Nontuberculous Mycobacterial Meningitis - Clinical Infectious ...

1266 

Nontuberculous Mycobacterial Meningitis: Report of Two Cases and Review 

Antonia Flor, Josep A. Capdevila, Nuria Martin, 

Joan Gavalda, and Albert Pahissa 

From the Department of Infectious Diseases and the Microbiology 

Service, Hospital General Vall dHebr6n, Universidad Aut6noma, 

Barcelona, Spain 

Nontuberculous mycobacterial meningitis (NTMM) is still a rare disease despite the increase in 

the number of cases of disseminated mycobacterial infection related to the AIDS epidemic. Moreover, 

there are doubts as to the clinical relevance of the isolation of mycobacteria other than Mycobacterium 

tuberculosis from cerebrospinal fluid. After analyzing the clinical and pathological data, we 

classified the cases of NTMM into three groups: definitive (28 cases), probable (19), and doubtful 

(5). We found that Mycobacterium avium is the most commonly isolated species (60% of cases). 

M. avium meningitis presents as a disseminated disease, is usually related to serious underlying 

conditions (mainly immunosuppression), and is associated with a death rate that approaches 70%. 

Mycobacterium fortuitum meningitis is associated with previous neurosurgery or back trauma; the 

prognosis for this infection is better when the concomitant abscesses are drained. The clinical 

characteristics of Mycobacterium kansasii meningitis are similar to those of M. tuberculosis meningitis, 

but the mortality related to M. kansasii meningitis is high despite appropriate antibiotic treatment. 

Herein, we present two cases of NTMM that occurred at our center, and we review 50 

additional cases reported in the English-language literature. 

The incidence of disease caused by nontuberculous mycobacteria 

has increased since the appearance of the AIDS epidemic 

[1-15]. Mycobacterium avium complex (MAC), the 

most commonly isolated nontuberculous mycobacterium, frequently 

produces disseminated disease [2, 16]. However, 

involvement of the CNS by MAC or other nontuberculous 

mycobacteria is rare. 

There is some question as to the real pathogenic role of 

nontuberculous mycobacteria that are isolated from CSF in the 

presence of CNS disease when no supporting clinical evidence 

or CSF biochemical abnormality is detected. In addition, diverse 

responses to therapy have been observed. Because this 

issue is still under discussion, we present two cases of MAC 

meningitis recently observed in our institution and review the 

English-language literature regarding nontuberculous mycobacterial 

meningitis (NTMM). 

Methods 

We searched the data base of Vall d'HebronHospital (Barcelona) 

to identify all patients from whom nontuberculous mycobacteria 

had been isolated between 1982 and 1994. Our hospital 

is an 850-bed university-affiliated institution that serves as a 

referral center for a population of 600,000. We reviewed the 

medical charts of all patients whose CSF cultures were positive 

for nontuberculous mycobacteria during the same period. 

Received 21 March 1996; revised 26 July 1996. 

Reprints or correspondence: Dr. J. A. Capdevila, Servicio de Enfermedades 

Infecciosas, Hospital General Valle de Hebron, po Valle de Hebron 119-129, 

08035-Barce1ona, Spain. 

Clinical Infectious Diseases 1996; 23:1266-73 

© 1996 by The University of Chicago. All rights reserved. 

1058-4838/96/2306-0026$02.00 

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The literature search was done with use of MEDLINE and 

the key words meningitis and non tuberculous Mycobacterium; 

secondary references in the retrieved articles were also reviewed. 

In analyzing the reported cases, we defined three categories. 

A case was considered to be definitive NTMM when 

nontuberculous mycobacteria were isolated in CSF samples 

from patients with clinical and biochemical features of meningitis, 

with or without supporting histological data. Those cases 

in which clinical data were lacking, the CSF biochemical profile 

was abnormal, and nontuberculous mycobacteria only were 

isolated from CSF samples and specimens obtained at autopsy 

were also considered definitive. A case was classified as probable 

NTMM when cultures were positive for nontuberculous 

mycobacteria, clinical manifestations of meningitis were present, 

CSF biochemical profiles were normal or were not reported, 

and other pathogens were identified concomitantly in 

CSF cultures or histological studies. Cases were considered to 

be doubtful when nontuberculous mycobacteria were isolated 

from CSF in the absence of other supporting data. 

