Occupational and Environmental Lung Diseases: Student/Resident Case Report Poster - Occupational and Environmental Lung Diseases |

Hot Tub Lung Without Microbiologic Evidence of Non-Tuberculous Mycobacterium FREE TO VIEW

Vivek Jayaschandran, MBBS; Enrique Soltero Mariscal, MD; Vishal Patel, MD; Nader Mina, MD; Bhavinkumar Dalal, MD
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William Beaumont Hospital, Royal Oak, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):943A. doi:10.1016/j.chest.2016.08.1044
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SESSION TITLE: Student/Resident Case Report Poster - Occupational and Environmental Lung Diseases

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Hot Tub Lung is a hypersensitivity pneumonitis like disease from exposure to Non-Tuberculous Mycobacterium (NTM) contaminating hot tub water. We describe here a case with biopsy highly suggestive of Hot Tub Lung, but with no microbiologic evidence of NTM

CASE PRESENTATION: 70-year-old, immunocompetent, African American female with history of chronic dyspnea and hypoxia presented with worsening dyspnea and cough. She had recurrent hospital admissions in the preceding months with similar presentation, which were managed as COPD exacerbations. PFT results revealed restrictive pattern and no obstruction. Chest CT and HRCT both showed diffuse, interstitial pattern with fibrosis and traction bronchiectasis predominantly in upper lobes. Borderline enlargement of mediastinal lymph nodes were noted. Bronchoscopy, BAL, trans-bronchial biopsy and endobronchial ultrasound guided trans-bronchial needle aspiration were negative for sarcoidosis. BAL demonstrated predominantly macrophages without evidence of infection. An open lung biopsy showed patchy chronic inflammation with few eosinophils, multiple foci of atypical adenomatous hyperplasia with non-necrotizing granulomas in interstitium and airspace suggestive of hypersensitivity pneumonitis (HP). The granulomas were larger and well-formed than those typically seen in HP and resembled a pathologic picture seen in hot tub lung disease. HP panel for allergens were negative. On inquiring for exposure, patient reported use hot pool therapy twice (for joint pains), for 12 weeks, around the time of onset of dyspnea exacerbations. She also had exposure to hot pool 30 years ago. However, BAL specimen and lung biopsy were negative for AFB.

DISCUSSION: The unique histopathology seen in hot tub pneumonitis differentiates it from other hypersensitivity pneumonitis and sarcoidosis. This is characterized by non-necrotizing granulomas in centri-lobular and bronchocentric distribution. Although microbiological data is critical, IDSA guidelines recommend that the characteristic histopathology alone may be sufficient to raise suspicion of diagnosis, as is the case in our patient. It is also interesting that our patient had no resolution of symptoms despite discontinuing hot tub exposure. We believe this could be due to two reasons. First, a source other than hot tub as the precipitant; as a matter of fact there have been reports of hot tub pneumonitis from exposure to shower. Second, disease had progressed enough to leave permanent lung damage and fibrosis.

CONCLUSIONS: To our knowledge, this is the first reported case of a biopsy picture highly suggestive of hot tub pneumonitis without corroborating microbiologic evidence.

Reference #1: Griffith, David E., et al. “An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases.”American journal of respiratory and critical care medicine 175.4 (2007): 367-416.

DISCLOSURE: The following authors have nothing to disclose: Vivek Jayaschandran, Enrique Soltero Mariscal, Vishal Patel, Nader Mina, Bhavinkumar Dalal

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