[The indication of surgical management in patients with pulmonary disease caused by Mycobacterium avium-intracellulare complex].

The surgical management of patients with nontuberculous Mycobacteriosis caused by Mycobacterium avium complex (MAC) was studied regarding the following cases: (1) We investigated whether there had been an appropriate time for surgical management of patients with MAC who had not responded to medication and who died after their conditions became worse retrospectively. During the past 10 years, 49 patients diagnosed with MAC died at the Toneyama national hospital. 26 patients of them died of respiratory failure, apparently due to the worsening of MAC. Excluding 2 patients who were extremely elderly, we investigated whether surgical management could have been applied in the remaining 24 patients. We found that surgical management would have been possible in only one patient, and that at the time of diagnosis of MAC in 23 patients, surgical management was already not possible. (2) There are patients with MAC who do not respond to medication and who continue to excrete bacilli, chest X-ray findings gradually become worse for several years. In 1989 we retrospectively studied chest X-ray findings from MAC patients and found that 36 out of 103 patients (35%) showed worsening chest X-ray findings. The strains were identified in 44 of the 103 patients by the DNA probes method. However, of 37 patients with M.avium (41%), 15 had worsening of chest X-ray findings, while none out of 7 patients with M. intracellulare had worsening of chest X-ray findings. We then observed the clinical course of 37 patients who showed continuous excretion of bacilli and whose serotypes had been identified (20 with serovars 4, 1 with serovars 6, 6 with serovars 8, 2 with serovars 12, 4 with serovars 14 and 5 with serovars 16) by using the fast-atom bombardment mass spectrometry (FAB/MS). Chest X-ray findings later worsened in 14 (70%) of 20 patients with serovars 4. Nine of these patients have since died; excluding one patient who had liver cancer, eight died of respiratory failure due to worsening of MAC. In 17 patients with serotypes except serovars 4, 4 (24%) patients had worsening of chest X-ray findings, but none of the 5 deaths in this group were due to respiratory failure owing to worsening of MAC. These results suggest that it is difficult to establish the indication of surgical management in MAC patients, except for patients with repeated hemoptysis at present. The prognosis and surgical management of pulmonary disease caused by M. avium complex should be considered.