Trombone Player’s Lung: A Probable New Cause of Hypersensitivity Pneumonitis FREE TO VIEW

A 35-year-old male professional trombone player sought care for a chronic, nonproductive cough that had not remitted for approximately 15 years. He denied symptoms suggesting rhinitis or esophageal reflux and had not responded to gastric acid suppression, bronchodilators, corticosteroids, and treatment of rhinitis. There had been periods when the cough was more severe and associated with dyspnea and low-grade fever. Allergy testing was negative. There was no relevant past history, medication use, substance use, or exposure. The physical examination and a chest radiograph were normal, and pulmonary function tests, including a methacholine challenge test were normal. A high-resolution CT (HRCT) scan of the chest demonstrated a mosaic pattern on the expiratory views. Bronchoscopic examination revealed no endobronchial abnormalities. Subsequently, the patient noted that his symptoms improved significantly when he did not play his trombone for 2 weeks and that the periods of more severe symptoms had been when he was playing more than usual.

A diagnosis of hypersensitivity pneumonitis (HP) due to a contaminated trombone was entertained (brass players inhale with the instrument at their mouth between measures). The inside of the instrument showed innumerable whitish plaques suggesting bacterial colonies. A smear of the biofilm revealed fungal elements, and the Ziehl-Neelsen smear revealed > 100 acid-fast bacilli per oil immersion field (×1,000). Cultures revealed large numbers of Mycobacterium chelonae/abscessus group, Fusarium sp (a mold), and scant Stenotrophomonas maltophilia and Escherichia coli. After the patient began immersing his instrument regularly in 91% isopropyl alcohol, his cough resolved completely over several weeks. He has been symptom free for approximately 20 months, except when he neglected to clean his instrument for more than a month.

After approval from our Human Subjects Committee and informed consent, instruments of seven additional brass musicians were sampled. Mycobacteria were identified using standard culture and molecular methods.¹ All seven musicians (95% CI, 63%-100%) had at least one instrument contaminated with either mycobacterial or fungal species previously associated with HP (Table 1).^2-7 Pulsed-field gel electrophoresis demonstrated that none of the three musicians who had instruments contaminated with M abscessus subsp abscessus shared the same strain.

Although we did not pursue a tissue diagnosis, we feel that our patient most likely had HP due to the contaminated trombone. The characteristic symptoms, the improvement when he was not playing and after the trombone was cleaned, and the temporary worsening when he neglected to clean the trombone all support a causal link. The systemic symptoms when he was most ill make other diagnoses such as irritant-induced bronchitis unlikely. His CT scan showed evidence of expiratory air trapping, also consistent with a diagnosis of HP. Although the HRCT scan did not demonstrate interstitial abnormalities, approximately 50% of patients with biopsy-proven HP due to inhalation of contaminated aerosols may have a normal HRCT scan.⁸

Because HP from exposure to aerosols containing mycobacteria or fungi is not an unusual, idiosyncratic reaction,^1,2,6,7 our findings suggest that many brass musicians are at risk for HP from contaminated instruments, and standard cleaning methods may not be adequate to prevent this complication. Regular cleaning with 91% isopropyl alcohol appears to be effective.

Other contributions: We acknowledge, with gratitude, the assistance of the staff of the University of Connecticut Health Center Microbiology Laboratory, including Donna Clout, MT; Tien Vo, MT; and Feliciano Dias, RM (NRM); and the assistance of the Mycobacteria/Nocardia Laboratory staff of the University of Texas Health Science Center at Tyler, including Steven McNulty, BS; Linda Bridge, BS; and Ravikiran Vasireddy, MBIOT.