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Hamilton KA, Weir MH, Haas CN. Dose response models and a quantitative microbial risk assessment framework for the Mycobacterium avium complex that account for recent developments in molecular biology, taxonomy, and epidemiology. WATER RESEARCH 2017; 109:310-326. [PMID: 27915187 DOI: 10.1016/j.watres.2016.11.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/20/2016] [Accepted: 11/22/2016] [Indexed: 06/06/2023]
Abstract
Mycobacterium avium complex (MAC) is a group of environmentally-transmitted pathogens of great public health importance. This group is known to be harbored, amplified, and selected for more human-virulent characteristics by amoeba species in aquatic biofilms. However, a quantitative microbial risk assessment (QMRA) has not been performed due to the lack of dose response models resulting from significant heterogeneity within even a single species or subspecies of MAC, as well as the range of human susceptibilities to mycobacterial disease. The primary human-relevant species and subspecies responsible for the majority of the human disease burden and present in drinking water, biofilms, and soil are M. avium subsp. hominissuis, M. intracellulare, and M. chimaera. A critical review of the published literature identified important health endpoints, exposure routes, and susceptible populations for MAC risk assessment. In addition, data sets for quantitative dose-response functions were extracted from published in vivo animal dosing experiments. As a result, seven new exponential dose response models for human-relevant species of MAC with endpoints of lung lesions, death, disseminated infection, liver infection, and lymph node lesions are proposed. Although current physical and biochemical tests used in clinical settings do not differentiate between M. avium and M. intracellulare, differentiating between environmental species and subspecies of the MAC can aid in the assessment of health risks and control of MAC sources. A framework is proposed for incorporating the proposed dose response models into susceptible population- and exposure route-specific QMRA models.
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Affiliation(s)
- Kerry A Hamilton
- Department of Civil, Architectural, and Environmental Engineering, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA.
| | - Mark H Weir
- Division of Environmental Health Sciences and Department of Civil Environmental and Geodetic Engineering, The Ohio State University, USA
| | - Charles N Haas
- Department of Civil, Architectural, and Environmental Engineering, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA
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Wassilew N, Hoffmann H, Andrejak C, Lange C. Pulmonary Disease Caused by Non-Tuberculous Mycobacteria. Respiration 2016; 91:386-402. [PMID: 27207809 DOI: 10.1159/000445906] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/31/2016] [Indexed: 11/19/2022] Open
Abstract
Non-tuberculous mycobacteria (NTM) include more than 160 ubiquitous, environmental, acid-fast-staining bacterial species, some of which may cause disease in humans. Chronic pulmonary infection is the most common clinical manifestation. Although patients suffering from chronic lung diseases are particularly susceptible to NTM pulmonary disease, many affected patients have no apparent risk factors. Host and pathogen factors leading to NTM pulmonary disease are not well understood and preventive therapies are lacking. NTM isolation and pulmonary disease are reported to rise in frequency in Europe as well as in other parts of the world. Differentiation between contamination, infection, and disease remains challenging. Treatment of NTM pulmonary disease is arduous, lengthy, and costly. Correlations between results of in vitro antibiotic susceptibility testing and clinical treatment outcomes are only evident for the Mycobacterium avium complex, M. kansasii, and some rapidly growing mycobacteria. We describe the epidemiology of NTM pulmonary disease as well as emerging NTM pathogens and their geographical distribution in non-cystic fibrosis patients in Europe. We also review recent innovations for the diagnosis of NTM pulmonary disease, summarize treatment recommendations, and identify future research priorities to improve the management of patients affected by NTM pulmonary disease.
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Affiliation(s)
- Nasstasja Wassilew
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
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Halstrom S, Price P, Thomson R. Review: Environmental mycobacteria as a cause of human infection. Int J Mycobacteriol 2015; 4:81-91. [PMID: 26972876 DOI: 10.1016/j.ijmyco.2015.03.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 03/12/2015] [Indexed: 10/23/2022] Open
Abstract
Pulmonary infections with nontuberculous mycobacteria (NTM) are recognized as a problem in immunodeficient individuals and are increasingly common in older people with no known immune defects. NTM are found in soil and water, but factors influencing transmission from the environment to humans are mostly unknown. Studies of the epidemiology of NTM disease have matched some clinical isolates of NTM with isolates from the patient's local environment. Definitive matching requires strain level differentiation based on molecular analyses, including partial sequencing, PCR-restriction fragment length polymorphism (RFLP) analysis, random amplified polymorphic DNA (RAPD) PCR, repetitive element (rep-) PCR and pulsed field gel electrophoresis (PFGE) of large restriction fragments. These approaches have identified hospital and residential showers and faucets, hot-tubs and garden soil as sources of transmissible pathogenic NTM. However, gaps exist in the literature, with many clinical isolates remaining unidentified within environments that have been tested, and few studies investigating NTM transmission in developing countries. To understand the environmental reservoirs and transmission routes of pathogenic NTM, different environments, countries and climates must be investigated.