In the review of reported cases, we obtained the following 

data: age of the patient; sex; underlying diseases; clinical manifestations; 

bacteriology (including nontubercuIous mycobacteria 

isolated from sites other than the CSF and concomitant 

pathogens isolated); autopsy findings; the CSF biochemical 

profiles; treatment; outcome; antibiotic susceptibility ofthe isolates; 

and clinical significance of the isolates according to our 

definition of NT MM. When the articles consulted did not specify 

genus and species names, we identified the mycobacterial 

group according to Runyon's classification [1]. 

Results 

Medical records review. From January 1982 to December 

1994, 2,590 nontuberculous mycobacteria were isolated from

em 1996;23 (December) Nontubercu1ous Mycobacterial Meningitis 1267 

clinical samples in our laboratory. Of these isolates, 308 

(11.9%) were MAC. Between 1982 and 1989, 51 MAC isolates 

were recovered from 24 patients, and between 1990 and 1994, 

257 MAC isolates were recovered from 100 patients. Over the 

entire study period, only two nontuberculous mycobacterial 

isolates were recovered from CSF cultures. 

Case Reports 

A summary of the findings for the two patients at our center 

who had AIDS and disseminated MAC disease is presented in 

table 1. One of the patients had meningitis with hemiparesis, 

and she died despite institution of antimycobacterial therapy. 

The other patient had only persistent fever without meningism, 

and MAC was isolated from a culture of CSF. This patient 

received therapy with isoniazid, rifampin, and ciprofloxacin, 

but he died 2 months later. 

Literature review. We identified 50 cases of NTMM in the 

English-language literature. The main characteristics of these 

cases are shown in table 1 [8, 17 -37], and their relations with 

underlying conditions are shown in table 2. Of the 50 cases 

of reported NTMM, we determined that 27 were definitive 

meningitis, 18 were probable meningitis, and five were doubtful 

meningitis according to the criteria described. The first case at 

our center was defined as definitive meningitis, and the second 

was defined as doubtful meningitis. 

Discussion 

Isolation of a single colony of Mycobacterium tuberculosis 

is always clinically significant; however, other species of my cobacteria 

may be pathogens or simply contaminants. Assessment 

of the pathogenicity of mycobacteria is aided by the following 

data: repeated isolation of the same organism; identity of the 

species; underlying predisposing conditions; and specimens 

cultured [1, 38-40]. Isolation of nontuberculous mycobacteria 

from a sterile fluid such as CSF is a significant finding; thus, 

we based our review on this finding. 

The species of nontuberculous mycobacteria reported to 

cause meningitis include the four groups of the Runyon classification 

[1]. There is considerable variation in the incidence of 

these species: 31 (60%) of the 52 cases were caused by MAC, 

nine (17%) were caused by mycobacteria from Runyon group 

II, six (11.5%) were caused by Mycobacterium kansasii, and 

six (11.5%) were caused by Mycobacterium fortuitum. 

NTMM occurred in all age-groups; however, the relative 

incidence of each species was more evenly distributed among 

children than among the total population of patients: 29% (4 

of 14 isolates) were MAC, 29% (4 of 14) were M kansasii, 

29% (4 of 14) were from Runyon group II, and 14% (2 of 14) 

were M fortuitum. The majority of cases in adults have been 

caused by MAC. 

It is interesting to note that most ofthe children with NTMM 

(all except one with lymphoma [37]) have been immunocompe- 



tent. Three had underlying predisposing conditions including 

chronic otitis and mastoiditis [20, 31] and a CSF shunt for 

hydrocephalus [28]. 

Since the appearance of the AIDS epidemic, the number of 

cases of MAC meningitis has increased [7, 9, 21, 24-26]; 22 

(71 %) ofthe 31 reported cases occurred in patients with AIDS. 

