Skip to main content

‘”Why me, why now?” Using clinical immunology and epidemiology to explain who gets nontuberculous mycobacterial infection



The prevalence of nontuberculous mycobacterial (NTM) disease is rising. An understanding of known risk factors for disease sheds light on the immunological and physical barriers to infection, and how and why they may be overcome. This review focuses on human NTM infection, supported by experimental and in vitro data of relevance to the practising clinician who seeks to understand why their patient has NTM infection and how to further investigate.


First, the underlying immune response to NTM disease is examined. Important insights regarding NTM disease susceptibility come from nature's own knockouts, the primary immune deficiency disorders. We summarise the current knowledge surrounding interferon-gamma (IFNγ)-interleukin-12 (IL-12) axis abnormalities, followed by a review of phagocytic defects, T cell lymphopenia and rarer genetic conditions known to predispose to NTM disease. We discuss how these define key immune pathways involved in the host response to NTM. Iatrogenic immunosuppression is also important, and we evaluate the impact of novel biological therapies, as well as bone marrow transplant and chemotherapy for solid organ malignancy, on the epidemiology and presentation of NTM disease, and discuss the host defence dynamics thus revealed. NTM infection and disease in the context of other chronic illnesses including HIV and malnutrition is reviewed. The role of physical barriers to infection is explored. We describe how their compromise through different mechanisms including cystic fibrosis, bronchiectasis and smoking-related lung disease can result in pulmonary NTM colonisation or infection. We also summarise further associations with host factors including body habitus and age.


We use the presented data to develop an over-arching model that describes human host defences against NTM infection, where they may fail, and how this framework can be applied to investigation in routine clinical practice.

Peer Review reports


Nontuberculous mycobacteria have historically been seen as environmental organisms of limited clinical relevance, overshadowed by their more aggressive cousin, Mycobacterium tuberculosis. It was not until the HIV pandemic highlighted disseminated Mycobacterium avium and intracellulare as major opportunistic infection syndromes that their significance was recognised by the general healthcare community, a role further cemented by the expansion of iatrogenic immunosuppression. Evidence to support an ongoing rise in disseminated NTM infection is limited [1]. This is not the case for chronic pulmonary NTM disease which is increasing [2] in part due to an aging, vulnerable population [3, 4].

NTM are regarded generally as low pathogenicity organisms, which can be transiently isolated from samples such as sputum, colonise body sites such as the lung, or cause persistent infection and disease. Distinguishing between these different clinical states can be surprisingly difficult. However, it is important to do as this underpins both clinical management decisions and predicts outcome. An accepted approach is to define NTM-associated pulmonary disease as that in which compatible clinical features occur in people from whom NTM are repeatedly isolated over time [5]. Treatment can be poorly tolerated and is certainly less effective than that for tuberculosis (TB) [6]. Hence an understanding of who is at risk enables us to both target interventions and potentially prevent disease occurring.

Research into monogenic disorders conferring susceptibility to disseminated NTM infection provides key insights into the critical host immune responses against these organisms, though many questions remain: in particular why such a large population of apparently immunocompetent people become infected and develop pulmonary disease.

We present here a summary of how specific conditions and iatrogenic interventions have elucidated both the essential and redundant components of human defences against NTM. We use this to suggest practical strategies for investigation in patients presenting with these infections.


Lessons from primary immune deficiencies

CLINICAL VIGNETTE: A 2-year old boy born to first-cousin parents presents with several weeks of fever, weight loss, diarrhoea and skin nodules. Examination reveals widespread lymphadenopathy and hepatosplenomegaly. Blood cultures are positive for M. avium.

A number of monogenic disorders conferring susceptibility to disseminated NTM infection are grouped together as Mendelian Susceptibility to Mycobacterial Disease (MSMD) conditions. Although extremely rare [7] and predominantly affecting children, these diseases offer insight into critical immune defences against mycobacteria.

Cytokine pathway defects

The immune response to mycobacterial infection is summarised in Box 1 and Figure 1, together with sites of dysfunction due to primary immunodeficiency syndromes. Essentially, defence is mediated by mononuclear phagocytes’ ability to kill mycobacteria and secrete IL-12, augmented by IFNγ-secreting lymphocytes (especially CD4+ T cells).

Fig. 1

The immune response to mycobacterial infection and known sites of dysfunction. Human genetic syndromes which affect the immune response to mycobacterial infection are known to result from disorders in the following genes: ISG15, IL-12B, IL12RB1, IFNGR1, IFNGR2, STAT1, IRF8, ISG-15, GATA2 and NADPH oxidase complex subunit genes such as CYBB. Nontuberculous mycobacteria (A) are phagocytosed (B), triggering release of IL-12 (C), a heterodimeric cytokine formed from the gene products of IL12A and IL12B, which binds a receptor heterodimer (D) of IL-12RB1 and IL-12RB2 on T cells and NK cells. Signalling to the nucleus mediated by TYK2 (E) then results in IFNγ production. IFN gamma binds its receptor (F), a heterodimer of IFNGR1 and IFNGR2, triggering phosphorylation of JAK2, JAK1, and STAT1 (G). The resultant phosphorylated STAT1 molecule homodimerises to form the pSTAT1 complex which translocates to the nucleus and binds the IFN gamma activating sequence. This triggers transcription of interferon stimulated genes (ISG) via IRF8 (H), and increases IL12, TNFα, ISG15 (I), and potentiation of macrophage activation. Activated macrophages demonstrate enhanced phagosome maturation and increased killing of intracellular pathogens, and upregulated antigen presentation, thereby activating Th1-phenotype T cells to proliferate and release further IFNγ. TNFα drives development of granulomas. IRF8 aids differentiation of myeloid progenitors into monocytes, and controls transcriptional responses of mature myeloid cells to interferons (IFNs) and Toll-like receptor (TLR) agonists. NFκB is a rapid-acting transcription factor modulated by NEMO (J) and activated by stimuli including signalling through CD40 (K), TLR (L), reactive oxygen species and TNFα. Activation allows a host of inflammatory and immune responses, including IL12 release. Effective intraphagosomal killing through reactive oxygen species requires an intact NADPH oxidase complex (M). Intact haematopoiesis of monocyte lineages is also required via GATA2 (N)

Increased susceptibility to mycobacterial disease is seen in several human genetic syndromes which result from mutations in critical cytokine pathways affecting IL-12β [8, 9], IL-12Rβ1 [10], IFNγR1 [1113] and IFNγR2 [14]. Mutations in the transcription factor STAT1 [1519] result in failure to respond to signals from type I (IFNα/β), type II (IFNγ) or type III (IFNλ1/2/3) interferons, and bring a dual risk of mycobacterial and viral infections, as can deficiency of tyrosine kinase 2 (TYK2), a janus kinase widely active in cytokine signalling. Loss of mycobacterial infection control in this latter condition is caused by loss of the intracellular signalling cascade triggered by IL-12 and mediated by the interaction of IL-12Rβ1 with TYK2 [20]. Mutations in interferon regulatory factor (IRF)-8 [21] impair production of IL-12 in response to IFNγ. Mutations in interferon-stimulated gene (ISG)-15 [22] also confer susceptibility to NTM: the gene product, interferon-induced 17 kDa protein, is involved in IFNγ production by T and NK cells. In some of these genetic syndromes, mycobacterial infection has been successfully treated with adjunctive interferon administration [2326].

Newly described mutations in RAR-related Orphan Receptor C (RORC) predispose to mycobacterial infection as well as mucocutaneous candidiasis. RORC encodes the RORγ and RORγT isoforms of a transcription factor involved in regulating immune function, cellular differentiation and metabolism. Although susceptibility to candidiasis is due to disturbances in the IL-17 pathway, the increased risk of mycobacterial infection is again via impaired IFNγ responses (in this instance from γδ T cells and CCR6+CXCR3+CD4+ αβ Th1 cells) [27].