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Affiliation(s)
- Samuel Halstrom
- School of Medicine, University of Queensland, Room 513, Level 5, Mayne Medical Building, Herston Campus, Herston, Brisbane, QLD 4006, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Brisbane, QLD 4120, Australia.
| | - Patricia Price
- School of Biomedical Science, Curtin University of Technology, GPO Box U1987, Perth, WA 6845, Australia.
| | - Rachel Thomson
- School of Medicine, University of Queensland, Room 513, Level 5, Mayne Medical Building, Herston Campus, Herston, Brisbane, QLD 4006, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Brisbane, QLD 4120, Australia.
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Weiss CH, Glassroth J. Pulmonary disease caused by nontuberculous mycobacteria. Expert Rev Respir Med 2013; 6:597-612; quiz 613. [PMID: 23234447 DOI: 10.1586/ers.12.58] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The propensity of various nontuberculous mycobacteria to cause lung disease varies widely and is conditioned by host factors; infection is believed to occur from environmental sources. Nontuberculous mycobacteria pulmonary disease (PNTM) is increasing worldwide and Mycobacterium avium complex is the most common cause. PNTM usually occurs in one of three prototypical forms: hypersensitivity pneumonitis, cavitary tuberculosis-like disease or nodular bronchiectasis. PNTM has been linked in some patients to genetic variants of the cystic fibrosis transmembrane conductance regulator gene and a distinct patient phenotype. Interactions between PNTM and other comorbidities are also increasingly appreciated. Guidelines for diagnosis, emphasizing chest imaging and microbiology, have been published; speciation using molecular techniques is critical for accuracy and for treatment decisions. Clinical trials are lacking to inform treatment for many species and experience with M. avium complex and several others species serves as a guide instead. Use of multiple drugs for a period of at least 12 months following sputum conversion is the norm for most species. In vitro drug susceptibility results for many drugs may not correlate with clinical outcomes and such testing should be done on a selective basis.
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Affiliation(s)
- Curtis H Weiss
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest 2012; 142:208-217. [PMID: 22796841 DOI: 10.1378/chest.11-2479] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an allergen to which the subject has been previously sensitized. The diagnosis of HP most often relies on an array of nonspecific clinical symptoms and signs developed in an appropriate setting, with the demonstration of interstitial markings on chest radiographs, serum precipitating antibodies against offending antigens, a lymphocytic alveolitis on BAL, and/or a granulomatous reaction on lung biopsies. The current classification of HP in acute, subacute, and chronic phases is now challenged, and a set of clinical predictors has been proposed. Nonspecific interstitial pneumonitis, usual interstitial pneumonia, and bronchiolitis obliterans organizing pneumonia may be the sole histologic expression of the disease. Presumably, like in idiopathic interstitial pneumonia, acute exacerbations of chronic HP may occur without further exposure to the offending antigen. New offending antigens, such as mycobacteria causing hot tub lung and metalworking fluid HP, have recently been identified and have stimulated further research in HP.
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Affiliation(s)
- Yves Lacasse
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada.
| | - Mélissa Girard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
| | - Yvon Cormier
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
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Abstract
Nontuberculous mycobacteria (NTM) are generally hardy, ubiquitous environmental bacteria that vary in geographic distribution and pulmonary pathogenicity. Relatively few of the more than 115 species of NTM have been associated with lung disease. Diagnosis of disease due to NTM relies on a combination of clinical, imaging, and microbiologic data. Because NTM may present as acid-fast bacilli in respiratory secretions of patients with clinical and radiologic features that mimic tuberculosis, laboratory discrimination of NTM from Mycobacterium tuberculosis is a priority. This discrimination is now often rapidly achievable using molecular techniques, although some tests have limited sensitivity. NTM species have different antibiotic response patterns, and success with medical treatment alone varies. Macrolides are an essential component of therapy for many species but must be combined with other drugs.