We found enough data to classify these cases: 18 were considered 

definitive; three, probable; and one, doubtful. In most (18 

of 22) of these patients, MAC caused disseminated disease 

before invading the meninges. 

Autopsy was performed in four cases and disclosed extensive 

involvement of the liver, spleen, lymph nodes, bone marrow, 

and gastrointestinal tract in each case. CNS involvement was 

usually characterized by low-grade inflammation and the presence 

of perivascular lesions, poorly formed granulomas without 

giant cells, and numerous acid-fast bacilli. There was no evidence 

of other opportunistic infections. 

The clinical findings varied, but all patients had a history of 

weight loss; one-half were febrile, and one-third had headache 

and altered mentation [21, 24, 26]. The CSF biochemical profiles 

showed moderate alterations with lymphocytosis; however, 

levels of glucose and protein were close to normal, perhaps 

because of the poor immunologic response in patients 

with AIDS. 

The two cases of MAC meningitis that we report (cases 

30 and 31) occurred in patients with AIDS. These patients 

presented with fever, weakness, somnolence, and behavioral 

disorders. Analysis of CSF samples showed an increased 

protein level and a decreased glucose level in one case and 

normal levels of these constituents in the other. In both cases, 

cultures of blood, CSF, and bone marrow were repeatedly 

positive for MAC. 

The overall death rate for patients with MAC disease has 

been high (77%); however, incomplete documentation makes 

it difficult to determine the crude death rate of meningitis due 

to this microorganism. The treatment administered has not been 

reported for a large number of patients [21,24-26], and some 

of the patients were lost to follow-up. In one series of 15 

patients with AIDS, Jacob et al. [26] found that the in-hospital 

death rate was 67%. This rate may indicate that MAC meningitis 

is a terminal event in the clinical evolution of AIDS. CNS 

disease caused by MAC in patients with AIDS who have no 

evidence of meningitis has also been reported [5, 9, 11, 14]. 

These cases, which clearly show the pathogenicity of MAC 

in the CNS, are differentiated from probable or doubtful cases 

of infection due to other pathogens or other underlying conditions 

(e.g., severe necrotizing cytomegalovirus encephalitis or 

primary brain lymphoma) [7, 11, 14, 21] and from cases of 

disseminated MAC disease in which MAC is isolated from 

brain tissue specimens [6, 13]. In 1986, Hawkins et al. [13] 

reviewed postmortem culture results for patients with AIDS 

and disseminated MAC disease and found that cultures of brain 

tissue were positive in 39%, of the cases; however, in a 1989 

review of autopsy findings for patients with AIDS, Santamaria



1268 Flor et al. CID 1996;23 (December) 

Table 1. Features of 52 cases of nontuberculous mycobacterial meningitis. 

NTM and other organisms 

Case no. Underlying Clinical findings related to isolated 

[reference] Age (y)/sex condition NTMM (site, no. of isolations) Autopsy findings 

1 [17] 291F None Meningitis MAC (CSF, 1) NA 

2 [18] 51F None Meningitis MAC (CSF) NA 

3 [18] 141M None Meningitis MAC (CSF) NA 

4 [19] 461F None Meningitis; mass in Cryptococcus neoformans NA 

posterior fossa on CT (CSF); MAC (CSF, 2) 

scan 

5 [20] lIF None Meningitis MAC (CSF) Mesenteric and tracheal 

nodes with caseum 

6 [20] 81M Chronic otitis Otitis, cervical adenitis; no MAC (CSF) NA 

media meningitis 

7 [21] 301M AIDS Dysphagia, dyspnea, CMV and MAC (CSF); Granulomata in spleen, 

encephalopathy MAC (sputum); bone marrow, lungs, 

MAC (urine) lymph nodes, adrenal 

glands, and brain 

8 [22] NA Leukemia Meningitis Escherichia coli + MAC NA 

(CSF) 

9 [23] 40/F None Meningitis MAC + Mycobacterium NA 

tuberculosis (CSF, 1) 

10 [23] 58IM Leukemia NA MAC (CSF) NA 

11, 12 [24] NA AIDS Meningoencephalitis MAC (CSF) NA 

13, 14 [25] NA AIDS Meningitis MAC (CSF) NA 

15-29 [26] 33 ± 4t/9M, 6F AIDS Weight loss, fever, seizures, MAC (CSF) CNS granulomata and AFB; 

confusion, headaches, disseminated MAC§ 

and vomiting! 

