Hypersensitivity pneumonitis associated with environmental mycobacteria.A previously healthy man working as a machine operator in an automotive factory developed respiratory symptoms. Medical evaluation showed abnormal pulmonary function tests, a lung biopsy showed hypersensitivity pneumonitis, and his illness was traced to his work environment. His physician asked the employer to remove him from exposure to metalworking fluids. Symptoms reoccurred when he was later reexposed to metalworking fluids, and further permanent decrement To subtract a number from another number. Decrementing a counter means to subtract 1 or some other number from its current value. in his lung function occurred. Investigation of his workplace showed that five of six large reservoirs of metalworking fluids (cutting oils) grew Mycobacterium chelonae (or Mycobacterium immunogenum), an organism previously associated with outbreaks of hypersensitivity pneumonitis in automaking factories. His lung function remained stable after complete removal from exposure. The employer, metalworking fluid supplier, union, and the National Institute for Occupational Safety and Health National Institute for Occupational Safety and Health, n.pr an institute of the Centers for Disease Control and Prevention that is responsible for assuring safe and healthful working conditions and for developing standards of safety and health. were notified of this sentinel health event. No further cases have been documented in this workplace. Key words: atypical mycobacteria, extrinsic allergic alveolitis extrinsic allergic alveolitis n. Pneumoconiosis resulting from hypersensitivity to inhaled organic dust. , hot tub, hypersensitivity pneumonitis, metalworking fluids, Mycobacterium chelonae, Mycobacterium immunogenum, nontuberculous mycobacteria, occupational lung disease Main Article COPD Occupational lung diseases are a specific branch of occupational diseases concerned primarily with work related exposures to harmful substances, be they dusts or gases, and the subsequent pulmonary disorders that may occur as a result. . Environ Health Perspect 113:767-770 (2005). doi:10.1289/ehp.7727 available via http://dx.doi.org/[Online 10 February 2005] ********** Case Presentation A 57-year-old nonsmoking auto-parts machine operator presented in 1995 because of shortness of breath Shortness of Breath Definition Shortness of breath, or dyspnea, is a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity. on exertion, cough, fatigue, and chest congestion The condition of a network when there is not enough bandwidth to support the current traffic load. congestion - When the offered load of a data communication path exceeds the capacity. . In his job he operated a machine that cut metal parts using a semi-synthetic metalworking fluid (Figure 1) that was collected and recycled through large tanks holding > 1,000 gal fluid. A chest radiograph radiograph /ra·dio·graph/ (-graf?) the film produced by radiography. ra·di·o·graph n. showed a generalized increase in interstitial markings. He was treated with empiric antibiotics on two occasions. Later, his treating physician suspected occupational asthma due to exposure to oil mist, and asked the employer to remove him from exposure to metalworking fluids. A trial of bronchodilator bronchodilator /bron·cho·di·la·tor/ (-di´la-ter) 1. expanding the lumina of the air passages of the lungs. 2. an agent which causes dilatation of the bronchi. medications was not effective in improving his symptoms, which were worse after work. Spirometry Spirometry The measurement, by a form of gas meter, of volumes of gas that can be moved in or out of the lungs. The classical spirometer is a hollow cylinder (bell) closed at its top. was performed by the factory's medical department just before and after a 5-day work week; no change in spirometry was noted. A measurement of total metalworking fluid aerosol done in the patient's work area showed that the mass of aerosol was 0.42 mg/[m.sup.3] of air sampled, which was below the recommended limit of a recent advisory committee. [FIGURE 1 OMITTED] When the physician's recommendations to remove the patient from all metalworking fluids was not followed and symptoms persisted, the patient was referred to a pulmonary specialist for further testing. Pulmonary function tests showed a reduced diffusing capacity of 67% predicted with oxygen desaturation desaturation /de·sat·u·ra·tion/ (de-sach?ah-ra´shun) the process of converting a saturated compound to one that is unsaturated, such as the introduction of a double bond between carbon atoms of a fatty acid. on ambulation (Table 1), and a carbachol challenge (a test for airway hyperreactivity in asthma) was negative. Bronchial alveolar lavage lavage /la·vage/ (lah-vahzh´) 1. the irrigation or washing out of an organ, as of the stomach or bowel. 