C68-34 A Window of Opportunity: A Palliative Intervention for Late-stage Nontuberculous Mycobacterial Infection

Abstract Introduction Pulmonary Mycobacterium Avium Complex (MAC) infection remains difficult to treat. Cure rates for non-cavitary disease can be over 80% but drop to 50-80% for cavitary disease and as low as 5% in macrolide-resistant isolates. Surgery and prolonged antibiotics are needed to achieve higher rates. Unfortunately, many patients with refractory cavitary disease are not surgical resection candidates, necessitating referrals to palliative care. A Clagett window is an infrequently used surgical technique that may play a role in palliating symptoms in patients with refractory cavitary MAC. Case A 68-year-old woman with a history of obstructive lung disease and esophageal dysmotility presented with a persistent cough and was diagnosed with cavitary MAC pulmonary disease. Despite guideline-based therapy, her disease was refractory and ultimately developed macrolide resistance. Her course was complicated by an aspergilloma, requiring prolonged posaconazole therapy. Surgical options were discussed with her, and she opted for a high-risk surgical resection over a lower-risk thoracostomy due to the implications of chronic wound management, a common concern. She underwent left upper and lower lobe wedge resections and postoperatively continued a multidrug regimen for MAC. Unfortunately, within two months of surgery, she developed a bronchopleural fistula and abscess. Despite chest tube placement and intrapleural lytic agents, the space did not collapse. At this point, she agreed to a Clagett window. The apical location of her window and the need for intensive nutrition beforehand were the primary challenges, but she tolerated the procedure well. Her husband was educated on routine care for the pleural space, and she was discharged less than one week postoperatively. She subsequently achieved culture conversion and has remained off antibiotics for over 5 years with excellent functional capacity. Discussion Surgical resection remains the mainstay of adjunctive treatment of refractory cavitary MAC pulmonary disease. For those who are not candidates or who suffer complications, a Claggett window as a palliative intervention, allowing for a significant reduction in mycobacterial burden via source control, may be an option. Open management of chest infections via thoracostomy has been a practice since the times of Hippocrates, but its application to refractory cavitary MAC pulmonary disease remains underutilized. Patients, like ours, often decline the procedure initially due to the intimidating nature of the suggestion. Still, as described above, our patient had an excellent outcome and likely added years and quality to her life. This case illustrates the utility of a Clagett window in palliating these infections. This abstract is funded by: None