Deficiency of nuclear factor‐κB essential modulator (NEMO) results in NTM susceptibility within the diverse phenotype of this X-linked condition, implicating NF-κB signalling and by extrapolation the upstream messenger TNF and/or signalling via Toll-like receptors (TLRs) [28, 29].

Phagocyte defects

Defence against intracellular pathogens such as NTM requires effective intracellular killing by phagocytes including neutrophils, monocytes, macrophages and dendritic cells. In chronic granulomatous disease (CGD), the respiratory burst - critical to phagocyte activation and intracellular killing - is impaired by the lack of functional NADPH oxidase.

A variable proportion of CGD patients (6-57 %, study-dependent) develop local and/or systemic complications following vaccination with bacillus Calmette-Guérin (BCG) [30]. The importance of the macrophage respiratory burst in defence against mycobacteria is highlighted by a mutation resulting in a reactive oxygen species formation defect in macrophages but not neutrophils that is nevertheless still associated with susceptibility to tuberculosis [31].

Intriguingly, although there is evidence from ex vivo experiments that human neutrophils restrict the growth of or kill many NTM species [3234] and that neutrophils contribute to the control of M. avium in mice [3537], there is little to suggest that patients with isolated neutrophil disorders or neutropenia have a specifically increased risk of NTM infection.

Other primary immunodeficiency syndromes

Autosomal dominant deficiency of the transcription factor GATA-2 carries a significant risk of NTM infection [38]. This disorder has a diverse presentation, such that it may be diagnosed at any time from early infancy to old age. Manifestations can vary from the asymptomatic to near-lethal. Typical features include monocytopenia, B and NK cell cytopenias, and myelodysplastic syndrome. Although multiple factors may contribute to NTM susceptibility, including NK cell deficiency and impaired cytokine release [39], the simplest explanation is a deficiency of mononuclear phagocytes [40, 41].

Immunodeficiencies that profoundly affect the number or function of T cells also predispose to NTM infection (as well as many other pathogens). This includes Severe Combined Immune Deficiency (SCID) [42] but also isolated CD4+ T cell deficiency [43], which is associated with both pulmonary and disseminated infection, emphasising the importance of this T cell type.

Some primary immunodeficiencies are not associated with a significantly increased risk, including the antibody-deficiency syndromes, such as Common Variable Immunodeficiency (CVID) [44] and X-linked Agammaglobulinaemia (XLA) [45]. The occasional NTM infections which do occur in such patients are generally associated with significant bronchiectasis - itself an independent risk factor, as described later.

Interferon-γ autoantibodies

Another characterised immune defect affecting host defence against NTM is anti-IFNγ autoantibody formation [46, 47]. A cohort of NTM patients, frequently of Asian origin and over 60 years old, have been demonstrated to produce these antibodies [4850]. Analysis typically demonstrates loss of IFNγ-mediated augmentation of TNFα and STAT1 phosphorylation in whole blood, which normalises when serum is removed, consistent with the presence of inhibitory antibodies against IFNγ [50]. Notably, patients with treatment-refractory disseminated NTM infection and IFNγ autoantibodies have been successfully treated with anti-CD20 (Rituximab) and experienced sustained remission from infection [51, 52].

Autoantibodies against IL-12 are also described, especially in association with thymoma [53]. These may be expected to increase risk of NTM infection, though their clinical significance remains unclear at present. Importantly, autoantibodies including those directed against cytokines, tend to be more prevalent in older adults [54].

Immunological insights from NTM patients and genome-wide associations

Many of the disorders discussed so far represent fundamental defects in key antimycobacterial pathways, and often manifest as disseminated infection in young people. However, older patients with isolated pulmonary NTM (p-NTM) infection may have more subtle abnormalities of the same immunological processes, such as impaired IFNγ (and often TNFα) production [5557] in stimulated whole blood or peripheral blood mononuclear cells. There are also reports of clinical improvement with the administration of IFNγ in patients with pulmonary MAC infections [24, 58].

However, these findings are not consistently replicated: in a prospective cohort study of 63 adults with p-NTM, no significant abnormality of immune function was found in the IL-12/IFNγ axis or numbers of lymphocyte subsets [59]. Studies of other cytokines in NTM disease including TGF-β, IL10, IL-17, and IL-18 reveal a differential balance relative to controls [60, 61]. This may indicate that multiple subtle immunological abnormalities co-exist in some patients that together increase overall risk. In another example of this, a recent report found an increased frequency of potentially significant polymorphisms in immune system genes (including IRF8 and STAT1) among NTM patients compared with their relatives or healthy controls [62]. One gene where polymorphisms are enhanced in NTM is NRAMP1, whose product improves resistance to intracellular pathogens by decreasing intraphagosomal iron and increasing production of inducible nitric oxide synthase (iNOS) [63]. Deleterious mutations in such a pathway would be consistent with the core immunological defence against mycobacteria: that is, a requirement for functional mononuclear phagocytes (especially macrophages) to kill mycobacteria, functional CD4+ T cells plus intact production of, and response to, IFNγ, IL-12 and TNFα.

Beyond intrinsic defects in host immunity, there are several other risks for NTM infection. These are summarised in the following sections.

Systemic illness

CLINICAL VIGNETTE: A 35-year old patient with significant graft-versus-host disease, eight weeks after unrelated-donor stem cell transplant for acute myeloid leukaemia, presents with fevers and malaise. Blood cultures from an indwelling central venous catheter are positive for M.fortuitum.

A number of systemic illnesses increase the likelihood of NTM infection. This association can generally be understood in terms of the key immune responses describe above. For example, there is a clear and long-established relationship between disseminated NTM infection (especially M.avium/intracellulare) and HIV-1-seropositivity, with the risk increasing sharply when the CD4+ T cell count falls below 50/mm3 [64]. There is also an increased risk of isolated pulmonary disease, especially with M.kansasii [65], whose pathogenicity and clinical manifestations more closely resemble tuberculosis than other NTMs. Again, the CD4+ T cell count is usually low [66].

Recipients of solid organ transplants are particularly vulnerable to NTM, consistent with their broad disease-related and iatrogenic immunosuppression [6770]. Similarly, stem cell transplant recipients, who have a profound deficiency of all lymphoid and myeloid cell types, are at significantly increased risk of NTM infection. This includes rapid-growing species which can cause central catheter infections [71]. Notably, the majority of infections probably occur outside periods of neutropenia [72], again confirming relative redundancy of neutrophils in NTM defence.

Other diseases, for example rheumatoid arthritis, are associated with heightened risk of NTM. This may relate to intrinsic T cell dysfunction [73] but also to the use of immunosuppressive medications, associated lung disease or reduced leptin levels – all discussed below. Diabetes, which is an established risk factor for TB [74] has, curiously, not been implicated in NTM infection to date.

Iatrogenic immunosuppression

Targeted therapies

As described, TNFα is essential for granuloma formation. Correspondingly, there is a significant risk of developing either pulmonary or disseminated NTM infection with anti-TNFα treatment [75]. An analysis of the United States Food and Drugs Administration database of adverse events associated with TNFα inhibitors revealed over 100 confirmed and probable cases of NTM infection in that population. The most common organism was Mycobacterium avium, and 44 % of cases demonstrated extrapulmonary disease [76].

