Emergence of Clinically Relevant Non-Tuberculous Mycobacterial Infections In Saudi Arabia Prof. Sahal Al-Hajoj, Ph.D. Senior Scientist Mycobacteriology Section Department of Infection and Immunity King Faisal Specialist Hospital and Research Center Riyadh, Kingdom of Saudi Arabia 34th Annual Congress, European Society of Mycobacteriology, 30th June-3rd July 2013, Florence, Italy.

Map of Saudi Arabia

Background: Demographical uniqueness of Saudi Arabia: 1- 8.5 millions expatriate workers mostly from TB endemic places. 2- 10 million annual pilgrims from around the world for Islamic rituals. What are lacking: 1- Availability of data on genetic diversity of non-tuberculous mycobacteria (NTM). 2- Unified and modern technologies in the diagnostic locations.

Background cont. What are available: 1- Limited case reports from around the country on the potential of NTM’s as causative agents for various diseases. 2- Identification of novel species of NTM, Mycobacterium riyadhense. 3- Recent publication on disease caused by Mycobacterium abscessus in immuno-competent. individuals.

What are available cont. Background cont. What are available cont. 4- Presence of 11.5% of suspected NTM’s in an annual nationwide Mycobacteria isolates collection (Al Hajoj et al; 2013). 5-Negligence or misinterpretation of NTM diseases.

Mycobacterium riyadhense: novel NTM species

Mycobacterium abscessus in immuno-competent individuals.

Aims: To take advantage of our current collection of isolates, look for the diversity of NTMs and to determine weather these NTMs are clinically important.

Materials and Methods: 1- Nationwide collection of 95 non-repetitive clinical NTM isolates. 2- Genotype mycobacterium MTBC kit (Hain Life science, Germany) for distinguishing NTM’s and Mycobacterium tuberculosis complex isolates. 3- Identification of NTM species by Genotype Mycobacterium CM or AS line probe assays (Hain Life science, Germany) kits.

Materials and Methods: 4- Applied American Thoracic Society (ATS) guidelines for ruling in / out the clinical relevance of respiratory isolates. 5- Demographical and clinical data collection from the mycobacterial registry of Ministry of Health.

Demographic data of the enrolled cases

Results: High species diversity (13 species). Domination of rapid growing NTM’s (61.0%). Predominance of Mycobacterium abscessus, M. fortuitum, M.intracellulare followed by M. kansassi, M. gordanae and M. avium. We report here for the first time the clinical relevance of M. celatum, xenopi, scrofulceum, lentiflavum, asiaticum and M. simiae.

Results cont.

Results cont. Clinically relevant respiratory cases were 67.1%. Non-respiratory cases were 23.2%. Respiratory colonizers were 9.7%. Predisposing risk factors or coexisting illness reported among 53.7% of the cases.

Major reported risk factors: Results cont. Major reported risk factors: 1- Previous history of Tuberculosis (29.5%). 2- Chronic obstructive pulmonary disorder (11.6%). 3- Human immunodeficiency virus infection ( 7.4%). 4- Continuous ambulatory peritoneal dialysis (5.3%). 5- Cystic fibrosis (3.2%). 6- Pulmonary fibrosis (1.0%). .

Conclusion: 1- Highly diverse clinically relevant NTM species are circulating in the country. 2- The predominant species are majorly rapid growers which is a clear opposite picture to what is found in the Western settings (Braun et al. 2013; Couto de Mello et al, 2013,; Davies et al., 2012; Thomson et al., 2010). 3- For first time we report 6 NTM species. 4-Saudi national are affected by the NTM’s.

Conclusion cont: 5- Vulnerability of Saudi population to NTM diseases might be suspected particularly with the immunosuppressive genetic disorders due to the highest rate of consanguinity (59%). 6- Funded study on national NTM surveillance about to start.

Publication of the Results

Acknowledgments: Many thanks to my team mate-Bright Varghese. Many thanks go to my administrators in hierarchy sequences. Many thanks go to King Abdulaziz City for Science and Technology for fund. Many thanks go to my collaborators: Overseas and local.

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