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Affiliation(s)
- Babafemi Taiwo
- Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Mukhopadhyay S, Gal AA. Granulomatous lung disease: an approach to the differential diagnosis. Arch Pathol Lab Med 2010; 134:667-90. [PMID: 20441499 DOI: 10.5858/134.5.667] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Granulomas are among the most commonly encountered abnormalities in pulmonary pathology and often pose a diagnostic challenge. Although most pathologists are aware of the need to exclude an infection in this setting, there is less familiarity with the specific histologic features that aid in the differential diagnosis. OBJECTIVE To review the differential diagnosis, suggest a practical diagnostic approach, and emphasize major diagnostically useful histologic features. This review is aimed at surgical pathologists who encounter granulomas in lung specimens. DATA SOURCES Pertinent recent and classic peer-reviewed literature retrieved from PubMed (US National Library of Medicine) and primary material from the institutions of both authors. CONCLUSIONS Most granulomas in the lung are caused by mycobacterial or fungal infection. The diagnosis requires familiarity with the tissue reaction as well as with the morphologic features of the organisms, including appropriate interpretation of special stains. The major noninfectious causes of granulomatous lung disease are sarcoidosis, Wegener granulomatosis, hypersensitivity pneumonitis, hot tub lung, aspiration pneumonia, and talc granulomatosis.
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Affiliation(s)
- Sanjay Mukhopadhyay
- Department of Pathology, State University of New York Upstate Medical University, Syracuse, New York 13210, USA.
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Bak JY, Kim KS, Park IN, Yum HK, Lee SH, Lee HK, Lee YM, Jung H, Hur JW, Lee SS, Lee HP, Choi SJ, Shin EA, Choi SB. Two Cases of Hot Tub Lung in Bodyscrubbers Working in a Public Bath. Tuberc Respir Dis (Seoul) 2009. [DOI: 10.4046/trd.2009.66.1.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Young Bak
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Kwang Sil Kim
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - I-Nae Park
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Ho-Kee Yum
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Seung Heon Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hyun-Kyung Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Young Min Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hoon Jung
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Jin-Won Hur
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Seong Soon Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hyuk Pyo Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Soo Jeon Choi
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Eun Ah Shin
- Department of Pathology, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Sang Bong Choi
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
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McGrath EE, McCabe J, Anderson PB. Guidelines on the diagnosis and treatment of pulmonary non-tuberculous mycobacteria infection. Int J Clin Pract 2008; 62:1947-55. [PMID: 19166441 DOI: 10.1111/j.1742-1241.2008.01891.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
While the prevalence of Mycobacterium tuberculosis continues to decline in the developed world, the same cannot be said for non-tuberculous mycobacteria (NTM). These organisms are increasing in incidence and prevalence throughout the world. This is probably because of a combination of increased exposure, improved diagnostic methods and an increase in the prevalence of risk factors that predispose individuals to infection. Considerable confusion can arise in determining in the wide range of species whether an isolated NTM is in fact a contaminant or a pathogenic organism when isolated in sputum or bronchoalveolar lavage. This confusion combined with increasing requests for advice on the treatment of disease has led to the development of guidelines to assist the clinician in diagnosing and treating infection accurately.
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Affiliation(s)
- E E McGrath
- Department of Respiratory Medicine, Northern General Hospital, Sheffield, UK.
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Glazer CS, Martyny JW, Lee B, Sanchez TL, Sells TM, Newman LS, Murphy J, Heifets L, Rose CS. Nontuberculous mycobacteria in aerosol droplets and bulk water samples from therapy pools and hot tubs. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2007; 4:831-40. [PMID: 17846927 DOI: 10.1080/15459620701634403] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Hot tub exposure has been causally associated with a steroid-responsive, granulomatous lung disease featuring nontuberculous mycobacterial (NTM) growth in both clinical and environmental samples. Little is known regarding prevalence of and risk factors for NTM-contamination and associated illness in these settings. In this study, the frequency of NTM growth and aerosolization in 18 public hot tubs and warm water therapy pools and the factors associated with mycobacterial growth were analyzed. Each site was characterized by water chemistry analysis; a questionnaire on maintenance, disinfection, and water quality; and air and water sampling for quantitative NTM culture. NTM were detected in air or water from 13/18 (72%) sites; a strong correlation was found between the maximum air and water NTM concentrations (rho 0.49, p = 0.04). Use of halogen (chlorine or bromine) disinfection was associated with significantly lower air and water concentrations of NTM compared with disinfection using ultraviolet light and hydrogen peroxide (p = 0.01-0.04). Higher water turnover rates were also associated with lower air and water NTM concentrations (p = 0.02-0.03). These findings suggest that NTM are frequently detectable in the air and water of spas and therapy pools and that particular maintenance and disinfection approaches affect NTM bioaerosol concentrations in these settings.