Other biologic and newer small molecule synthetic therapies are less well studied, but theoretical risks – based on their impact versus the key NTM defences detailed above – are discussed in Box 2 and Table 1. Those agents with high associated risk (++ or +++) are more likely to predispose to disseminated NTM disease than those with modest or low risk, although concomitant immunocompromise from underlying conditions or adjunctive treatments would compound the effect of any agent. All implicated therapies may predispose to pulmonary infection, especially in patients with structural lung disorders. Current best practice for clinicians considering prescribing biologic immunosuppressive agents is to carry out a screen for latent TB prior to initiating therapy. We suggest that consideration should also be given to detecting NTM infection (via sputum culture) prior to treatment with high-risk molecules, especially in patients with underlying pulmonary disease.

Table 1 Potential effects of targeted small molecule/monoclonal agents on risk of NTM Infection

Broadly acting immunosuppressive agents

Within the adult NTM disease patient population there is a considerable burden of chronic respiratory disease (discussed below). Inhaled and oral steroids are frequently used for treatment of many of these conditions, and a corresponding increased susceptibility to disease is found. In a Danish population-based study of respiratory disease, use of inhaled corticosteroids in COPD increased the odds ratio for p-NTM disease from 7.6 to 19.6, and a dose-risk response was noted with increasing doses [77]. A relationship with steroids and rising NTM disease risk is also seen in the treatment of rheumatoid arthritis [78] and asthma [79].

NTM disease has been associated with immunosuppressive medications such as azathioprine, cyclophosphamide, mycophenolate and cyclosporine, as well as with anti-TNFα agents [78]. Again, clinicians should consider screening for NTM before starting these drugs and remain vigilant for infection and disease during treatment.

Structural lung disease

CLINICAL VIGNETTE: A 76 male smoker with known COPD was investigated for new changes on his chest radiograph associated with increased sputum and a gradual reduction in his exercise capacity. He had not responded to several short courses of antibacterials. Sputum cultures isolated M. xenopi with no initial evidence for underlying lung neoplasia.

Discussion thus far has focussed on immunological defences against NTM infection, but it is clear that the physical barriers integral to healthy lungs are also critical. In p-NTM disease case series, chronic respiratory diseases such as bronchiectasis and COPD are common associations. Equally, NTM prevalence in bronchiectasis is high [80] - estimated at 9.3 % according to a recent meta-analysis [81]. Given that lung damage, such as cavitation or bronchiectasis, is often regarded as an integral component of p-NTM disease diagnosis [5], it can be difficult to determine whether lung structural changes predispose to, or arise as a consequence of, p-NTM disease. Although non-CF bronchiectasis is a diverse entity with multiple aetiologies, a unifying patho-mechanism is provided by Cole’s vicious cycle model [82] where local pulmonary damage results in non-clearing infection that leads to an excessive inflammatory response, with consequent further lung damage (dilatation and destruction, i.e. bronchiectasis) and more infection.

The complexity of predisposition to p-NTM disease is demonstrated by a whole-exome sequencing study of 69 immunocompetent p-NTM disease patients and 18 unaffected family members. This revealed that patients with p-NTM have more low-frequency, protein-affecting variants in immune, cystic fibrosis transmembrane conductance regulator (CFTR), cilia, and connective tissue genes than their unaffected family members and control subjects [62], demonstrating the complexity of predisposition to NTM disease.

Chronic obstructive pulmonary disease

COPD is a chronic, progressive lung disease characterised by airflow limitation with poor reversibility. Lung injury, triggered most often by smoking, causes inflammation, tissue destruction and remodelling of elastin and collagen, with occlusion of small airways by narrowing, obliteration and mucus plugs [83], The heightened susceptibility to infection was demonstrated in a prospective cohort of COPD exacerbations where 22 % of subjects were culture-positive for NTM [84]. The extent to which NTM infection itself may promote COPD has been investigated, and might partly explain the apparent high frequency of reported mycobacterial isolation [85]. Both bronchiectasis and COPD are characterised by neutrophilic inflammation [86, 87]. As described previously, this cell type is probably not central to NTM defence, but instead can cause host damage via the release of cytotoxic contents and thereby further compromise physical barriers to infection.

Cystic fibrosis

Specific mutations in the CFTR gene, most commonly the delta-F508 mutation, lead to defective function of the cyclic-AMP stimulated chloride channel in the membrane of epithelial cells and the clinical disease of cystic fibrosis (CF). Homozygosity for these mutations results in disordered sodium and chloride transport across the epithelium with thickened respiratory secretions. The heightened risk of pulmonary infection is well established, and has a complex aetiology ranging from impaired mucociliary function and viscous, inspissated secretions, to compromise of many immunological defences [88].

The predisposition to NTM infection is striking: CF respiratory cultures exhibit a 10,000 fold greater prevalence of NTM than the general population, with the most common being Mycobacterium avium complex (MAC) and M. abscessus [89]. The importance of studying this population is highlighted by the reported transmissibility of M. abscessus from patient to patient [90]. The implication of this for people at high risk of NTM disease using healthcare services with other NTM patients is considerable. Importantly, there are an increasing number of reported CFTR polymorphisms that do not result in frank CF but nonetheless may predispose to bronchiectasis and NTM infection [62, 9193].

Other associations with structural lung disease are summarised in Box 3. In all of these cases, it remains difficult to determine how much of the NTM colonisation, infection and disease relate to anatomical changes and secretions that are hard to clear, and how much to associated dysregulated immune and inflammatory responses.

Other host traits as risk factors for NTM infection

Aging appears to increase susceptibility to p-NTM disease (the mean age at presentation in a US study was 68.2 years [94]). Age greater than 65 is also associated with worse outcomes (hazard ratio for death 9.17, 95 % confidence interval 4.98-16.86 [95]). Whilst this may simply reflect the fact that predisposing factors for NTM infection, such as structural lung disease, are more common with age, immunosenescence [9699] affecting key host defences (especially T cell function) may also be important.

Many p-NTM prevalence studies reveal a greater number of female than male patients [2, 59, 100]; females with non-CF bronchiectasis seem to be at particularly high risk [80]. A possible explanation may be the lower levels of oestrogen in post-menopausal females, as experiments in ovariectomised mice show that oestrogen enhances the clearance of MAC [101], albeit human data are inconclusive [102, 103].

Low body mass index (BMI) appears to be a risk factor for NTM infection, with a protective effect seen at higher BMIs [55, 104, 105]. Lower levels of subcutaneous fat are present in p-NTM patients compared to controls [106]. It has been suggested that the adipokines leptin and adiponectin may be responsible. Leptin, a hormone expressed by white fat cells and whose levels positively correlate with body fat, regulates satiety but also has immunomodulatory effects such as driving T cell differentiation towards a Th1 IFNγ-producing phenotype, enhancing phagocyte function and increasing TNF and IL-12 secretion [55]. Leptin deficient mice (ob/ob) mice have delayed clearance of Mycobacterium abscessus lung infection compared to wild-type mice [107]. Conversely, adiponectin is a protein that has a role in fatty acid oxidation and inversely correlates with body fat; this adipokine has immunosuppressive effects on Th1 responses [104].

P-NTM disease has been reported in a patient group characterised by greater than average height, thoracic skeletal abnormalities and mitral valve prolapse [59]. The evidence that this is related to an underlying connective tissue disorder is currently limited [108]. However, abnormalities of the thoracic skeleton such as scoliosis and pectus excavatum do appear to be more common than in patients with TB or the general population [105, 109].

Severe vitamin D deficiency appears to be associated with p-NTM disease [110], although the mechanism remains less clear than for M.tuberculosis [111].