30 [PRJ 26/F AIDS Meningoencephalitis, MAC (CSF), disseminated NA 

hemiplegia; MAC 

pachymeningitis on MRI 

31 [PRJ 361M AIDS Fever, coma, hemiplegia; MAC (CSF), disseminated NA 

brain abscess on CT scan MAC 

32 [17] 291F None Meningitis; cavity on CXR Runyon group II (CSF, 5) NA 

33 [17] 321F None Meningitis; cavity on CXR Runyon, group II (CSF, 2) NA 

34 [17] 201F None Meningitis; miliary on CXR Runyon group II (CSF, 2) NA 

35 [17] 81M None Meningitis Runyon group II (CSF, 2) NA 

36 [17] 21F None Meningitis Runyon group II (CSF, 2) NA 

37 [18] 18 molM None Cervical adenitis, no Runyon group II (lymph NA 

meningitis node); Runyon group II 

(CSF) 

38 [27] 251F Pregnancy Meningitis, pulmonary M. tuberculosis, Runyon M tuberculosis meningitis 

tuberculosis 1 mo before group II (CSF, 1); 

NTMM diagnosed M tuberculosis (sputum) 

39 [23] 65/M Myeloma Meningitis; infiltrate on Mycobacterium gordonae NA 

CXR (CSF) 

40 [28] 21M Hydrocephalus Meningitis M. gordonae (CSF and NA 

ascitic fluid) 

41 [26] 281M AIDS Fever, headache; infiltrate Mycobacterium fortuitum NA 

onCXR (CSF) 

42 [29] 81M None Cauda equina abscess, M. fortuitum (CSF and NA 

meningitis cauda equina abscess)

cm 1996;23 (December) Nontuberculous Mycobacterial Meningitis 1269 

Table 1. (Continued) 



Antibiotic susceptibilities Classification 

CSF findings Treatment Outcome (result) ofNTMM 

NA NA Cured NA Probable 

"Increased cells and protein, low NA Died NA Definitive 

glucose" 

Cloudy; WBCs, 3,000/rnm3 Pen, SSZ Rapid improvement, NA Probable 

CSF normal 

WBCs, 83/rnm3 (100% lymphocytes); AmB, 5-FC*; INH + Rif Improved; spastic INH (R), PAS (R), Rif (R), Probable 

protein, 38 mg/dL; glucose, added gait after AmB Etb (R), Stm (R), Cyse 

32 mg/dL therapy (S), Etbi (S) 

NA NA Died after 3 d NA Probable 

NA NA Cured NA Doubtful 

NA NA Died NA Probable 


WBCs, 4711rnm3 (13% PMNs, 84% Pen, Clm, INH, Rif Developed mild NA Probable 

lymphocytes); protein, 234 mg/dL; hydrocephalus 

glucose, 41 mg/dL 

NA NA Died NA Doubtful 

WBCs, 13/rnm3 and 15/mm3; protein NA Died NA Definitive 

levels increased 


Lymphocytes, 71%; protein, 41 mg/dL NA In-hospital mortality, NA Definitive 

:±: 18 mg/dLt ; glucose, 54 mg/dL :±: 67% 

23 mg/dO 

WBCs, 4/rnm3; protein, 115 mg/dL; INH, Rif, Etb; Clm, Ofx, Died NA Definitive 

glucose, 36 mg/dL; adenosine Amik added 

deaminase, 1.5 UIL 

Normal INH, Rif, Eth Died NA Doubtful 



NA NA Died 3 mo later NA Probable 



NA NA NA NA Doubtful 

Xantbochromic, hypertensive INH, PAS, Stm, Prd; Miscarried; died 5 w INH (R), PAS (R) Probable 

