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Mycobacterial disease: A historical and epidemiologic perspective
Mycobacterial Disease: A Historical and Epidemiologic Perspective MINDY
SCHUSTER,
MD
H
uman mycobacterial infections are ancient diseases. There is paleopathologic evidence of Mycobacterium tuberculosis as early as 3700 B.C.E. in Egypt and 2500 to 1500 B.C.E. in Europe,’ and there are several biblical references to M. Ieprae infections. Cutaneous involvement with M. tuberculosis was first described as the “prospector’s wart” by Laennet in 1826. Subsequent discovery of the tubercle bacillus was made in 1882 by Koch. The causative agent of leprosy, M. lepae, was discovered by Hansen in 1873.’ Although nontuberculous mycobacteria (NTM) were identified shortly after this time, appreciation of their ability to cause human disease did not occur until the middle of this century. It is estimated that one third of the world population (approximately 1.7 billion persons) is infected with M. tuberculosis, and each year there are 8 million new cases worldwide.3 In the United States, the number of cases of tuberculosis declined from 84,304 in 1953 to 22,201 in 1985, representing an average annual decrease of 5.8%.4 From 1985 to 1992, however, the number of cases rose 20%, with approximately 39,000 more cases than expected.5 In African countries, the annual incidence of tuberculosis has increased 100% during this decade.6 The increase in tuberculosis infections has been attributed to the HIV epidemic, poverty and malnutrition, and a decline in tuberculosis control efforts. Rates of tuberculosis infection approach 50% in homeless populations in the United States,7 and infection disproportionately affects minority groups living under crowded inner-city conditions with poor access to health care. Leprosy remains a significant unconquered problem, with an estimated 12 million people infected worldwide, and many of these untreated.’ Leprosy is endemic in Asia, Africa, Latin America, and the Pacific. Unfortunately, little is known about the epidemiology of M. leprae. Up to 25% of patients will have some physical handicap as a result of infection. Leprosy is clearly a disease of tremendous economic and social importance. Physicians in nonendemic areas may be unfamiliar with this infection, and misdiagnoFrom the Division of Infectious Diseases, Department of Medicine, University of Pennsylvania,Philadelphia, Pennsylvania. Address correspondence to Mindy Schuster, MD, Division ofInfectious Diseases, Department of Medicine, University of Pennsylvania, 536 Johnson Pavilion, Philadelphia, PA 19104-6073.
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York,
NY 10010
sis is common. Multidrug therapy has been a significant recent advance in the treatment of this infection. Nontuberculous mycobacterial infections are of growing importance. NTM infections are the most frequent bacterial infections in patients with HIV infection. Both disseminated and local cutaneous involvement has been reported. There are increasing reports of infections with NTM in other immunosuppressed hosts, as well as nosocomial infection in normal hosts. This increase is likely a result of both improved culture techniques and the greater number of susceptibIe hosts who are subject to an increasing number of medical procedures. NTM infections can present with a diversity of cutaneous manifestations and often represent both diagnostic and therapeutic challenges. Given the dramatic rise in cases of tuberculosis, the continuing worldwide problem with leprosy, and an increase in infections caused by NTM, in conjunction with a changing population of patients at risk for these infections, it is extremely important for clinicians to be familiar with the diagnostic and therapeutic aspects of these diseases. The dermatologist may often have a unique opportunity to diagnose a disseminated mycobacterial infection when it presents with cutaneous involvement. This issue reviews the epidemiologic and microbiologic characteristics of mycobacterial infections and discusses current diagnostic and treatment strategies for cutaneous infections, as well as the toxic effects of pharmacologic interventions,
References 1.
2. 3. 4.
5. 6.
7. 8.