NTM are increasingly isolated from respiratory secretions, and this appears to reflect a rise in true disease. Analysis of immune function and host phenotype reveals the fundamental mechanisms of successful host defence against NTM. These are an intact IFNγ-IL-12 axis, effective phagocytosis and intracellular killing, adequate monocyte haemopoiesis and circulating CD4+ T cell numbers, plus an undamaged pulmonary epithelium with effective clearance of secretions. Most NTM lung disease occurs in older patients. At our current level of knowledge, the largest patient population, i.e. people with isolated lung disease, appear to have minimal evidence for clear-cut, underlying immune defects. However, a small but important group will have demonstrable and relevant alterations in their ability to control NTM infection. Furthermore, subtle immune perturbations may combine with lung damage to increase the overall risk of NTM infection and disease.

Figure 2 summarises the elements described in this article. Many of these risks are predictable and modifiable: clinicians and patients alike should strive to avoid NTM infection as its treatment is prolonged and associated with considerable morbidity [5].

Fig. 2

Systemic factors predisposing to NTM disease. Apparently ‘immunocompetent’ individuals may have an elevated risk of NTM disease due to structural lung disease or specific host features such as advanced age, female gender or polymorphisms of immune, cilia, connective tissue or CFTR genes. Immunocompromise causing susceptibility to NTM disease can be caused by primary immune deficiency, drugs targeting the immune system such as anti-TNFα reagents, or systemic disease

The degree to which investigations are performed to identify these risks depends on the patient’s clinical features and resources available. Figure 3 lists our advice for the investigation of adult patients presenting with NTM infection. Children or anyone presenting with apparently unexplained disseminated infection should be referred to a clinical immunologist and undergo whole exome sequencing if no defined susceptibility is identified; the pathway for investigating early-onset MSMD conditions has been described elsewhere [69].

Fig. 3

Flowchart for investigation of adult patients presenting with NTM disease

All adult patients should be offered HIV testing and assessed for underlying disease leading to immune compromise. A careful drug history should include biologics or other therapies whose most recent administration may have been weeks or months previously. Vitamin D deficency is an easily reversible risk factor.

Clinicians should be aware in particular of the haematological characteristics of GATA-2 deficiency (monocytopenia, NK and B cell cytopenias), due to its protean manifestations and wide range of age at first presentation. Lymphocyte subsets help to identify this pattern as well as idiopathic CD4 lymphopenia.

In pulmonary infection, the wide availability of high resolution CT lung scanning at an acceptable radiation dosage means that this is now an important component of p-NTM work-up. Lung function tests will help to identify COPD in patients without a pre-existing diagnosis, and also serve as a baseline for future management. We advocate testing immunoglobulins in patients with bronchiectasis to exclude an immunological basis for the structural lung disease, even though hypogammaglobulinemia is not a particular risk for NTM infection itself. Patients with significant bronchiectasis should be investigated for underlying CF.

If no abnormalities are identified via these tests then we advocate assessing for response to, and release of, IFNγ and IL-12. Defects in these pathways can present clinically at a later age, and the tests can inform whether IFNγ may be a treatment adjunct worth considering. Anti-cytokine antibodies are more common in older patients and should be measured; if present, consideration may be given to immunomodulatory therapy (i.e. rituximab). T cell proliferation and assays for CGD should be considered if there is a compatible history, especially of other opportunistic infections.



bacillus Calmette-Guérin


chronic granulomatous disease


cystic fibrosis transmembrane conductance regulator


Common Variable Immunodeficiency




human immunodeficiency virus


interferon gamma




Mycobacterium avium complex




nuclear factor‐κB essential modulator

NK cells:

natural killer cells


nontuberculous mycobacteria


primary immune deficiency


pulmonary nontuberculous mycobacteria


RAR-related Orphan Receptor C


Severe Combined Immune Deficiency




tumour necrosis factor alpha


X-linked Agammaglobulinaemia


  1. 1.

    Chetchotisakd P, Kiertiburanakul S, Mootsikapun P, Assanasen S, Chaiwarith R, Anunnatsiri S. Disseminated nontuberculous mycobacterial infection in patients who are not infected with HIV in Thailand. Clin Infect Dis. 2007;45:421–7.

    PubMed  Article  Google Scholar 

  2. 2.

    Prevots DR, Shaw PA, Strickland D, Jackson LA, Raebel MA, Blosky MA, et al. Nontuberculous mycobacterial lung disease prevalence at four integrated health care delivery systems. Am J Respir Crit Care Med. 2010;182:970–6.

    PubMed  PubMed Central  Article  Google Scholar 

  3. 3.

    Adjemian J, Olivier KN, Seitz AE, Holland SM, Prevots DR. Prevalence of nontuberculous mycobacterial lung disease in U.S. Medicare beneficiaries. Am J Respir Crit Care Med. 2012;185:881–6.

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Shah N, Davidson J, Anderson L, Lalor M, Kim J, Thomas H, et al. BMC Infectious Diseases Pulmonary Mycobacterium avium-intracellulare is the main driver of the rise in non-tuberculous mycobacteria incidence in England, Wales and Northern Ireland, 2007–2012. BMC Infect Dis. 2016. In Press.

  5. 5.

    Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175:367–416.

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Satta G, McHugh TD, Mountford J, Abubakar I, Lipman M. Managing pulmonary nontuberculous mycobacterial infection: Time for a patient-centered approach. Ann Am Thorac Soc. 2014;11:117–21.

    PubMed  PubMed Central  Article  Google Scholar 

  7. 7.

    Casanova JL, Blanche S, Emile JF, Jouanguy E, Lamhamedi S, Altare F, et al. Idiopathic disseminated bacillus Calmette-Guérin infection: a French national retrospective study. Pediatrics. 1996;98(4 Pt 1):774–8.

    CAS  PubMed  Google Scholar 

  8. 8.

    Prando C, Samarina A, Bustamante J, Boisson-Dupuis S, Cobat A, Picard C, et al. Inherited IL-12p40 deficiency: genetic, immunologic, and clinical features of 49 patients from 30 kindreds. Medicine (Baltimore). 2013;92:109–22.

    CAS  Article  Google Scholar 

  9. 9.

    Picard C, Fieschi C, Altare F, Al-Jumaah S, Al-Hajjar S, Feinberg J, et al. Inherited interleukin-12 deficiency: IL12B genotype and clinical phenotype of 13 patients from six kindreds. Am J Hum Genet. 2002;70:336–48.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Fieschi C, Dupuis S, Catherinot E, Feinberg J, Bustamante J, Breiman A, et al. Low penetrance, broad resistance, and favorable outcome of interleukin 12 receptor beta1 deficiency: medical and immunological implications. J Exp Med. 2003;197:527–35.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  11. 11.

    Newport MJ, Huxley CM, Huston S, Hawrylowicz CM, Oostra BA, Williamson R, et al. A mutation in the interferon-gamma-receptor gene and susceptibility to mycobacterial infection. N Engl J Med. 1996;335:1941–9.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Jouanguy E, Dupuis S, Pallier A, Döffinger R, Fondanèche MC, Fieschi C, et al. In a novel form of IFN-gamma receptor 1 deficiency, cell surface receptors fail to bind IFN-gamma. J Clin Invest. 2000;105:1429–36.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Holland SM, Dorman SE, Kwon A, Pitha-Rowe IF, Frucht DM, Gerstberger SM, et al. Abnormal regulation of interferon-gamma, interleukin-12, and tumor necrosis factor-alpha in human interferon-gamma receptor 1 deficiency. J Infect Dis. 1998;178:1095–104.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Dorman SE, Holland SM. Mutation in the signal-transducing chain of the interferon-gamma receptor and susceptibility to mycobacterial infection. J Clin Invest. 1998;101:2364–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  15. 15.

    Dupuis S, Dargemont C, Fieschi C, Thomassin N, Rosenzweig S, Harris J, et al. Impairment of mycobacterial but not viral immunity by a germline human STAT1 mutation. Science. 2001;293:300–3.