Cyse added later 

WBCs, 1Irnm3; protein, 55 mg/dL; Oxa, Om, INH Died NA Definitive 


WBCs, 53/rnm3 (100% lymphocytes); INH, Stm, Etb, INHII Improved after NA Definitive 

protein, 500 mg/dL; glucose, 27 removal of shunt 

mg/dL 

Normal NA Cured NA Probable 

Cloudy; WBCs, 3,025/mm3 (77% PZA, Eth, Etbi, Km; Improved after INH (R), PAS (R), Stm Definitive 

PMNs); protein, 237 mg/dL; drainage of cauda drainage; residual (R), Cyse (R), Km (S), 

glucose, 51 mg/dL equina abscess; final motor weakness Oxa (S) 

tberapy with Km + 

Oxa

1270 Flor et al. CID 1996; 23 (December) 


Case no. 

[reference] 

Underlying Clinical findings related to 

NTM and other organisms 

isolated 

Age (y)/sex condition 

NTMM (site, no. of isolations) Autopsy findings 

43 [30] 19/F None Meningitis after diskectomy M. jortuitum (CSF, 2) NA 

44 [31] 101M Chronic otitis 

media 

45 [32] 

46 [33] 

NA 

161M None (back 

trauma) 

Subdural empyema, brain M. fortuitum (CSF and NA 

abscess, meningitis abscess) 

None Fever, headache M. fortuitum (CSF, 1) NA 

47 [8] NA AIDS Hemiplegia, malaise, fever, 

hypoadrenalism 

48 [18] 131M None Meningitis, papilledema, 

hemiplegia 

49 [34] 34/F Pregnancy 

50 [35] 2/F None 

51 [36] 9 molM None 

52 [37] 131M Lymphoma 

Meningitis, lumbar abscess M. fortuitum (CSF, lumbar NA 

abscess) 

Meningitis, peritonitis; 

miliary on CXR 

Meningitis, malaise 

Meningitis 

Meningitis 

M. kansasii (CSF) NA 

M. kansasii (CSF) Granulomas and caseum in 

lungs, hilar nodes, 

meninges; M. kansasii 

recovered from 

meningeal membranes 

M. kansasii (CSF) 

NA 

M. kansasii (CSF, 1); 

M. tuberculosis (CSF, 

3); AFB (CSF, 4) 

AFB (CSF); M. kansasii 

(CSF) 

M. kansasii (CSF) 

Miliary lesions in spleen, 

adrenal glands, and brain; 

creamy meninges; 

M. kansasii recovered 

from meningeal 

membranes; 

M. tuberculosis recovered 

from lymph nodes and 

CSF 

NA 

NOTE. AFB = acid-fast bacilli; AmB = amphotericin B; Amik = amikacin; Clm = clarithromycin; CMV = cytomegalovirus; Cpm = capreomycin; CXR 

= chest radiograph; Cyse = cycloserine; Dox = doxycycline; Ern = erythromycin; Eth = ethambutol; Ethi = ethionamide; Gm = gentamicin; 5-FC = flucytosine; 

INH = isoniazid; Km = kanamycin; MAC = Mycobacterium aviul11 complex; NA = not available; NTM = nontuberculous mycobacteria; NTMM = nontuberculous 

mycobacterial meningitis; Oxa = oxacillin; Ofx = ofloxacin; PAS = para-aminosalicylic acid; PCP = Pneumocytis carinii pneumonia; Pen = penicillin; PMN 

= polymorphonuclear cells; PR = present report; Prd = prednisone; PZA = pyrazinamide; R = resistant; Rif = rifampin; S = susceptible; Stm = streptomycin; 

SSZ = sulfizoxazole; Tm = tobramycin; TMP-SMZ = trimethoprim-sulfamethoxazole. 

[IS] reported an incidence of CNS involvement with MAC that 

ranged from 3% to 10%. 