Ayvazian LF. History of tuberculosis. In: Reichman LB, Hershfield ES, editors. Tuberculosis: A comprehensive international approach. New York: Marcel Dekker. Ehring F. Leprosy illustration in medical literature. Int J Dennatol 1994;33:872-82. Sundre P, ten Dam G, Kochi A. Tuberculosis: A global overview of the situation today. &III WHO 1992;70:149-59. Rieder HL, Cauthen GM, Cornstock GW, Snider DE. Epidemiology of tuberculosis in the United States. Epidemiol Rev 1989;11:79-98. Centers for Disease Control and Prevention. TubercuIosis morbidity-United States, 1992. MMWR 1993;42:696-7@4. Arachi A. The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle 1991;72:1-6. Schieffelbein CW Jr, Snider DE Jr. Tuberculosis control among homeless populations. JAMA 1988;143:184~. WHO Expert Committee on Leprosy. Fifth Report. Tech Rep Ser 19977:607. 0738-OHIxl951$9.50 SSDZ 0;.38-O81x(95KIOOOZ-V
SCHUSTER,
MD
H
uman mycobacterial infections are ancient diseases. There is paleopathologic evidence of Mycobacterium tuberculosis as early as 3700 B.C.E. in Egypt and 2500 to 1500 B.C.E. in Europe,’ and there are several biblical references to M. Ieprae infections. Cutaneous involvement with M. tuberculosis was first described as the “prospector’s wart” by Laennet in 1826. Subsequent discovery of the tubercle bacillus was made in 1882 by Koch. The causative agent of leprosy, M. lepae, was discovered by Hansen in 1873.’ Although nontuberculous mycobacteria (NTM) were identified shortly after this time, appreciation of their ability to cause human disease did not occur until the middle of this century. It is estimated that one third of the world population (approximately 1.7 billion persons) is infected with M. tuberculosis, and each year there are 8 million new cases worldwide.3 In the United States, the number of cases of tuberculosis declined from 84,304 in 1953 to 22,201 in 1985, representing an average annual decrease of 5.8%.4 From 1985 to 1992, however, the number of cases rose 20%, with approximately 39,000 more cases than expected.5 In African countries, the annual incidence of tuberculosis has increased 100% during this decade.6 The increase in tuberculosis infections has been attributed to the HIV epidemic, poverty and malnutrition, and a decline in tuberculosis control efforts. Rates of tuberculosis infection approach 50% in homeless populations in the United States,7 and infection disproportionately affects minority groups living under crowded inner-city conditions with poor access to health care. Leprosy remains a significant unconquered problem, with an estimated 12 million people infected worldwide, and many of these untreated.’ Leprosy is endemic in Asia, Africa, Latin America, and the Pacific. Unfortunately, little is known about the epidemiology of M. leprae. Up to 25% of patients will have some physical handicap as a result of infection. Leprosy is clearly a disease of tremendous economic and social importance. Physicians in nonendemic areas may be unfamiliar with this infection, and misdiagnoFrom the Division of Infectious Diseases, Department of Medicine, University of Pennsylvania,Philadelphia, Pennsylvania. Address correspondence to Mindy Schuster, MD, Division ofInfectious Diseases, Department of Medicine, University of Pennsylvania, 536 Johnson Pavilion, Philadelphia, PA 19104-6073.
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York,
NY 10010
sis is common. Multidrug therapy has been a significant recent advance in the treatment of this infection. Nontuberculous mycobacterial infections are of growing importance. NTM infections are the most frequent bacterial infections in patients with HIV infection. Both disseminated and local cutaneous involvement has been reported. There are increasing reports of infections with NTM in other immunosuppressed hosts, as well as nosocomial infection in normal hosts. This increase is likely a result of both improved culture techniques and the greater number of susceptibIe hosts who are subject to an increasing number of medical procedures. NTM infections can present with a diversity of cutaneous manifestations and often represent both diagnostic and therapeutic challenges. Given the dramatic rise in cases of tuberculosis, the continuing worldwide problem with leprosy, and an increase in infections caused by NTM, in conjunction with a changing population of patients at risk for these infections, it is extremely important for clinicians to be familiar with the diagnostic and therapeutic aspects of these diseases. The dermatologist may often have a unique opportunity to diagnose a disseminated mycobacterial infection when it presents with cutaneous involvement. This issue reviews the epidemiologic and microbiologic characteristics of mycobacterial infections and discusses current diagnostic and treatment strategies for cutaneous infections, as well as the toxic effects of pharmacologic interventions,
References 1.
2. 3. 4.
5. 6.
7. 8.
Ayvazian LF. History of tuberculosis. In: Reichman LB, Hershfield ES, editors. Tuberculosis: A comprehensive international approach. New York: Marcel Dekker. Ehring F. Leprosy illustration in medical literature. Int J Dennatol 1994;33:872-82. Sundre P, ten Dam G, Kochi A. Tuberculosis: A global overview of the situation today. &III WHO 1992;70:149-59. Rieder HL, Cauthen GM, Cornstock GW, Snider DE. Epidemiology of tuberculosis in the United States. Epidemiol Rev 1989;11:79-98. Centers for Disease Control and Prevention. TubercuIosis morbidity-United States, 1992. MMWR 1993;42:696-7@4. Arachi A. The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle 1991;72:1-6. Schieffelbein CW Jr, Snider DE Jr. Tuberculosis control among homeless populations. JAMA 1988;143:184~. WHO Expert Committee on Leprosy. Fifth Report. Tech Rep Ser 19977:607. 0738-OHIxl951$9.50 SSDZ 0;.38-O81x(95KIOOOZ-V