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    Chapgier A, Kong X-F, Boisson-Dupuis S, Jouanguy E, Averbuch D, Feinberg J, et al. A partial form of recessive STAT1 deficiency in humans. J Clin Invest. 2009;119:1502–14.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Sampaio EP, Bax HI, Hsu AP, Kristosturyan E, Pechacek J, Chandrasekaran P, et al. A novel STAT1 mutation associated with disseminated mycobacterial disease. J Clin Immunol. 2012;32:681–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Averbuch D, Chapgier A, Boisson-Dupuis S, Casanova J-L, Engelhard D. The clinical spectrum of patients with deficiency of Signal Transducer and Activator of Transcription-1. Pediatr Infect Dis J. 2011;30:352–5.

    PubMed  Article  Google Scholar 

  19. 19.

    Chapgier A, Boisson-Dupuis S, Jouanguy E, Vogt G, Feinberg J, Prochnicka-Chalufour A, et al. Novel STAT1 alleles in otherwise healthy patients with mycobacterial disease. PLoS Genet. 2006;2, e131.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  20. 20.

    Kreins AY, Ciancanelli MJ, Okada S, Kong X-F, Ramírez-Alejo N, Kilic SS, et al. Human TYK2 deficiency: Mycobacterial and viral infections without hyper-IgE syndrome. J Exp Med. 2015;212:1641–62.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  21. 21.

    Hambleton S, Salem S, Bustamante J, Bigley V, Boisson-Dupuis S, Azevedo J, et al. IRF8 mutations and human dendritic-cell immunodeficiency. N Engl J Med. 2011;365:127–38.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Bogunovic D, Byun M, Durfee LA, Abhyankar A, Sanal O, Mansouri D, et al. Mycobacterial disease and impaired IFN-γ immunity in humans with inherited ISG15 deficiency. Science. 2012;337:1684–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Takeda K, Kawai T, Nakazawa Y, Komuro H, Shoji K, Morita K, et al. Augmentation of antitubercular therapy with IFNγ in a patient with dominant partial IFNγ receptor 1 deficiency. Clin Immunol. 2014;151:25–8.

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    Hallstrand TS, Ochs HD, Zhu Q, Liles WC. Inhaled IFN-gamma for persistent nontuberculous mycobacterial pulmonary disease due to functional IFN-gamma deficiency. Eur Respir J. 2004;24:367–70.

    CAS  PubMed  Article  Google Scholar 

  25. 25.

    Bax HI, Freeman AF, Ding L, Hsu AP, Marciano B, Kristosturyan E, et al. Interferon alpha treatment of patients with impaired interferon gamma signaling. J Clin Immunol. 2013;33:991–1001.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Ward CM, Jyonouchi H, Kotenko SV, Smirnov SV, Patel R, Aguila H, et al. Adjunctive treatment of disseminated Mycobacterium avium complex infection with interferon alpha-2b in a patient with complete interferon-gamma receptor R1 deficiency. Eur J Pediatr. 2007;166:981–5.

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Okada S, Markle JG, Deenick EK, Mele F, Averbuch D, Lagos M, et al. Impairment of immunity to Candida and Mycobacterium in humans with bi-allelic RORC mutations. Science (80-). 2015;349:606–13.

    CAS  Article  Google Scholar 

  28. 28.

    Nedorost ST, Elewski B, Tomford JW, Camisa C. Rosacea-like lesions due to familial Mycobacterium avium-intracellulare infection. Int J Dermatol. 1991;30:491–7.

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Filipe-Santos O, Bustamante J, Haverkamp MH, Vinolo E, Ku C-L, Puel A, et al. X-linked susceptibility to mycobacteria is caused by mutations in NEMO impairing CD40-dependent IL-12 production. J Exp Med. 2006;203:1745–59.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  30. 30.

    Deffert C, Cachat J, Krause K-H. Phagocyte NADPH oxidase, chronic granulomatous disease and mycobacterial infections. Cell Microbiol. 2014;16:1168–78.

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Bustamante J, Arias AA, Vogt G, Picard C, Galicia LB, Prando C, et al. Germline CYBB mutations that selectively affect macrophages in kindreds with X-linked predisposition to tuberculous mycobacterial disease. Nat Immunol. 2011;12:213–21.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Nibbering PH, Pos O, Stevenhagen A, Van Furth R. Interleukin-8 enhances nonoxidative intracellular killing of Mycobacterium fortuitum by human granulocytes. Infect Immun. 1993;61:3111–6.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Newman GW, Guarnaccia JR, Remold HG, Kazanjian PH. Cytokines enhance neutrophils from human immunodeficiency virus-negative donors and AIDS patients to inhibit the growth of Mycobacterium avium in vitro. J Infect Dis. 1997;175:891–900.

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Hartmann P, Becker R, Franzen C, Schell-Frederick E, Römer J, Jacobs M, et al. Phagocytosis and killing of Mycobacterium avium complex by human neutrophils. J Leukoc Biol. 2001;69:397–404.

    CAS  PubMed  Google Scholar 

  35. 35.

    Appelberg R, Castro AG, Gomes S, Pedrosa J, Silva MT. Susceptibility of beige mice to Mycobacterium avium: role of neutrophils. Infect Immun. 1995;63:3381–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Bermudez LE, Petrofsky M, Stevens P. Treatment with recombinant granulocyte colony-stimulating factor (Filgrastin) stimulates neutrophils and tissue macrophages and induces an effective non-specific response against Mycobacterium avium in mice. Immunology. 1998;94:297–303.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  37. 37.

    Petrofsky M, Bermudez LE. Neutrophils from Mycobacterium avium-infected mice produce TNF-alpha, IL-12, and IL-1 beta and have a putative role in early host response. Clin Immunol. 1999;91:354–8.

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Hsu AP, Sampaio EP, Khan J, Calvo KR, Lemieux JE, Patel SY, et al. Mutations in GATA2 are associated with the autosomal dominant and sporadic monocytopenia and mycobacterial infection (MonoMAC) syndrome. Blood. 2011;118:2653–5.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Dickinson RE, Milne P, Jardine L, Zandi S, Swierczek SI, McGovern N, et al. The evolution of cellular deficiency in GATA2 mutation. Blood. 2014;123:863–74.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  40. 40.

    Spinner MA, Sanchez LA, Hsu AP, Shaw PA, Zerbe CS, Calvo KR, et al. GATA2 deficiency: a protean disorder of hematopoiesis, lymphatics, and immunity. Blood. 2014;123:809–21.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  41. 41.

    Collin M, Dickinson R, Bigley V. Haematopoietic and immune defects associated with GATA2 mutation. Br J Haematol. 2015;169:173–87.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  42. 42.

    Marciano BE, Huang C-Y, Joshi G, Rezaei N, Carvalho BC, Allwood Z, et al. BCG vaccination in patients with severe combined immunodeficiency: complications, risks, and vaccination policies. J Allergy Clin Immunol. 2014;133:1134–41.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Ahmad DS, Esmadi M, Steinmann WC. Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases. Avicenna J Med. 2013;3:37–47.

    PubMed  PubMed Central  Article  Google Scholar 

  44. 44.

    Oksenhendler E, Gérard L, Fieschi C, Malphettes M, Mouillot G, Jaussaud R, et al. Infections in 252 patients with common variable immunodeficiency. Clin Infect Dis. 2008;46:1547–54.

    PubMed  Article  Google Scholar 

  45. 45.

    Winkelstein JA, Marino MC, Lederman HM, Jones SM, Sullivan K, Burks AW, et al. X-linked agammaglobulinemia: report on a United States registry of 201 patients. Medicine (Baltimore). 2006;85:193–202.

    Article  Google Scholar 

  46. 46.