It is difficult to draw conclusions concerning MAC meningitis 

in immunocompetent patients because only two cases 

have been well documented (cases 2 [18] and S [20], table 

1). Both patients were children with disease diagnosed by 

clinicians as "typical tuberculous meningitis" that resulted 

in death, and the treatments were not reported. The other 

cases that have been reported were probable or doubtful; 

three resolved with no therapy or inappropriate therapy 

(cases 1 [17], 6 [20], and 3 [18]), and in two of these cases, 

concomitant infections including tuberculosis (case 9 [23]) 

and cryptococcosis (case 4 [19]) were present. A case of CNS 



involvement with MAC in an immunocompetent patient has 

been reported [41]. 

Meningitis due to organisms of Runyon group II has been 

associated with certain geographical areas such as Japan. 

Yamamoto et al. [17] described five probable cases (five of 

nine reported cases) that occurred in Japan before 1967. 

These authors did not report specific therapies or follow-up; 

however, the patients had a disseminated form ofthe disease, 

with miliary or fibrocaseous pulmonary infiltrates and meningitis 

and all but one of them recovered (mortality, 20%). 

Mycobacterium gordonae was recovered in the two cases 

classified as definitive meningitis. An underlying condition 

was present in both of the patients-a child with hydroceph- 

NA



CSF findings 

WBCs, 400/mm'; protein, 20 mg/dL; 


WBCs, 200/mm' 

Normal 

Cloudy; WBCs, 1,085/mm'; protein 

and glucose levels, normal 

Normal 

Increased number of cells and protein 

level 

NA 

WBCs, 200/mm' (70% lymphocytes); 


WBCs, 70/mm' (90% PMNs); protein, 

500 mg/dL; glucose, 20 mg/dL 

Protein, 60 mg/dL; glucose, 18 mg/dL 

Treatment 

INH, Rif, Eth, Stm; 

laminectomy and Dox 

Em, INH, Km, and partial 

resection of abscess; 

Dox, Ethi, and 

intrathecal Amik added 

None 

Pen, TMP-SMZ, Gm; 

INH and drainage of 

abscess and fistula 

INH, Rif, Eth 

" Antituberculous 

therapy" 

Pen, Strn, PAS 

Pen, sulfonamides, Clm, 

Strn, INH, cortisone 

"Antituberculous 

therapy" 

INH, Rif, PZA, Prd 

Outcome 

Infection persisted; 

improved after 

laminectomy 

Improved after 

intrathecal therapy 

Cured 

Improved 

Progressive lethargy; 

died of PCP 

* Given for 79 days. 

tMean ± SD. 

I Fifteen patients had weight loss, eight had fever, two had seizures, four had confusion, and five had headaches and vomiting. 

§ Autopsy was performed in three cases. 

II Given for 1 year, then given again for 5 years. 

alus (case 40 [28]) and an adult with myeloma (case 39 

[23]). The first patient was cured by removal of an infected 

derivative shunt; the other patient, who was treated with 

aminoglycosides and isoniazid, died. 

Meningitis due to M. fortuitum has been clearly documented 

(four definitive cases ofNTMM) and related to previous CNS 

surgery and trauma, and a neurocutaneous fistula that lasts for 

years has been described in these cases; drainage and/or removal 

of a foreign body has been demonstrated to be the best 

therapy. Intrathecal treatment with aminoglycosides has also 

been described [31]. Of the patients with M. fortuitum meningitis, 

only one died (this patient also had AIDS). Since abscesses 

are frequently present in cases of M. fortuitum meningitis, it 



Died 

Died 5 weeks after 

laparotomy 

Died after 5 d 

Died 

Died after 7 d 

Antibiotic susceptibilities 

(result) 

Cpm (S), Dox (S) 

Amik (S), Km (R), Dox (R) 

NA 

Amik (S), Tm (S), Dox (S), 

INH (R), TMP-SMZ (R), 

Strn (R) 

NA 

NA 

NA 

INH (R), PAS (R) 

NA 

NA 

Classification 

ofNTMM 

Definitive 

Definitive 

Doubtful 

Definitive 

Probable 

Definitive 

Probable 

Probable 

Definitive 

Definitive 

is not surprising that the CSF biochemical findings in these 

cases generally include a predominance of polymorphonuclear 

cells. 