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Affiliation(s)
- Craig S Glazer
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Sood A, Sreedhar R, Kulkarni P, Nawoor AR. Hypersensitivity pneumonitis-like granulomatous lung disease with nontuberculous mycobacteria from exposure to hot water aerosols. ENVIRONMENTAL HEALTH PERSPECTIVES 2007; 115:262-6. [PMID: 17384775 PMCID: PMC1817695 DOI: 10.1289/ehp.9542] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2006] [Accepted: 11/06/2006] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Human activities associated with aerosol-generating hot water sources are increasingly popular. Recently, a hypersensitivity pneumonitis (HP)-like granulomatous lung disease, with non-tuberculous mycobacteria from exposure to hot water aerosols from hot tubs/spas, showers, and indoor swimming pools, has been described in immunocompetent individuals (also called "hot tub lung"). Our objective in this study was to examine four additional cases of hot tub lung and compare these cases with others reported in the English print literature on this disease. DATA SOURCES AND EXTRACTION We retrospectively reviewed all cases (n = 4) of presumptively diagnosed hot tub lung in immunocompetent individuals at the various physician practices in Springfield, Illinois, during 2001-2005. In addition, we searched MEDLINE for cases of hot tub lung described in the literature. DATA SYNTHESIS We summarized the clinical presentation and investigations of four presumptive cases and reviewed previously reported cases of hot tub lung. CONCLUSIONS There is a debate in the literature whether hot tub lung is an HP or a direct infection of the lung by nontuberculous mycobacteria. Primary prevention of this disease relies on ventilation and good use practices. Secondary prevention of this disease requires education of both the general public and clinicians to allow for the early diagnosis of this disease.
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Affiliation(s)
- Akshay Sood
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131, USA.
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Abstract
As the prevalence of tuberculosis (TB) declines in the developed world, the proportion of mycobacterial lung disease due to nontuberculous mycobacteria (NTM) is increasing. It is not clear whether there is a real increase in prevalence or whether NTM disease is being recognized more often because of the introduction of more sensitive laboratory techniques, and that more specimens are being submitted for mycobacterial staining and culture as the result of a greater understanding of the role of NTM in conditions such as cystic fibrosis, posttransplantation and other forms of iatrogenic immunosuppression, immune reconstitution inflammatory syndrome, fibronodular bronchiectasis, and hypersensitivity pneumonitis. The introduction of BACTEC liquid culture systems (BD; Franklin Lakes, NJ) and the development of nucleic acid amplification and DNA probes allow more rapid diagnosis of mycobacterial disease and the quicker differentiation of NTM from TB isolates. High-performance liquid chromatography, polymerase chain reaction, and restriction fragment length polymorphism analysis have helped to identify new NTM species. Although treatment regimens that include the newer macrolides are more effective than the earlier regimens, failure rates are still too high and relapse may occur after apparently successful therapy. Moreover, treatment regimens are difficult to adhere to because of their long duration, adverse effects, and interactions with the other medications that these patients require. The purpose of this article is to review the common presentations of NTM lung disease, the conditions associated with NTM lung disease, and the clinical features and treatment of the NTM that most commonly cause lung disease.
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Affiliation(s)
- Stephen K Field
- Division of Respiratory Medicine, University of Calgary Medical School and Tuberculosis Services, Calgary Health Region, Calgary, AB, Canada.
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Hanak V, Kalra S, Aksamit TR, Hartman TE, Tazelaar HD, Ryu JH. Hot tub lung: presenting features and clinical course of 21 patients. Respir Med 2005; 100:610-5. [PMID: 16194601 DOI: 10.1016/j.rmed.2005.08.005] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 08/17/2005] [Accepted: 08/18/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hot tub lung is an emerging lung disorder associated with exposure to Mycobacterium avium complex organisms contaminating hot tub water. OBJECTIVES To define the clinical characteristics and outcome of patients with hot tub lung. METHODS Retrospective review of 21 patients diagnosed with hot tub lung at a tertiary medical center over a 7-year period. RESULTS The mean (+/-sd) age at presentation was 46 (+/- 15) years; 9 patients were men (43%). All patients described ongoing exposure to hot tubs. The most common referral diagnoses were sarcoidosis, bronchitis, and asthma. Dyspnea and cough were present in all patients, hypoxemia was noted in 10 patients (48%). High-resolution computed tomography of the chest had been performed in 20 patients and demonstrated diffuse centrilobular nodules and/or ground-glass opacities in all patients. M. avium complex was isolated from the hot tub water, respiratory secretions and/or lung tissue in all patients. Bronchoscopic or surgical lung biopsy was obtained in 18 patients and demonstrated bronchiolocentric granulomatous inflammation. With avoidance of exposure, clinical and radiologic improvement was observed in all patients. Additionally, 13 patients (62%) received corticosteroid therapy, 1 (5%) antimycobacterial therapy, 2 (10%) received both, and 5 patients (24%) received no pharmacologic therapy. CONCLUSIONS Hot tub lung likely represents hypersensitivity pneumonitis due to inhalational exposure to M. avium complex. Antimycobacterial therapy does not appear to be required in the management of this disease. Although corticosteroids may be helpful in the treatment of severely affected patients, others can be managed by avoidance of additional exposure alone.
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Affiliation(s)
- Viktor Hanak
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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