    Höflich C, Sabat R, Rosseau S, Temmesfeld B, Slevogt H, Döcke W-D, et al. Naturally occurring anti-IFN-gamma autoantibody and severe infections with Mycobacterium cheloneae and Burkholderia cocovenenans. Blood. 2004;103:673–5.

    PubMed  Article  CAS  Google Scholar 

  47. 47.

    Döffinger R, Helbert MR, Barcenas-Morales G, Yang K, Dupuis S, Ceron-Gutierrez L, et al. Autoantibodies to interferon-gamma in a patient with selective susceptibility to mycobacterial infection and organ-specific autoimmunity. Clin Infect Dis. 2004;38:e10–4.

    PubMed  Article  Google Scholar 

  48. 48.

    Browne SK. Anticytokine autoantibody-associated immunodeficiency. Annu Rev Immunol. 2014;32:635–57.

    CAS  PubMed  Article  Google Scholar 

  49. 49.

    Otome O, O’Reilly M, Lim L. Disseminated Mycobacterium haemophilum skeletal disease in a patient with interferon-gamma deficiency. Intern Med J. 2015;45:1073–6.

    CAS  PubMed  Article  Google Scholar 

  50. 50.

    Browne SK, Burbelo PD, Chetchotisakd P, Suputtamongkol Y, Kiertiburanakul S, Shaw PA, et al. Adult-onset immunodeficiency in Thailand and Taiwan. N Engl J Med. 2012;367:725–34.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  51. 51.

    Czaja CA, Merkel PA, Chan ED, Lenz LL, Wolf ML, Alam R, et al. Rituximab as successful adjunct treatment in a patient with disseminated nontuberculous mycobacterial infection due to acquired anti-interferon-γ autoantibody. Clin Infect Dis. 2014;58:e115–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  52. 52.

    Browne SK, Zaman R, Sampaio EP, Jutivorakool K, Rosen LB, Ding L, et al. Anti-CD20 (rituximab) therapy for anti-IFN-γ autoantibody-associated nontuberculous mycobacterial infection. Blood. 2012;119:3933–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  53. 53.

    Meager A, Vincent A, Newsom-Davis J, Willcox N. Spontaneous neutralising antibodies to interferon--alpha and interleukin-12 in thymoma-associated autoimmune disease. Lancet (London, England). 1997;350:1596–7.

    CAS  Article  Google Scholar 

  54. 54.

    Moulias R, Proust J, Wang A, Congy F, Marescot MR, Deville Chabrolle A, et al. Age-related increase in autoantibodies. Lancet (London, England). 1984;1:1128–9.

    CAS  Article  Google Scholar 

  55. 55.

    Kartalija M, Ovrutsky AR, Bryan CL, Pott GB, Fantuzzi G, Thomas J, et al. Patients with nontuberculous mycobacterial lung disease exhibit unique body and immune phenotypes. Am J Respir Crit Care Med. 2013;187:197–205.

    PubMed  Article  Google Scholar 

  56. 56.

    Greinert U, Schlaak M, Rũsch-Gerdes S, Flad H-D, Ernst M. Low In Vitro Production of Interferon-γ and Tumor Necrosis Factor-α in HIV-Seronegative Patients with Pulmonary Disease Caused by Nontuberculous Mycobacteria. J Clin Immunol. 2000;20:445–52.

    CAS  PubMed  Article  Google Scholar 

  57. 57.

    Kwon YS, Kim EJ, Lee S-H, Suh GY, Chung MP, Kim H, et al. Decreased cytokine production in patients with nontuberculous mycobacterial lung disease. Lung. 2007;185:337–41.

    CAS  PubMed  Article  Google Scholar 

  58. 58.

    Milanés-Virelles MT, García-García I, Santos-Herrera Y, Valdés-Quintana M, Valenzuela-Silva CM, Jiménez-Madrigal G, et al. Adjuvant interferon gamma in patients with pulmonary atypical Mycobacteriosis: a randomized, double-blind, placebo-controlled study. BMC Infect Dis. 2008;8:17.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  59. 59.

    Kim RD, Greenberg DE, Ehrmantraut ME, Guide SV, Ding L, Shea Y, et al. Pulmonary nontuberculous mycobacterial disease: prospective study of a distinct preexisting syndrome. Am J Respir Crit Care Med. 2008;178:1066–74.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  60. 60.

    Lim A, Allison C, Price P, Waterer G. Susceptibility to pulmonary disease due to Mycobacterium avium-intracellulare complex may reflect low IL-17 and high IL-10 responses rather than Th1 deficiency. Clin Immunol. 2010;137:296–302.

    CAS  PubMed  Article  Google Scholar 

  61. 61.

    Lim A, Allison C, Tan DBA, Oliver B, Price P, Waterer G. Immunological markers of lung disease due to non-tuberculous mycobacteria. Dis Markers. 2010;29:103–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  62. 62.

    Szymanski EP, Leung JM, Fowler CJ, Haney C, Hsu AP, Chen F, et al. Pulmonary Nontuberculous Mycobacterial Infection. A Multisystem, Multigenic Disease. Am J Respir Crit Care Med. 2015;192:618–28.

    PubMed  Article  Google Scholar 

  63. 63.

    Koh W-J, Kwon OJ, Kim EJ, Lee KS, Ki C-S, Kim JW. NRAMP1 gene polymorphism and susceptibility to nontuberculous mycobacterial lung diseases. Chest. 2005;128:94–101.

    CAS  PubMed  Article  Google Scholar 

  64. 64.

    Horsburgh CR. Mycobacterium avium complex infection in the acquired immunodeficiency syndrome. N Engl J Med. 1991;324:1332–8.

    PubMed  Article  Google Scholar 

  65. 65.

    Bloch KC, Zwerling L, Pletcher MJ, Hahn JA, Gerberding JL, Ostroff SM, et al. Incidence and clinical implications of isolation of Mycobacterium kansasii: results of a 5-year, population-based study. Ann Intern Med. 1998;129:698–704.

    CAS  PubMed  Article  Google Scholar 

  66. 66.

    Campo RE, Campo CE. Mycobacterium kansasii disease in patients infected with human immunodeficiency virus. Clin Infect Dis. 1997;24:1233–8.

    CAS  PubMed  Article  Google Scholar 

  67. 67.

    Meije Y, Piersimoni C, Torre-Cisneros J, Dilektasli AG, Aguado JM. Mycobacterial infections in solid organ transplant recipients. Clin Microbiol Infect. 2014;20 Suppl 7:89–101.

    PubMed  Article  Google Scholar 

  68. 68.

    Piersimoni C. Nontuberculous mycobacteria infection in solid organ transplant recipients. Eur J Clin Microbiol Infect Dis. 2012;31:397–403.

    CAS  PubMed  Article  Google Scholar 

  69. 69.

    Wu U-I, Holland SM. Host susceptibility to non-tuberculous mycobacterial infections. Lancet Infect Dis. 2015;15.

  70. 70.

    Ho TA, Rommelaere M, Coche E, Yombi J-C, Kanaan N. Nontuberculous mycobacterial pulmonary infection in renal transplant recipients. Transpl Infect Dis. 2010;12:138–42.

    CAS  PubMed  Article  Google Scholar 

  71. 71.

    Al-Anazi KA, Al-Jasser AM, Al-Anazi WK. Infections caused by non-tuberculous mycobacteria in recipients of hematopoietic stem cell transplantation. Front Oncol. 2014;4:311.

    PubMed  PubMed Central  Google Scholar 

  72. 72.

    Gaviria JM, Garcia PJ, Garrido SM, Corey L, Boeckh M. Nontuberculous mycobacterial infections in hematopoietic stem cell transplant recipients: characteristics of respiratory and catheter-related infections. Biol Blood Marrow Transplant. 2000;6:361–9.

