Trombone Player's Lung
2010; Elsevier BV; Volume: 138; Issue: 3 Linguagem: Inglês
10.1378/chest.10-0374
ISSN1931-3543
AutoresMark L. Metersky, Scott B. Bean, John D. Meyer, Miriam Mutambudzi, Barbara A. Brown‐Elliott, Michael E. Wechsler, Richard J. Wallace,
Tópico(s)Pleural and Pulmonary Diseases
ResumoA 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.1Wallace Jr, RJ Zhang Y Wilson RW Mann L Rossmoore H Presence of a single genotype of the newly described species Mycobacterium immunogenum in industrial metalworking fluids associated with hypersensitivity pneumonitis.Appl Environ Microbiol. 2002; 68: 5580-5584Crossref PubMed Scopus (92) Google Scholar 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).2Falkinham III, JO Mycobacterial aerosols and respiratory disease.Emerg Infect Dis. 2003; 9: 763-767Crossref PubMed Scopus (120) Google Scholar, 3Lumb R Stapledon R Scroop A et al.Investigation of spa pools associated with lung disorders caused by Mycobacterium avium complex in immunocompetent adults.Appl Environ Microbiol. 2004; 70: 4906-4910Crossref PubMed Scopus (45) Google Scholar, 4Lee SK Kim SS Nahm DH et al.Hypersensitivity pneumonitis caused by Fusarium napiforme in a home environment.Allergy. 2000; 55: 1190-1193Crossref PubMed Scopus (37) Google Scholar, 5Colin G Lelong J Tillie-Leblond I Tonnel AB Hypersensitivity pneumonitis in a chicory worker [in French].Rev Mal Respir. 2007; 24: 1139-1142Crossref PubMed Scopus (5) Google Scholar, 6Veillette M Cormier Y Israël-Assayaq E Meriaux A Duchaine C Hypersensitivity pneumonitis in a hardwood processing plant related to heavy mold exposure.J Occup Environ Hyg. 2006; 3: 301-307Crossref PubMed Scopus (19) Google Scholar, 7Winck JC Delgado L Murta R Lopez M Marques JA Antigen characterization of major cork moulds in suberosis (cork worker's pneumonitis) by immunoblotting.Allergy. 2004; 59: 739-745Crossref PubMed Scopus (20) Google Scholar Pulsed-field gel electrophoresis demonstrated that none of the three musicians who had instruments contaminated with M abscessus subsp abscessus shared the same strain.Table 1Organisms Cultured From Brass InstrumentsPatient and SubjectsInstrumentMycobacterial CultureAFB/FieldaNumber of organisms per oil immersion field (× 1,000) in direct smear of unconcentrated biofilm.FungusBacteriaLower Respiratory SymptomsPatientTromboneMycobacterium chelonae/abscessus groupbThese isolates were not available for further speciation.> 100Fusarium spStenotrophomonas maltophiliaProlonged coughEscherichia coliSubject 1TromboneM avium complexbThese isolates were not available for further speciation.1–2Fusarium spS maltophiliaAsthma1 untypeable GNRSubject 2TromboneM avium complexbThese isolates were not available for further speciation.> 100Fusarium sp3 untypeable GNRsDyspneaSubject 3TromboneM intracellulare1–2Fusarium spMyroides spNoneElizabethkingia spUntypeable GNRSubject 4TromboneM chelonae/abscessus groupbThese isolates were not available for further speciation.> 100Fusarium spS maltophiliaNoneFlavobacterium spAgrobacterium spSubject 5Trumpet 1M chelonae/abscessus groupbThese isolates were not available for further speciation.5–10Candida albicans2 untyped GNRsAsthmaTrumpet 2M terrae/nonchromogenicum> 100C albicans2 untyped GNRsSubject 6Trombone 1M abscessus subsp abscessus< 1Fusarium sp3 untyped GNRsNoneC albicansTrombone 2M abscessus subsp abscessus0Paecilomyces sp3 untyped GNRsSubject 7Trumpet 1M abscessus subsp abscessus10–20Fusarium sp3 untyped GNRsProlonged coughTrumpet 2M abscessus subsp abscessus> 100Fusarium sp2 untyped GNRsPenicillium spAFB = acid fast bacilli; GNR = gram-negative rods.a Number of organisms per oil immersion field (× 1,000) in direct smear of unconcentrated biofilm.b These isolates were not available for further speciation. Open table in a new tab AFB = acid fast bacilli; GNR = gram-negative rods. 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.8Lynch DA Rose CS Way D King Jr, TE Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study.AJR Am J Roentgenol. 1992; 159: 469-472Crossref PubMed Scopus (142) Google Scholar Because HP from exposure to aerosols containing mycobacteria or fungi is not an unusual, idiosyncratic reaction,1Wallace Jr, RJ Zhang Y Wilson RW Mann L Rossmoore H Presence of a single genotype of the newly described species Mycobacterium immunogenum in industrial metalworking fluids associated with hypersensitivity pneumonitis.Appl Environ Microbiol. 2002; 68: 5580-5584Crossref PubMed Scopus (92) Google Scholar, 2Falkinham III, JO Mycobacterial aerosols and respiratory disease.Emerg Infect Dis. 2003; 9: 763-767Crossref PubMed Scopus (120) Google Scholar, 6Veillette M Cormier Y Israël-Assayaq E Meriaux A Duchaine C Hypersensitivity pneumonitis in a hardwood processing plant related to heavy mold exposure.J Occup Environ Hyg. 2006; 3: 301-307Crossref PubMed Scopus (19) Google Scholar, 7Winck JC Delgado L Murta R Lopez M Marques JA Antigen characterization of major cork moulds in suberosis (cork worker's pneumonitis) by immunoblotting.Allergy. 2004; 59: 739-745Crossref PubMed Scopus (20) Google Scholar 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. Wind-Instruments Lung: A Foul NoteCHESTVol. 138Issue 3PreviewMetzger et al1 (see page 724 ) and Metersky et al2 (see page 754 ) are to be complimented for their very interesting and important clinical observations and their insight for analyzing the microbial flora of musical instruments of the index cases and that of other similar musical instruments. To play a wind instrument, such as a saxophone or a trombone, one needs good lungs. As described in the above-mentioned articles in this issue of CHEST, these instruments themselves can cause hypersensitivity pneumonitis (HP), a respiratory problem that will decrease lung function, making it impossible for the musician to continue playing. Full-Text PDF
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