Hypersensitivity pneumonitis reaction to Mycobacterium avium in household water.
BACKGROUND
Hypersensitivity pneumonitis has been described with exposure to aerosolized Mycobacterium avium complex (MAC) in indoor hot tubs (hot tub lung).


OBJECTIVE
To describe a case of MAC-associated hypersensitivity pneumonitis-like reaction possibly from showering and review previous hot tub lung reports.


METHODS
For the case report, we investigated a patient with histologically diagnosed hypersensitivity pneumonitis and MAC-positive sputum culture findings. Mycobacterial cultures were obtained from his home and workplace. Isolates were typed using pulsed-field gel electrophoresis. For the review, MEDLINE and EMBASE were searched for hot tub lung reports, which were reviewed and summarized.


RESULTS
A 50-year-old man had progressive dyspnea and episodic fever and myalgias. Pulmonary function testing results revealed obstruction and impaired diffusion; a chest CT scan found diffuse, centrilobular, ground-glass nodules, and air trapping, and a lymphocytic alveolitis with an elevated CD4/CD8 ratio. Transbronchial biopsy showed multiple well-formed nonnecrotizing granulomas. Multiple respiratory samples and shower and bathtub specimens grew MAC, with matching pulsed-field gel electrophoresis patterns. The patient changed from showering to tub bathing. Prednisone and antimycobacterial drugs were administered for approximately 1 year. His symptoms, pulmonary function abnormalities, and CT scan findings resolved. The literature review yielded 36 cases of hot tub lung. Clinical features included dyspnea (97%), cough (78%), and fever (58%). Pulmonary function testing showed obstruction (67%), restriction (55%), and impaired diffusion (75%). A chest CT scan showed ground-glass opacification (95%) and nodules (67%). Granulomas were well-formed in 95%. Treatments included discontinuation of hot tub use and prednisone, antimycobacterial drugs, or both. Outcomes were favorable.


CONCLUSIONS
A hypersensitivity pneumonitis-like reaction to mycobacteria can occur from exposures other than hot tubs. There are key differences between classic hypersensitivity pneumonitis and MAC-associated hypersensitivity pneumonitis. Antimycobacterial therapy may be required. The possibility of MAC hypersensitivity pneumonitis from showering raises potential implications in the investigation of patients with hypersensitivity pneumonitis.
Marras
Theodore K
TK
Division of Respirology, Toronto Western Hospital, Edith Cavell 4-022, 399 Bathurst St, Toronto, ON, Canada M5T 2S8. ted.marras@utoronto.ca
Wallace
Richard J
RJ
Koth
Laura L
LL
Stulbarg
Michael S
MS
Cowl
Clayton T
CT
Daley
Charles L
CL
D000542:Alveolitis, Extrinsic Allergic / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D001706:Biopsy; D006801:Humans; D006875:Hydrotherapy; D008168:Lung / Q000473:pathology; D008297:Male; D008875:Middle Aged; D015269:Mycobacterium avium Complex; D015270:Mycobacterium avium-intracellulare Infection / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D014057:Tomography, X-Ray Computed; D014871:Water Microbiology