    CAS  PubMed  Article  Google Scholar 

  73. 73.

    Koetz K, Bryl E, Spickschen K, O’Fallon WM, Goronzy JJ, Weyand CM. T cell homeostasis in patients with rheumatoid arthritis. Proc Natl Acad Sci. 2000;97:9203–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  74. 74.

    Hodgson K, Morris J, Bridson T, Govan B, Rush C, Ketheesan N. Immunological mechanisms contributing to the double burden of diabetes and intracellular bacterial infections. Immunology. 2015;144:171–85.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  75. 75.

    Winthrop KL, Baxter R, Liu L, Varley CD, Curtis JR, Baddley JW, et al. Mycobacterial diseases and antitumour necrosis factor therapy in USA. Ann Rheum Dis. 2013;72:37–42.

    CAS  PubMed  Article  Google Scholar 

  76. 76.

    Winthrop KL, Chang E, Yamashita S, Iademarco MF, LoBue PA. Nontuberculous Mycobacteria Infections and Anti–Tumor Necrosis Factor-α Therapy. Emerg Infect Dis. 2009;15:1556–61.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  77. 77.

    Andrejak C, Nielsen R, Thomsen VO, Duhaut P, Sorensen HT, Thomsen RW. Chronic respiratory disease, inhaled corticosteroids and risk of non-tuberculous mycobacteriosis. Thorax. 2012;68:256–62.

    PubMed  Article  Google Scholar 

  78. 78.

    Brode SK, Jamieson FB, Ng R, Campitelli MA, Kwong JC, Paterson JM, Li P, et al. Increased risk of mycobacterial infections associated with anti-rheumatic medications. Thorax. 2015;70:677–82.

    PubMed  Article  Google Scholar 

  79. 79.

    Hojo M, Iikura M, Hirano S, Sugiyama H, Kobayashi N, Kudo K. Increased risk of nontuberculous mycobacterial infection in asthmatic patients using long-term inhaled corticosteroid therapy. Respirology. 2012;17:185–90.

    PubMed  Article  Google Scholar 

  80. 80.

    Mirsaeidi M, Hadid W, Ericsoussi B, Rodgers D, Sadikot RT. Non-tuberculous mycobacterial disease is common in patients with non-cystic fibrosis bronchiectasis. Int J Infect Dis. 2013;17:e1000–4.

    PubMed  PubMed Central  Article  Google Scholar 

  81. 81.

    Chu H, Zhao L, Xiao H, Zhang Z, Zhang J, Gui T, et al. Prevalence of nontuberculous mycobacteria in patients with bronchiectasis: a meta-analysis. Arch Med Sci. 2014;10:661–8.

    PubMed  PubMed Central  Article  Google Scholar 

  82. 82.

    Cole PJ. Inflammation: a two-edged sword--the model of bronchiectasis. Eur J Respir Dis Suppl. 1986;147:6–15.

    CAS  PubMed  Google Scholar 

  83. 83.

    Ojo O, Lagan AL, Rajendran V, Spanjer A, Chen L, Sohal SS, et al. Pathological changes in the COPD lung mesenchyme - Novel lessons learned from in??vitro and in??vivo studies. Pulm Pharmacol Ther. 2014;29(April):1–8.

    Google Scholar 

  84. 84.

    Hoefsloot W, van Ingen J, Magis-Escurra C, Reijers MH, van Soolingen D, Dekhuijzen RPN, et al. Prevalence of nontuberculous mycobacteria in COPD patients with exacerbations. J Infect. 2013;66:542–5.

    PubMed  Article  Google Scholar 

  85. 85.

    Yeh J-J, Wang Y-C, Sung F-C, Chou CY-T, Kao C-H. Nontuberculosis Mycobacterium Disease is a Risk Factor for Chronic Obstructive Pulmonary Disease: A Nationwide Cohort Study. Lung. 2014;192:403–11.

    PubMed  Article  Google Scholar 

  86. 86.

    McDonnell MJ, Ward C, Lordan JL, Rutherford RM. Non-cystic fibrosis bronchiectasis. QJM. 2013;106:709–15.

    CAS  PubMed  Article  Google Scholar 

  87. 87.

    Hassett DJ, Borchers MT, Panos RJ. Chronic obstructive pulmonary disease (COPD): Evaluation from clinical, immunological and bacterial pathogenesis perspectives. J Microbiol. 2014;52:211–26.

    PubMed  Article  Google Scholar 

  88. 88.

    Tang AC, Turvey SE, Alves MP, Regamey N, Tümmler B, Hartl D. Current concepts: host-pathogen interactions in cystic fibrosis airways disease. Eur Respir Rev. 2014;23:320–32.

    PubMed  Article  Google Scholar 

  89. 89.

    Martiniano SL, Nick JA. Nontuberculous mycobacterial infections in cystic fibrosis. Clin Chest Med. 2015;36:101–15.

    PubMed  Article  Google Scholar 

  90. 90.

    Bryant JM, Grogono DM, Greaves D, Foweraker J, Roddick I, Inns T, et al. Whole-genome sequencing to identify transmission of Mycobacterium abscessus between patients with cystic fibrosis: a retrospective cohort study. Lancet (London, England). 2013;381:1551–60.

    CAS  Article  Google Scholar 

  91. 91.

    Ziedalski TM. Prospective Analysis of Cystic Fibrosis Transmembrane Regulator Mutations in Adults With Bronchiectasis or Pulmonary Nontuberculous Mycobacterial Infection. CHEST J. 2006;130:995.

    Article  Google Scholar 

  92. 92.

    Fowler CJ, Olivier KN, Leung JM, Smith CC, Huth AG, Root H, et al. Abnormal nasal nitric oxide production, ciliary beat frequency, and Toll-like receptor response in pulmonary nontuberculous mycobacterial disease epithelium. Am J Respir Crit Care Med. 2013;187:1374–81.

    PubMed  PubMed Central  Article  Google Scholar 

  93. 93.

    Jang M-A, Kim S-Y, Jeong B-H, Park HY, Jeon K, Kim J-W, et al. Association of CFTR gene variants with nontuberculous mycobacterial lung disease in a Korean population with a low prevalence of cystic fibrosis. J Hum Genet. 2013;58:298–303.

    CAS  PubMed  Article  Google Scholar 

  94. 94.

    Prevots DR, Marras TK. Epidemiology of human pulmonary infection with nontuberculous mycobacteria: a review. Clin Chest Med. 2015;36:13–34.

    PubMed  PubMed Central  Article  Google Scholar 

  95. 95.

    Andréjak C, Thomsen VØ, Johansen IS, Riis A, Benfield TL, Duhaut P, et al. Nontuberculous pulmonary mycobacteriosis in Denmark: incidence and prognostic factors. Am J Respir Crit Care Med. 2010;181:514–21.

    PubMed  Article  Google Scholar 

  96. 96.

    Ye P, Kirschner DE. Measuring emigration of human thymocytes by T-cell receptor excision circles. Crit Rev Immunol. 2002;22:483–97.

    CAS  PubMed  Article  Google Scholar 

  97. 97.

    Cicin-Sain L, Messaoudi I, Park B, Currier N, Planer S, Fischer M, et al. Dramatic increase in naive T cell turnover is linked to loss of naive T cells from old primates. Proc Natl Acad Sci U S A. 2007;104:19960–5.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  98. 98.

    Naylor K, Li G, Vallejo AN, Lee W-W, Koetz K, Bryl E, Witkowski J, et al. The influence of age on T cell generation and TCR diversity. J Immunol. 2005;174:7446–52.

    CAS  PubMed  Article  Google Scholar 

  99. 99.

