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Mycobacterium phocaicum and Mycobacterium avium-intracellulare in a patient with hot tub lung.

Wethasinghe J, Hotu S, Taylor S, Anderson G, Wong C - Respirol Case Rep (2015)

Bottom Line: Transbronchial biopsies revealed non-necrotizing granulomatous inflammation.Sputum and spa pool water cultured M ycobacterium phocaicum but not MAC.She stopped using the spa pool and was treated with oral prednisone, which led to symptomatic, pulmonary function, and radiographic improvement.

View Article: PubMed Central - PubMed

Affiliation: Medicine Department, Middlemore Hospital Auckland, New Zealand.

ABSTRACT
A 77-year-old woman who used her spa pool at least twice a day to relieve pain from osteoarthritis, developed progressive breathlessness, impaired pulmonary function, and radiographic changes consistent with hypersensitivity pneumonitis-like lung disease. M ycobacterium avium-intracellulare complex (MAC) was cultured from bronchoalveolar lavage fluid. Transbronchial biopsies revealed non-necrotizing granulomatous inflammation. Sputum and spa pool water cultured M ycobacterium phocaicum but not MAC. She stopped using the spa pool and was treated with oral prednisone, which led to symptomatic, pulmonary function, and radiographic improvement. This is the first case of hypersensitivity pneumonitis-like granulomatous lung disease associated with exposure to M . phocaicum in spa pool water.

No MeSH data available.


Related in: MedlinePlus

Transbronchial lung biopsies demonstrating non-necrotizing granulomata and thickened interstitium with an associated interstitial inflammatory response. Hematoxylin–eosin staining (A) 100× magnification. (B) 200× magnification.
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fig02: Transbronchial lung biopsies demonstrating non-necrotizing granulomata and thickened interstitium with an associated interstitial inflammatory response. Hematoxylin–eosin staining (A) 100× magnification. (B) 200× magnification.

Mentions: In February 2010, a 77-year-old New Zealand European woman was admitted to hospital with 10 months of progressive shortness of breath. She had troublesome osteoarthritis in her knees and used an indoor spa pool two to four times a day to relieve the discomfort. She had never smoked, did not own pets, and had no significant history of travel. Physical examination revealed bilateral crackles in the lung bases. Oxygen saturation was 89% on air and 95% on 2 l/min of oxygen. Initial chest radiography showed diffuse, bilateral, interstitial changes. High-resolution computed tomography (HRCT) showed patchy ground glass opacification throughout both lungs with upper lobe predominance (Fig. 1A). Pulmonary function tests showed forced expiratory volume in 1 sec (FEV1) 1.6 l (87% predicted), forced vital capacity (FVC) 2.3 l (85% predicted), total lung capacity (TLC) 4.73 (99%), and diffusing capacity of lung for carbon monoxide (DLCO) 13.9 ml/mmHb/min (80%). Serologic testing for collagen vascular diseases and vasculitides was negative. Transbronchial lung biopsies showed non-necrotizing granulomatous inflammation (Fig. 2). Auramine-rhodamine smears of bronchoalveolar lavage fluid were negative for acid fast bacilli, but M. avium-intracellulare complex (MAC) was isolated after 10 days of incubation and identified using a DNA probe (AccuProbe, Gen-Probe, San Diego, CA, USA). Subsequent spontaneous sputum smears revealed 2+ acid fast bacilli (one to nine organisms per 10 high-power fields), and a nontuberculous mycobacterium was isolated after 6 days of incubation. This isolate was MAC DNA probe negative. Around this time a sample of the patient's spa pool water was tested and a nontuberculous mycobacterium isolated after 13 days. The isolates cultured from sputum and spa pool water were referred to a reference laboratory for speciation and were both identified as M. phocaicum by heat shock protein (HSP) 65 gene analysis. Samples of pool water were not collected around the time of the MAC-positive BAL sample. She was advised to stop using her spa pool and treated with prednisone for a total of 7 months. Prednisone was commenced at a dose of 30 mg daily for 1 month followed by 20 mg daily for 3 months. Thereafter, prednisone was tapered off over the next 3 months. Her symptoms completely resolved over this period. Subsequently, the spa pool was removed because the risk of recurrence was thought to outweigh the benefits of bathing in the spa pool. Repeat HRCT scan of the chest in August 2010 showed complete resolution of the pneumonitis (Fig. 1B). Lung function tests in February 2011 showed improved lung function with FEV1 1.99 l, FVC 2.78 l, TLC 5.34 l and DLCO 16.7 ml/mmHb/min.