The severity of meningitis due to M. kansasii and the 

associated high mortality are striking. Of the six cases found 

in the literature, three were definitive (case 48 [18], case 51 

[36], and case 52 [37]; table 1), and three were probable 

(case 47 [8], case 49 [34] and case 50 [35]) by our definition. 

M. kansasii causes disseminated disease that is similar to 

meningitis due to M. tuberculosis. Until culture results are 

available, tuberculous meningitis is initially suspected in 

these cases when the CSF biochemical profile is consistent 

with lymphocytic meningitis. In the two cases of M. kansasii

1272 Flor et al. CID 1996;23 (December) 

Table 2. Mycobacterial species isolated among 52 patients with 

nontuberculous mycobacterial meningitis and predisposing underlying 

conditions. 

Mycobacterium isolate recovered 

Underlying Runyon 

condition MAC group II Mfortuitum M kansasii 

None 6 7 3 4 

Chronic otitis media 0 1 0 

Hematologic disease 2 0 

AIDS 21 0 I I 

Hydrocephalus 0 I 0 0 

Back trauma 0 0 0 

Neurosurgery 0 0 0 

NOTE. MAC = Mycobacterium avium complex. 

meningitis in which autopsies were performed, caseous granulomata 

were found in the patients' lungs and meninges. 

Despite institution of antituberculous therapy, all of the patients 

died. 

The majority ofNTMM cases present as lymphocytic meningitis. 

The CSF is normal or close to normal in patients with 

AIDS, and polymorphonuclear cells predominate in the CSF 

of patients with meningitis due to M. fortuitum. In all but two 

cases, direct smears of CSF for acid-fast bacilli were negative 

for mycobacteria. 

Concomitant pathogens were isolated in six (11 %) ofthe 52 

cases of NTMM. We consider these cases to be mixed infections 

and have classified them as probable NTMM. The combined 

isolates recovered were M. tuberculosis and a Runyon 

group II mycobacterium (case 38 [27], table 1), M. tuberculosis 

andM. kansasii (case 50 [35]), M. tuberculosis and MAC (case 

9 [23]), Cryptococcus neoformans and MAC (case 4 [19]), 

cytomegalovirus and MAC (case 7 [21]), and Escherichia coli 

and MAC (case 8 [22]). 

NTMM is frequently associated with immunosuppression: 

the incidence of immunosuppression in these 52 cases was 54% 

(28 cases). Among the immunosuppressed patients, AIDS was 

the most common underlying condition (24 [46%] of the 52 

patients). However, NTMM has also been reported in association 

with other immunosuppressive states (e.g., hematologic 

malignancy and immunosuppression due to treatment with corticoid 

drugs): two (8%) of these 24 cases were due to MAC 

(cases 8 [22] and 10 [23]), one was due to M. kansasii (case 

52 [37]), and one was due to M. gordonae (case 39 [23]). It 

is surprising that NTMM has not been observed in patients 

receiving hemodialysis or in transplant recipients even though 

mycobacterial disease is a well-recognized complication under 

such circumstances [15, 23, 42, 43]. 

In summary, nontubercu10us mycobacterial microorganisms 

are able to cause meningitis, and when these organisms are 

isolated in cultures of CSF, they should not routinely be assumed 

to be contaminants. M. avium is the most commonly 



isolated species in patients with NTMM, especially since the 

beginning of the AIDS epidemic. M. fortuitum meningitis is 

clearly associated with previous neurosurgery or spinal trauma 

and with chronic infection; the prognosis is good when the 

concomitant abscess is drained. The clinical characteristics of 

patients with M. kansasii meningitis are similar to those of 

patients with tuberculous meningitis, but mortality due to 

M. kansasii is higher despite adequate therapy. 

Acknowledgment 

The authors thank Celine L. Cavallo for her editorial assistance. 

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