment (severity + adherence + side effects)
  4. Monitor monthly sputum
  5. 12 months after culture conversion
  6. Reassess relapse risk

321.2.3.2 Hot Tub Lung Treatment

  • Source control (clean/drain hot tub)
  • Avoidance
  • Steroids (some advocate)
  • Antimicrobial controversial in pure hypersensitivity
  • Most resolve with avoidance