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1/6. Hot tub-related Mycobacterium avium intracellulare pneumonitis.

    Atypical Mycobacteria have been widely known to cause opportunistic infections in patients with AIDS. Recently, cases have been reported of patients colonized with atypical Mycobacteria who are only partially responsive to antibacterial treatment. It is thought that perhaps these cases represent a clinically different subset of patients that not only have underlying infection, but hypersensitivity disease as well, which may be responsive to concomitant treatment with oral corticosteroids.
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2/6. hypersensitivity pneumonitis associated with mycobacterium avium complex and hot tub use.

    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.
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keywords = avium
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3/6. 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). OBJECTIVES: 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.
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keywords = avium
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4/6. Characterization of functional, radiologic and lung function recovery post-treatment of hot tub lung. A case report and review of the literature.

    Hot tub lung is described as an acute pulmonary illness that is characterized by fever, dyspnea and interstitial nodular infiltrates. Although not entirely clear, the etiology may be a hypersensitivity pneumonitis, an infection secondary to Mycobacterium avium intracellulare (MAC), or possibly both. Herein we describe the most well-characterized physiologic, radiographic, and functional recovery from hot tub lung reported in the literature to date. Pulmonary function testing and CT scans of the chest were obtained after each therapeutic intervention, and the patient had the most dramatic improvement with simply avoiding the hot tub. prednisone therapy offered minimal further improvement while anti-MAC therapy provided no further improvement. These results are suggestive of a hypersensitivity pneumonitis rather than an infectious etiology.
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keywords = avium
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5/6. A woman with cough, fever, and micronodular infiltrates on chest radiograph.

    Hot tub lung is a form of hypersensitivity pneumonitis (HP) reported to be associated with exposure to large aerosolized inocula of mycobacterium avium complex (MAC). Although the pathogenesis of the disease is still poorly understood, the pathology of MAC-related HP can be similar to that of sarcoidosis, with well-formed granulomas. We describe a patient with HP featuring well-formed granulomas on transbronchial biopsy specimens, a finding believed to be unique to MAC-related HP, also referred to as "hot tub lung".
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6/6. Pulmonary illness associated with exposure to Mycobacterium-avium complex in hot tub water. hypersensitivity pneumonitis or infection?

    BACKGROUND: mycobacterium avium complex is common in water. When aerosolized, it is frequently inhaled but rarely causes illness in healthy people. hypersensitivity pneumonitis to inhaled aerosols has been described; these aerosols are from several sources of water. The pneumonitis forms are collectively known as humidifier lung; the responsible agent in the water remains uncertain. PURPOSE: To report five cases of respiratory illness in healthy subjects using hot tubs contaminated with M avium complex. DESIGN: Descriptive case reports. SETTING: Consultations in two teaching hospitals. patients: Five healthy people developed respiratory illnesses characterized by bronchitis, fever, and "flu-like" symptoms after using a hot tub. Acute exacerbations of their illness developed within hours of heavy use of the hot tubs. INVESTIGATIONS: A chest radiograph and sputum culture in all, BAL in one, CT scan and lung biopsy in another were performed. culture of the water of the two hot tubs also was done. RESULTS: Chest radiographs showed interstitial infiltrates or a miliary nodular pattern. Cultures of all sputum samples, the lung biopsy specimens, lung lavage and water samples were positive for M avium complex. The lung biopsy specimen revealed noncaseating granulomas. All patients recovered with no treatment for M avium complex. CONCLUSION: We conclude that the M avium complex in the water was responsible for the pulmonary illnesses. The symptoms and the results of investigations are more suggestive of a hypersensitivity pneumonitis than of an infection, but no serologic proof of an immunologic reaction to the M avium complex or water was obtained.
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keywords = avium
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