Hypersensitivity Pneumonitis Associated With Mycobacterium avium Complex and Hot Tub Use

doi:10.4065/77.11.1233

Mayo Clinic Proceedings

Volume 77, Issue 11, November 2002, Pages 1233-1237

https://doi.org/10.4065/77.11.1233 Get rights and content

Many diseases, mainly infectious and inhalational, have been associated with the use of hot tubs. “Hot tub lung” is a recently described disease entity associated with Mycobacterium avium complex (MAC) and is thought to be either an infection or a hypersensitivity pneumonitis. We describe 2 patients with progressively worsening respiratory symptoms and pulmonary function, along with diffuse radiographic changes consisting primarily of ground-glass opacities. Treatment with corticosteroids, based on lung biopsies suggesting sarcoidosis in 1 patient and eosinophilic bronchiolitis in the other, resulted in little improvement with both patients experiencing respiratory failure. Both patients continued regular and continued hot tub use despite ongoing respiratory difficulties, and MAC was identified in the hot tub water and/or lung tissue from each patient. Discontinuation of hot tub use, without antimycobacterial therapy, led to prompt improvement in symptoms, pulmonary function, and radiographic abnormalities, strongly supporting a diagnosis of hypersensitivity pneumonitis. Hypersensitivity to MAC, rather than an infection, is the likely underlying mechanism in these 2 cases of hot tub lung.

Section snippets

Case 1

A 45-year-old female exsmoker (25 pack-years; quit in February 2000) presented to our institution in July 2000 for a second opinion regarding a diagnosis of “sarcoidosis.” She had a history of rheumatoid arthritis and fibromyalgiabut no lung disease. Her problems began in February 2000 when she developed fever (38.3°C), chills, cough, and dyspnea. Pneumonia was diagnosed, and she was treated with a course of antibiotics, inhaled bronchodilators, and eventually prednisone. She noted marked

DISCUSSION

MAC is commonly found in natural waters and tap water.⁷ It rarely causes disease in the immunocompetent host in whom it has been recognized mainly as a chronic pulmonary infection, often associated with bronchiectasis.⁸ In patients with the acquired immunodeficiency syndrome and other immunosuppressed hosts, disseminated MAC occurs more frequently. other manifestations of MAC include lymphadenopathy, pulmonary nodules, consolidation, interstitial infiltrates, cavities, and even masslike lesions.

CONCLUSION

Our 2 patients had many features of hypersensitivity pneumonitis, including ground-glass infiltrates, clinical improvement with corticosteroids, and resolution of symptoms with discontinuation of hot tub use. Neither patient received antimicrobial therapy appropriate for MAC; in fact, both improved with immunosuppression. Of note, all the cases of hot tub lung reported in the literature have been associated with a hot tub indoors at a personal residence. Although hot tub lung often demonstrates