    Nikolich-Zugich J. Ageing and life-long maintenance of T-cell subsets in the face of latent persistent infections. Nat Rev Immunol. 2008;8:512–22.

    CAS  PubMed  Article  Google Scholar 

  100. 100.

    Griffith DE, Girard WM, Wallace RJ. Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients. Am Rev Respir Dis. 1993;147:1271–8.

    CAS  PubMed  Article  Google Scholar 

  101. 101.

    Tsuyuguchi K, Suzuki K, Matsumoto H, Tanaka E, Amitani R, Kuze F. Effect of oestrogen on Mycobacterium avium complex pulmonary infection in mice. Clin Exp Immunol. 2001;123:428–34.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  102. 102.

    Danley J, Kwait R, Peterson DD, Sendecki J, Vaughn B, Nakisbendi K, et al. Normal estrogen, but low dehydroepiandrosterone levels, in women with pulmonary Mycobacterium avium complex. A preliminary study. Ann Am Thorac Soc. 2014;11:908–14.

    CAS  PubMed  Article  Google Scholar 

  103. 103.

    Mirsaeidi M, Sadikot RT. Gender susceptibility to mycobacterial infections in patients with non-CF bronchiectasis. Int J Mycobacteriology. 2015;4:92–6.

    Article  Google Scholar 

  104. 104.

    Chan ED, Iseman MD. Slender, older women appear to be more susceptible to nontuberculous mycobacterial lung disease. Gend Med. 2010;7:5–18.

    PubMed  Article  Google Scholar 

  105. 105.

    Dirac MA, Horan KL, Doody DR, Meschke JS, Park DR, Jackson LA, et al. Environment or host?: A case–control study of risk factors for Mycobacterium avium complex lung disease. Am J Respir Crit Care Med. 2012;186:684–91.

    PubMed  Article  Google Scholar 

  106. 106.

    Lee SJ, Ryu YJ, Lee JH, Chang JH, Shim SS. The impact of low subcutaneous fat in patients with nontuberculous mycobacterial lung disease. Lung. 2014;192:395–401.

    CAS  PubMed  Article  Google Scholar 

  107. 107.

    Ordway D, Henao-Tamayo M, Smith E, Shanley C, Harton M, Troudt J, et al. Animal model of Mycobacterium abscessus lung infection. J Leukoc Biol. 2008;83:1502–11.

    CAS  PubMed  Article  Google Scholar 

  108. 108.

    Leung JM, Fowler C, Smith C, Adjemian J, Frein C, Claypool RJ, et al. A familial syndrome of pulmonary nontuberculous mycobacteria infections. Am J Respir Crit Care Med. 2013;188:1373–6.

    PubMed  PubMed Central  Article  Google Scholar 

  109. 109.

    Iseman MD, Buschman DL, Ackerson LM. Pectus excavatum and scoliosis. Thoracic anomalies associated with pulmonary disease caused by Mycobacterium avium complex. Am Rev Respir Dis. 1991;144:914–6.

    CAS  PubMed  Article  Google Scholar 

  110. 110.

    Jeon K, Kim S-Y, Jeong B-H, Chang B, Shin SJ, Koh W-J. Severe vitamin D deficiency is associated with non-tuberculous mycobacterial lung disease: a case–control study. Respirology. 2013;18:983–8.

    PubMed  Article  Google Scholar 

  111. 111.

    Chun RF, Adams JS, Hewison M. Immunomodulation by vitamin D: implications for TB. Expert Rev Clin Pharmacol. 2011;4:583–91.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  112. 112.

    Casanova J-L, Abel L. The human model: a genetic dissection of immunity to infection in natural conditions. Nat Rev Immunol. 2004;4:55–66.

    CAS  PubMed  Article  Google Scholar 

  113. 113.

    Tsai T-F, Chiu H-Y, Song M, Chan D. A case of latent tuberculosis reactivation in a patient treated with ustekinumab without concomitant isoniazid chemoprophylaxis in the PEARL trial. Br J Dermatol. 2013;168:444–6.

    PubMed  Article  Google Scholar 

  114. 114.

    Souto A, Maneiro JR, Salgado E, Carmona L, Gomez-Reino JJ. Risk of tuberculosis in patients with chronic immune-mediated inflammatory diseases treated with biologics and tofacitinib: a systematic review and meta-analysis of randomized controlled trials and long-term extension studies. Rheumatology (Oxford). 2014;53:1872–85.

    Article  Google Scholar 

  115. 115.

    Hopman RK, Lawrence SJ, Oh ST. Disseminated tuberculosis associated with ruxolitinib. Leukemia. 2014;28:1750–1.

    CAS  PubMed  Article  Google Scholar 

  116. 116.

    Winthrop KL, Iseman M. Bedfellows: mycobacteria and rheumatoid arthritis in the era of biologic therapy. Nat Rev Rheumatol. 2013;9:524–31.

    PubMed  Article  Google Scholar 

  117. 117.

    Novosad SA, Winthrop KL. Beyond tumor necrosis factor inhibition: the expanding pipeline of biologic therapies for inflammatory diseases and their associated infectious sequelae. Clin Infect Dis. 2014;58:1587–98.

    CAS  PubMed  Article  Google Scholar 

  118. 118.

    de Masson A, Maillart E, Veziris N, Meyssonnier V, Papeix C, Caumes E. Cavitary pulmonary disease in a patient treated with natalizumab. Presse Med. 2014;43:1009–12.

    PubMed  Article  Google Scholar 

  119. 119.

    Chan ED, Kaminska AM, Gill W, Chmura K, Feldman NE, Bai X, et al. Alpha-1-antitrypsin (AAT) anomalies are associated with lung disease due to rapidly growing mycobacteria and AAT inhibits Mycobacterium abscessus infection of macrophages. Scand J Infect Dis. 2007;39:690–6.

    CAS  PubMed  Article  Google Scholar 

  120. 120.

    McGrath EE, Bardsley P. An association between Mycobacterium malmoense and coal workers’ pneumoconiosis. Lung. 2009;187:51–4.

  121. 121.

    Kim YM, Kim M, Kim SK, Park K, Jin S-H, Lee US, et al. Mycobacterial infections in coal workers’ pneumoconiosis patients in South Korea. Scand J Infect Dis. 2009;41:656–62.

    PubMed  Article  CAS  Google Scholar 

  122. 122.

    Witty LA, Tapson VF, Piantadosi CA. Isolation of mycobacteria in patients with pulmonary alveolar proteinosis. Medicine (Baltimore). 1994;73:103–9.

    CAS  Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to David M. Lowe.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors have given final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MAL drafted the main body of the manuscript. LA reviewed and summarised primary laboratory studies. MCL participated in the review design and helped draft the manuscript. DL conceived of the review, participated in its design and helped draft the manuscript. All authors read and approved the final manuscript.

Authors’ information

MCL is a respiratory physician and DL is an immunologist and infectious diseases physician at the Royal Free Hospital, London, UK. MAL is an honorary research associate and specialist registrar in infectious diseases, and LA is a research scientist. The hospital is a tertiary referral centre for immunodeficiency and infectious disease, has a large transplant service and has a significant patient population with isolated pulmonary NTM infection. MCL and DL have an active research programme in tuberculosis which is now increasingly focussing on non-tuberculous mycobacteria.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lake, M.A., Ambrose, L.R., Lipman, M.C.I. et al. ‘”Why me, why now?” Using clinical immunology and epidemiology to explain who gets nontuberculous mycobacterial infection. BMC Med 14, 54 (2016).

Download citation


  • Nontuberculous mycobacteria
  • Host defence
  • Primary immune deficiency
  • Interferon gamma
  • Interleukin 12
  • Bronchiectasis
  • Cystic fibrosis
  • Immune response