Mycobacterium phocaicum and Mycobacterium avium-intracellulare in a patient with hot tub lung.

Wethasinghe J, Hotu S, Taylor S, Anderson G, Wong C - Respirol Case Rep (2015)

Transbronchial lung biopsies demonstrating non-necrotizing granulomata and thickened interstitium with an associated interstitial inflammatory response. Hematoxylin–eosin staining (A) 100× magnification. (B) 200× magnification.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4364793&req=5

fig02: Transbronchial lung biopsies demonstrating non-necrotizing granulomata and thickened interstitium with an associated interstitial inflammatory response. Hematoxylin–eosin staining (A) 100× magnification. (B) 200× magnification.
Mentions: In February 2010, a 77-year-old New Zealand European woman was admitted to hospital with 10 months of progressive shortness of breath. She had troublesome osteoarthritis in her knees and used an indoor spa pool two to four times a day to relieve the discomfort. She had never smoked, did not own pets, and had no significant history of travel. Physical examination revealed bilateral crackles in the lung bases. Oxygen saturation was 89% on air and 95% on 2 l/min of oxygen. Initial chest radiography showed diffuse, bilateral, interstitial changes. High-resolution computed tomography (HRCT) showed patchy ground glass opacification throughout both lungs with upper lobe predominance (Fig. 1A). Pulmonary function tests showed forced expiratory volume in 1 sec (FEV1) 1.6 l (87% predicted), forced vital capacity (FVC) 2.3 l (85% predicted), total lung capacity (TLC) 4.73 (99%), and diffusing capacity of lung for carbon monoxide (DLCO) 13.9 ml/mmHb/min (80%). Serologic testing for collagen vascular diseases and vasculitides was negative. Transbronchial lung biopsies showed non-necrotizing granulomatous inflammation (Fig. 2). Auramine-rhodamine smears of bronchoalveolar lavage fluid were negative for acid fast bacilli, but M. avium-intracellulare complex (MAC) was isolated after 10 days of incubation and identified using a DNA probe (AccuProbe, Gen-Probe, San Diego, CA, USA). Subsequent spontaneous sputum smears revealed 2+ acid fast bacilli (one to nine organisms per 10 high-power fields), and a nontuberculous mycobacterium was isolated after 6 days of incubation. This isolate was MAC DNA probe negative. Around this time a sample of the patient's spa pool water was tested and a nontuberculous mycobacterium isolated after 13 days. The isolates cultured from sputum and spa pool water were referred to a reference laboratory for speciation and were both identified as M. phocaicum by heat shock protein (HSP) 65 gene analysis. Samples of pool water were not collected around the time of the MAC-positive BAL sample. She was advised to stop using her spa pool and treated with prednisone for a total of 7 months. Prednisone was commenced at a dose of 30 mg daily for 1 month followed by 20 mg daily for 3 months. Thereafter, prednisone was tapered off over the next 3 months. Her symptoms completely resolved over this period. Subsequently, the spa pool was removed because the risk of recurrence was thought to outweigh the benefits of bathing in the spa pool. Repeat HRCT scan of the chest in August 2010 showed complete resolution of the pneumonitis (Fig. 1B). Lung function tests in February 2011 showed improved lung function with FEV1 1.99 l, FVC 2.78 l, TLC 5.34 l and DLCO 16.7 ml/mmHb/min.

Bottom Line: Transbronchial biopsies revealed non-necrotizing granulomatous inflammation.Sputum and spa pool water cultured M ycobacterium phocaicum but not MAC.She stopped using the spa pool and was treated with oral prednisone, which led to symptomatic, pulmonary function, and radiographic improvement.

View Article: PubMed Central - PubMed

Affiliation: Medicine Department, Middlemore Hospital Auckland, New Zealand.

ABSTRACT
A 77-year-old woman who used her spa pool at least twice a day to relieve pain from osteoarthritis, developed progressive breathlessness, impaired pulmonary function, and radiographic changes consistent with hypersensitivity pneumonitis-like lung disease. M ycobacterium avium-intracellulare complex (MAC) was cultured from bronchoalveolar lavage fluid. Transbronchial biopsies revealed non-necrotizing granulomatous inflammation. Sputum and spa pool water cultured M ycobacterium phocaicum but not MAC. She stopped using the spa pool and was treated with oral prednisone, which led to symptomatic, pulmonary function, and radiographic improvement. This is the first case of hypersensitivity pneumonitis-like granulomatous lung disease associated with exposure to M . phocaicum in spa pool water.

No MeSH data available.


Related in: MedlinePlus