Elderly immunocompromised man with several years of intermittent dry cough but more green and productive over the last month. Carries diagnosis of asthma on symbicort and PE on eliquis. Afebrile, satting well on room air, but some bibasilar crackles.
Chest imaging showed scattered opacities, slightly reticular, more at the bases. He improved with CTX/azithro; after a week, grew a variety of NTM organisms from multiple samples, including M. abscessus (usually want to treat, more likely to progress and more virulent than MAC).
Group consensus was to send for susceptibilities at National Jewish, but not to treat given symptomatic improvement and repeat CT was much improved (near normal) without treatment for NTM.
Teaching point: Susceptibility showed azithromycin susceptible but high MIC of 32, concerning for something that would have inducible azithro resistance. Functional erm gene also a marker of difficulty to eradicate.
Ongoing discussions regarding treating (if so, with what? to what goal?) and immunosuppression adjustments…
Thanks, Dr. Olson!