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Chest Infections |

Trombone Lung: A New Cause of Atypical Mycobacterium Infection

William Corrao, MD
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Alpert School of Medicine, Brown University, Providence, RI


Chest. 2014;145(3_MeetingAbstracts):111A. doi:10.1378/chest.1826469
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Abstract

SESSION TITLE: Infectious Disease Case Reports Posters III

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Abstract: A previously healthy 24-year-old male presented with a two-day history of hemoptysis. Chest Xray and CT scan showed a multi-cavitary lesion in the right upper lobe. Sputum acid-fast bacilli (AFB) was positive. Cultures grew Mycobacterium Kansasii. The patient played trombone in a band. The slide of his instrument was smeared and cultured. The smear was positive for AFB. The trombone was felt to be the source of the patient’s infection. While there are case reports of atypical mycobacterium associated with hypersensitivity pneumonitis, infection from this type of exposure is felt to be rare.

CASE PRESENTATION: A 24-year-old male presented to his primary care physician with a two-day history of hemoptysis. He reported coughing bright red blood four times withing a 48 hour period, approximately a teaspoonful each time. The patient denied sputum mixed with blood, epistaxis, chest pain, shortness of breath, fever, chills, sweats, anorexia, and weight loss. He had not traveled outside of his hometown in many years. He was a non-smoker, monogamous, had no pets, and was employed as a musician. Past medical history: negative - no alcohol or substance abuse Review of systems: negative Physical examination: Awake, alert, in no acute distress Vital signs: BP 132/76; PR 88; RR 18; T 98F HEENT: no epistaxis; normal oro pharynx; normal teeth/gingiva Chest: rhonchi heard posteriorly RUL Heart: regular rate & rhythm; no murmurs, gallops, or rubs Abdomen: no organomegaly Neurologic: normal Extremities: no clubbing, cyanosis, or edema PPD - 10mm in duration Laboratory: chest Xray - RUL multi-cavitary lesion; no air fluid levels. CT scan: Multi-cavitary lesion in the RUL; no other abnormalities seen CBC: normal Hgb/Hct, WBC and differential Normal BG, BUN, Cr, electrolytes, LFT’s, IgG’s, HIV test, RF, c’ANCA, p’ANCA, ANA Expectorated sputum: positive AFB; sputum culture positive for Mycobacterium Kansasii

DISCUSSION: Clinical Course: After the initial positive AFB smear, a four-drug regimen with isoniazid, rifampin, ethambutol, and pyrazinamide was started for presumed Mycobacterium Tuberculosis. Two weeks later, the sputum culture grew Mycobacterium Kansasii. Isoniazid and Pyrazinamide were discontinued. Rifampin and ethambutol were continued for 18 months. The patient has remained asymptomatic. His chest Xray showed closure of the right upper lobe cavities with a small scar forming in the affected area. The unusual feature of this case was the finding of Mycobacterium Kansasii in a young, normal host in a geographic area where this mycobacterium is rarely cultured.

CONCLUSIONS: There have been cases of hypersensitivity pneumonitis caused by atypical mycobacterium in wind instrument musicians. This patient played the trombone. The slide of his instrument was rinsed with sterile normal saline, smeared, and cultured. The smear was positive for AFB; culture was negative. The trombone was felt to be the reservoir for the source of the patient’s mycobacterial infection.

Reference #1: Khoor A, Leslie KO, Tazelaar HD, Helmers RA, Colby TV. Diffuse Pulmonary Disease Caused by Non-Tuberculous Mycobacteria in Immunocompetent People (Hot Tub Lung). American Journal of Clinical Pathology 2001, 115: 755-62.

Reference #2: Catanzaro A. Diagnosis, Differentiating Colonization, Infection and Disease. Clinics in Chest Medicine 2002, 23(3): 559-602.

Reference #3: Evans SA, Colville A. Pulmonary Mycobacterium kansasii infection: comparison of the clinical features, treatment, & outcome with pulmonary tuberculosis. Thorax 1996, 51: 1248-52.

DISCLOSURE: The following authors have nothing to disclose: William Corrao

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