Chest
Volume 111, Issue 3, March 1997, Pages 813-816
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Selected Reports
Pulmonary Illness Associated With Exposure to Mycobacterium-avium Complex in Hot Tub Water: Hypersensitivity Pneumonitis or Infection?

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Background: Mycobacterium avium

complex is common in water. When aerosolized, it is frequently inhaled but rarely causes illness in healthy people. Hypersensitivity pneumonitis to inhaled aerosols has been described; these aerosols are from several sources of water. The pneumonitis forms are collectively known as humidifier lung; the responsible agent in the water remains uncertain.

Purpose

To report five cases of respiratory illness in healthy subjects using hot tubs contaminated with M avium complex.

Design

Descriptive case reports.

Setting

Consultations in two teaching hospitals.

Patients

Five healthy people developed respiratory illnesses characterized by bronchitis, fever, and “flu-like” symptoms after using a hot tub. Acute exacerbations of their illness developed within hours of heavy use of the hot tubs.

Investigations

A chest radiograph and sputum culture in all, BAL in one, CT scan and lung biopsy in another were performed. Culture of the water of the two hot tubs also was done.

Results

Chest radiographs showed interstitial infiltrates or a miliary nodular pattern. Cultures of all sputum samples, the lung biopsy specimens, lung lavage and water samples were positive for M avium complex. The lung biopsy specimen revealed noncase ating granulomas. All patients recovered with no treatment for M avium complex.

Conclusion

We conclude that the M avium complex in the water was responsible for the pulmonary illnesses. The symptoms and the results of investigations are more suggestive of a hypersensitivity pneumonitis than of an infection, but no serologic proof of an immunologic reaction to the M avium complex or water was obtained.

Section snippets

CASE 1

A 28-year-old healthy plumber used his indoor hot tub for 1 h daily. It was filled with well water in October and emptied in May without water changes. The temperature of the tub water was 37 to 39°C and the pH level was 7 to 8. In the second year of hot tub use, he developed episodes of a “flu-like” illness consisting of fever (38°C), chills, malaise, and headaches. He was empirically treated for bronchitis and chose to increase his hot tub use to alleviate symptoms. He became progressively

DISCUSSION

We believe that the temporal relationship between use of the hot tubs, the presence of the M avium complex in the water, and the isolation of M avium complex from the lung biopsy specimen and BAL specimen as well as from the sputum sample establish that this organism was responsible for the illnesses reported. Though the two isolates from the water did not match those from the patients, the hot tub water may have contained a mixed population of M avium complex, and the specific causal organism

ACKNOWLEDGMENT

We acknowledge the consultation from Dr. A. Pan on the first case, the radiologic assistance of Dr. B. Maycher for the CT scan, the work of Ms. J. Wolfe in the Mycobacterial Laboratory, Winnipeg, and the expertise of Charlotte Smith for serologic testing in the Centers for Disease Control and Prevention, Atlanta.

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    Reprint requests: Dr. Warren, Respiratory Hospital, 810 Sherbrook Street, Winnipeg, Manitoba, R3A 1R8 Canada

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