2. to wash out, or irrigate. lav·age n. showed 90% lymphocytes and 10% macrophages in alveolar lining fluid, with negative smear and culture for acid fast bacilli (mycobacteria) and fungi. A transbronchial lung biopsy transbronchial lung biopsy A biopsy from the lung by an endoscopically-guided forceps, used to diagnose benign–eg, interstitial fibrosis, sarcoidosis and malignant–eg, cancer, lymphoma–lesions. See Transbronchial needle aspiration biopsy. (Figure 2) showed interstitial chronic inflammation and collections of epithelioid cells suggestive of granulomas with negative stains for acid-fast bacilli and fungus and, on review, diagnostic of hypersensitivity pneumonitis. Several years later, testing of the preserved tissue block by polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is was negative for sequences found in Mycobacterium chelonae. The patient's treating pulmonologist pul·mo·nol·o·gist n. A physician who specializes in the diagnosis and treatment of respiratory disorders. suspected that the hypersenstivitiy pneumonitis pneumonitis /pneu·mo·ni·tis/ (noo?mo-ni´tis) inflammation of the lung; see also pneumonia. hypersensitivity pneumonitis was due to bacteria growing in the metalworking fluid. Serum-precipitating antibodies to a standard panel of nine substances, including bacteria, several fungi, and pigeon serum, were all negative. The pulmonologist gave the patient a brief note for his employer restricting exposure to metalworking fluids; the company physician misinterpreted the message as indicating that the patient had chronic obstructive pulmonary disease chronic obstructive pulmonary disease n. Abbr. COPD A chronic lung disease, such as asthma or emphysema, in which breathing becomes slowed or forced. made worse by metalworking fluid exposures, and changed his work location but did not fully restrict him from exposure to metalworking fluids. [FIGURE 2 OMITTED] No specific interventions were made in the workplace with regard to the metalworking fluids, although a plantwide program of reduction of fluid aerosol exposures for all workers was already in progress. Several months later the patient had an uncomplicated myocardial infarction, and after 3 months returned to work with continued exposure to metalworking fluids. Three years later, in 2000, he noted daily nasal congestion associated with work, and worsening dyspnea on exertion dyspnea on exertion Cardiology Shortness of breath which occurs with effort, often a sign of heart failure or ischemia . His pulmonologist repeated lung function tests Lung function tests Tests of how much air the lungs can move in and out, and how quickly and efficiently this can be done. Lung function tests are usually done by breathing into a device that measures air flow. Mentioned in: Pulmonary Fibrosis , which showed a further decline in diffusing capacity to 44% predicted (Table 1), and a thin-section computed tomography (CT) scan of the chest (Figure 3) showed "ground glass" opacities indicating interstitial lung disease Interstitial lung disease About 180 diseases fall into this category of breathing disorders. Injury or foreign substances in the lungs (such as asbestos fibers) as well as infections, cancers, or inherited disorders may cause the diseases. and mild bronchiectasis bronchiectasis Abnormal expansion of bronchi in the lungs. It usually results when preexisting lung disease causes bronchial inflammation and obstruction. Bronchial wall fibres degenerate, and bronchi become dilated or paralyzed, preventing removal of secretions, which . A visit to the patient's residence by a treating physician trained in occupational and environmental medicine did not reveal any exposures suggestive of contributing to his hypersensitivity pneumonitis. [FIGURE 3 OMITTED] With the assistance of the county health department, samples of metalworking fluid were obtained for culture from the large reservoir supplying metalworking fluids to the patient's work area. Standard bacterial and fungal counts were below the level of detection of 10 organisms/mL, unusually low for industrial metalworking fluids, which are usually contaminated by microorganisms. Stain of the centrifuged fluid pellet for acid-fast bacilli was qualitatively "very high," and culture grew 1.6 x [10.sup.5] mycobacteria/mL, which were identified as M. chelonae. This mycobacterium, although similar to the M. chelonae-abscessus group, has been proposed as a new species, Mycobacterium immunogenum (Brown-Elliott and Wallace 2002). Additional, separate fluid specimens were sent to another laboratory, which cultured and identified the same organism. Samples of fluid from five reservoirs, a blank of "virgin" metalworking fluid, and a tap water control were for a third time tested and showed > 2,500 mycobacteria/mL, with single-stranded conformational polymorphism analysis showing M. chelonae subtype M. immunogenurn in the used fluid samples, and none in the virgin fluid or tap water. Endotoxin, the active agent in the walls of gram-negative bacteria, was measured in the five samples from the five reservoirs at from 2.4 x [10.sup.2] to 2.5 x [10.sup.4] endotoxin units per milliliter of fluid by the Limulus assay. Based on these findings, the patient was removed completely from exposure to metalworking fluids. The treating occupational physician scheduled a meeting with the plant occupational physician, industrial hygienists, and the contracting supplier of the metalworking fluids to recommend a) a survey of symptoms and chest X rays of workers exposed to metalworking fluids to identify any additional cases and b) testing of all metalworking fluid reservoirs in the facility for mycobacteria. In addition, the disease occurrence was reported to the Division of Respiratory Disease Studies of the National Institute for Occupational Safety and