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Nontuberculous mycobacterial pulmonary disease (NTM-PD) is increasingly recognized in the U.S. and worldwide as a debilitating disease that is challenging to diagnose and manage. Beyond the principle task of recognizing the protean imaging manifestations of NTM-PD, radiologists will need to appropriately communicate with pulmonology and infectious disease colleagues in multidisciplinary management discussions. This update on nontuberculous mycobacteria (NTM) species, their clinical significance, and imaging features aims to support these roles. Terminology mirrors that laid out by the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) published guidelines on NTM-PD.¹
Approach to the diagnosis and treatment of non-tuberculous mycobacterial disease
2021, Journal of Clinical Tuberculosis and Other Mycobacterial Diseases
Non-tuberculous mycobacteria (NTM) is a collective name given to a group of more than 190 species of Mycobacterium. The clinical presentation for most NTM infections is non-specific, often resulting in delayed diagnosis. Further complicating matters is that NTM organisms can be difficult to isolate. Medications used to treat NTM infection can be difficult for patients to tolerate, and prolonged courses of anti-mycobacterial therapy are often required for adequate suppression or eradication. Herein, we review different NTM syndromes, appropriate diagnostic tests, and treatment regimens.
Hypersensitivity pneumonitis: A new strategy for serodiagnosis and environmental surveys
2019, Respiratory Medicine
Citation Excerpt :
More than 30 specific molds and mycobacteria have been identified as playing a causative role [29]. Among the many factors and circumstances that contribute to the development of domestic HP are contaminated humidifiers, faulty ventilation systems and jacuzzis (Mycobacterium avium) [30,31]. Even HP due to leisure activities [32–34] are now recognized [14].
We propose a strategy for serodiagnosis of hypersensitivity pneumonitis (HP): 1) question patients about their private or occupational activity, or visit him on site; 2) select panels of six somatic specific antigens appropriate for each type of exposure; 3) and use ELISA to test concomitantly two recombinant antigens highly specific to Farmer's lung, Metalworking-fluid HP, and for Bird fancier's lung. The serodiagnosis provides an immunological argument that may complete radiological, functional lung exploration and clinical features; 4) If the serodiagnosis is negative but the suspicion of HP is strong, a microbial analysis of the patient's specific exposure is conducted; 5) “A la carte” antigens are produced from the microorganisms isolated in the patient's environment sample and tested; 6) Finally, the patient may be asked to undergo a specific inhalation challenge with the offending antigens in a safety cabin, or to avoid his usual environment for a few days.
Hypersensitivity pneumonitis and abscess reaction to nontuberculous mycobacteria acquired form jacuzzi aerosol
2019, Revue des Maladies Respiratoires
Le complexe Mycobacterium avium (MAC) peut donner plusieurs tableaux radiocliniques allant d’une infection invasive à une pneumopathie d’hypersensibilité (PHS) secondaire à des inhalations répétées d’antigènes. Le diagnostic de PHS repose sur un faisceau d’arguments cliniques, radiologiques, biologiques et microbiologiques.
Nous rapportons le cas d’un homme de 61 ans qui a développé une PHS à mycobactéries atypiques secondaire à l’utilisation répétée d’un spa personnel, compliquée d’une insuffisance respiratoire chronique, dont le diagnostic a été fortement orienté par l’analyse environnementale. Le traitement immunosuppresseur par corticoïdes et méthotrexate a permis une amélioration modérée mais a aussi probablement favorisé l’apparition d’un abcès à Mycobacterium intracellulare. Malgré un traitement antibiotique bien conduit pendant douze mois, l’évolution fut défavorable avec récidive de l’infection à M. intracellulare trois mois après l’arrêt de celui-ci, puis décès du patient.
La PHS à mycobactéries doit être suspectée chez les patients disposant d’un spa. En l’absence de documentation microbiologique, l’analyse environnementale peut orienter le diagnostic. L’évolution défavorable des PHS n’est pas habituelle, le pronostic dépend du degré de fibrose sous-jacent.
Mycobacterium avium complex can be responsible for a number of different radio-clinical presentations, ranging from invasive infections to hypersensitivity pneumonitis due to repeated inhalation of antigens. The diagnosis of hypersensitivity pneumonitis is clinical, radiological, biological and microbiological.
A 61-year-old male developed a hypersensitivity pneumonitis reaction to non-tuberculous mycobacteria, following the repeated use of his own spa, which later evolved into chronic respiratory failure. The diagnosis was made via an environmental analysis. Immunosuppressive treatment comprising corticosteroids and methotrexate led to moderate improvement, but may also have been responsible for the development of a M. intracellulare abscess. Despite 12 months of well-conducted antibiotic treatment, the evolution was unfavourable, with a relapse of a M. intracellulare infection three months after the end of treatment, followed by the patient's death.
Hypersensitivity pneumonitis reaction to non-tuberculous mycobacteria should be considered in patients who have their own spa. In the absence of microbiological identification, environmental analysis may guide the diagnosis. A fatal evolution of PHS is infrequent but prognosis may depend on the degree of associated fibrosis.
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
2017, Water Research
Citation Excerpt :
However, summarizing these outbreaks can also help to contextualize HP-dose relationships. Multiple studies have described point source-associated cases or outbreaks of hypersensitivity pneumonitis after exposure to MAC in hot tubs or spas (Aksamit, 2003; Cappelluti et al., 2003; Embil et al., 1997; Fjällbrant et al., 2013; Glazer et al., 2007; Hanak et al., 2006; Kahana et al., 1997; Khoor et al., 2001; Koschel, 2006; Lumb et al., 2004; Mangione et al., 2001; Marchetti et al., 2004; Marras et al., 2005; Moraga-McHaley et al., 2013; O'Neil et al., 2006; Pham et al., 2003; Rickman et al., 2002; Sood et al., 2007; Sugita et al., 2000; Travaline and Kelsen, 2003). Others hypersensitivity pneumonitis outbreaks have been reported in swimming pool attendants, water damaged-buildings, and occupational settings, but did not identify MAC specifically during patient examinations or environmental investigations (Falkinham, 2003).
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.
Review: Environmental mycobacteria as a cause of human infection
2015, International Journal of Mycobacteriology
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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Mayo Clinic Proceedings

Section snippets

Case 1

DISCUSSION

CONCLUSION

REFERENCES (21)

Another hot tub hazard: toxicity secondary to bromine and hydrobromic acid exposure

Chest

Mycobacterium avium complex infection in an immunocompetent young adult related to hot tub exposure

Chest

Pulmonary illness associated with exposure to Mycobacterium-avium complex in hot tub water: hypersensitivity pneumonitis or infection?

Chest

Machine operator's lung: a hypersensitivity pneumonitis disorder associated with exposure to metalworking fluid aerosols

Chest

The diagnosis of hypersensitivity pneumonitis [editorial]

Chest

Hypersensitivity systemic reaction following intravesical bacillus Calmette-Guerin: successful treatment with steroids

J Urol

Humidifier lung and humidifier fever

Lung

Hot tub legionellosis: Legionnaires' disease and Pontiac fever after a point-source exposure to Legionella pneumophila

Arch Intern Med

Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung)

Am J Clin Pathol

Diagnosis and treatment of disease caused by nontuberculous mycobacteria

Am J Respir Crit Care Med

Cited by (75)

Nontuberculous Mycobacterial Pulmonary Disease: A Clinical and Radiologic Update

Approach to the diagnosis and treatment of non-tuberculous mycobacterial disease

Hypersensitivity pneumonitis: A new strategy for serodiagnosis and environmental surveys

Hypersensitivity pneumonitis and abscess reaction to nontuberculous mycobacteria acquired form jacuzzi aerosol

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

Review: Environmental mycobacteria as a cause of human infection

Case ReportHypersensitivity Pneumonitis Associated With Mycobacterium avium Complex and Hot Tub Use

Section snippets

Case 1

DISCUSSION

CONCLUSION

Chest

Chest

Chest

Chest

Chest

J Urol

Humidifier lung and humidifier fever

Lung

Hot tub legionellosis: Legionnaires' disease and Pontiac fever after a point-source exposure to Legionella pneumophila

Arch Intern Med

Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung)

Am J Clin Pathol

Diagnosis and treatment of disease caused by nontuberculous mycobacteria

Am J Respir Crit Care Med

Case Report
Hypersensitivity Pneumonitis Associated With Mycobacterium avium Complex and Hot Tub Use