Health (NIOSH NIOSH National Institute for Occupational Safety & Health, see there NIOSH Recommendations for Safety & Health Standards Agent NIOSH REL*/OSHA PEL† Health effects ) and the New York State Health Department Occupational Lung Disease registry. Discussion Metalworking fluids are widely used where metal is cut, drilled, milled, or otherwise shaped with cutting tools, to remove heat from both the machine tool and the product being made and to lubricate the parts, remove metal debris, and inhibit metal corrosion. Hypersensitivity pneumonitis is a serious environmental immunologic lung disease in which recurrent exposures to inhaled antigens lead to immunologic sensitization sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun) 1. administration of an antigen to induce a primary immune response. 2. exposure to allergen that results in the development of hypersensitivity. with a predominantly cell-mediated lung response. Subsequent exposures then cause an inflammatory response in the lung that can produce symptoms of dyspnea, cough, and wheeze wheeze (hwez) a whistling type of continuous sound. wheeze v. To breathe with difficulty, producing a hoarse whistling sound. n. A wheezing sound. ; fever and elevated blood white count; and transient, lung infiltrates and hypoxemia hypoxemia /hy·pox·emia/ (hi?pok-sem´e-ah) deficient oxygenation of the blood. hy·pox·e·mi·a n. Insufficient oxygenation of arterial blood. . Persistent disease can cause permanent loss of lung function and even death. Many patients develop disease from exposures associated with work, although exposure to biologic aerosols from home can also cause disease (Apostolakos et al. 2001; Kawai et al. 1984; Wright et al. 1999). Hypersensitivity pneumonitis was first described in dairy farmers exposed to aerosol from stored, moldy moldy animal feed overgrown with fungus; the feed may be harvested and stored or be still in the ground. moldy corn disease see leukoencephalomalacia, fusariummoniliforme. hay containing mixed microorganisms. The list of inhaled substances or mixtures known to cause this condition has grown over the years (Patel et al. 2001); most (but not all) causative agents are biologic materials, including proteins from pigeons and other domestic birds. Blood tests for serum precipitating antibodies to a panel of approximately 10 common causes of hypersensitivity pneumonitis are available from commercial laboratories. However, disease may occur from exposure to substances not included in these panels. In addition, exposure may result in asymptomatic sensitization. Use of precipitating antibodies in diagnosis of hypersensitivity pneumonitis is limited by these factors. Metalworking fluids may be pure petroleum oils ("straight oils"), emulsions of petroleum in a water base (semisynthetic semisynthetic /semi·syn·thet·ic/ (-sin-thet´ik) produced by chemical manipulation of naturally occurring substances. sem·i·syn·thet·ic adj. 1. fluids), or emulsions of synthetic oils in water (synthetic fluids). Because they contain biologically available carbon (in the form of lipids) and water, water-based metalworking fluids routinely sustain microbial growth, but excess growth degrades the fluids and leads to loss of usefulness. Thus, standard use of these metalworking fluids in industry often includes routine testing for bacteria counts (without identification of all organisms) and the use of microbicides with the objective of suppressing, although not necessarily sterilizing, microbial growth. A variety of respiratory illnesses have been reported to be associated with occupational inhalation of metalworking fluids, including bronchitis, asthma, and lipoid pneumonia (Cullen et al. 1981; Kennedy et al. 1989; Leigh and Hargreave 1999), and their toxicology has recently been reviewed (Gordon 2004). Currently there is no specific Occupational Safety and Health Administration Occupational Safety and Health Administration (OSHA), U.S. agency established (1970) in the Dept. of Labor (see Labor, United States Department of) to develop and enforce regulations for the safety and health of workers in businesses that are engaged in interstate (OSHA OSHA n. Occupational Safety and Health Administration, a branch of the US Department of Labor responsible for establishing and enforcing safety and health standards in the workplace. ) standard for metalworking fluids, although guidance in prevention of health hazards is provided in an NIOSH criteria document [Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ) 1998]. An advisory panel appointed by OSHA recommended a new permissible exposure limit The Permissible Exposure Limit (PEL or OSHA PEL) is a legal limit in the United States for exposure of an employee to a substance, usually expressed in parts per million (ppm), or sometimes in milligrams per cubic metre (mg/m3). of 0.4 mg/[m.sup.3] thoracic particulate and 0.5 mg/[m.sup.3] total particulate (OSHA 1999), based in large part on the NIOSH criteria document. However, at present, this recommendation has not been the subject of rule making. Hypersensitivity pneumonitis associated with metalworking fluids was first described in 1995 (Bernstein et al. 1995). Since then, numerous outbreaks have been described, associated with inhalation of aerosols of water-containing metalworking fluids (reviewed in Kreiss and Cox-Gaenser 1997). Prevention efforts have focused on reduction of inhalation exposures by workplace modifications that reduce generation of aerosols or improve dilution and ventilation of workplace air, and one follow-up study has documented successful remediation (Bracker et al. 2003). More recently, outbreaks of this condition have been found in workplaces with metalworking fluids containing nontuberculous mycobacteria (CDC 2002; Kreiss and Cox-Gaenser 1997), most frequently M. immunogenum. Detection of these mycobacteria requires special laboratory culture and identification techniques that are not included in routine microbiologic testing of industrial metalworking fluids, such that their identification requires knowledge of their potential for growth and the ability to perform special testing. During recent years, association of hypersensitivity pneumonitis disease with a different species, Mycobacterium avium complex Mycobacterium avium complex (MAC) is a group of genetically-related bacteria belonging to the genus Mycobacterium. It includes Mycobacterium avium subspecies avium (MAA), Mycobacterium avium subspecies hominis (MAH), and (MAC), from hot tubs, whirlpool baths, and spas has also been identified, sometimes referred to as "hot tub lung" (Capelluti et al. 2003; Grimes et al. 2001; Rickman et al. 2002; Scully et al. 1997). In these hot water bathing tubs, water may be agitated by powerful jets of air or water that produce bubbles and hence aerosols of water droplets. MAC grows well in the high water temperature of the indoor hot tub. The combination of MAC organisms' growth and jet aerosolization and subsequent inhalation of large amounts of MAC presumably pre·sum·a·ble adj. That can be presumed or taken for granted; reasonable as a supposition: presumable causes of the disaster. leads to the development of this disease. Hot tub lung appears to be hypersensitivity pneumonitis to MAC aerosol rather than a direct infection of the lung, although this subject is still a matter of debate (Aksamit 2003; Embil et al. 1997). Interestingly, there have been no documented cases of hot tub lung with outdoor hot tubs. In hot tub lung, pulmonary function tests were mainly restrictive with occasional obstruction (Anonymous 2000; Kahana and Kay 1997; Khoor et al. 2001; Mangione et al. 2001; Mery and Horan 2002; Rihawi et al. 2004). Chest radiography shows diffuse infiltrates, and high-resolution CT of the chest shows ground glass opacities and micronodules (Pham et al. 2003). Sputum culture was positive for MAC in about 70% of the patients; transbronchial biopsy and bronchoalveolar lavage cultures increased the yield further (Anonymous 2000; Kahana and Kay 1997; Khoor et al. 2001; Mangione et al. 2001; Mery and Horan 2002). Hot tub water usually grows MAC. The histopathologic findings reveal discrete nonnecrotizing granulomas with centrilobular and bronchiolocentric distribution. The granulomas described in hot tub lung were more exuberant and well formed than those seen in typical cases of hypersensitivity pneumonitis from other causes. There is no standard approach to treatment of hot tub lung. Case reports describe significant improvement with removal from exposure to the hot tubs. Oral corticosteroids, antimycobacterial therapy, or both have also been used. The expected course of this disease after the above measures is recovery without relapse. Measures proposed as being helpful in prevention include better ventilation of the hot tub room, frequent cleaning of the hot tub, frequent change of hot tub water, and use of disinfectants such as chloramines, bromine bromine (brō`mēn, –mĭn) [Gr.,=stench], volatile, liquid chemical element; symbol Br; at. no. 35; at. wt. 79.904; m.p. –7.2°C;; b.p. 58.78°C;; sp. gr. of liquid 3.12 at 20°C;; density of vapor 7. , and ultraviolet light. These measures are similar to those usually proposed for prevention of hypersensitivity due to exposure to mycobacteria in metalworking fluids. Conclusions Environmental mycobacteria have been associated with a serious lung condition, hypersensitivity pneumonitis, when inhaled as part of liquid droplet aerosols generated from large volumes of liquids serving as a culture medium. These organisms are found commonly in nature and are able to grow in sufficient quantities to cause disease. The case reported here involved an occupational source of such an exposure (aerosolized metalworking fluid in a machining environment), although aerosols containing mycobacteria have been described in other settings as well (aerosolized water from hot tubs). For this reason, specific investigation of sources of aerosols in the work or home environment of patients with this condition should consider the growth of mycobacteria as one of the potential sources of disease. As with other causes of hypersensitivity pneumonitis, removal from exposure and remediation of exposure are the first approaches to treatment.
Table 1. Patient's pulmonary function laboratory data.
Date FE[V.sub.1] (%) FVC (%) [D.sub.L]CO (%)
June 1985 2.70 (88) 3.0 (70) --
January 1996 2.77 (94) 3.47 (95) --
January 1996 2.98 (101) 3.40 (93) --
September 1997 -- -- --
January 1998 -- -- (67)
April 2000 2.52 (89) 3.14 (89) 9.8 (44)
June 2000 1.86 (60) 2.55 (65) --
Apri12004 2.42 (89) 3.15 (92) 11.5 (45)
[O.sub.2]
saturation (%)
Date Rest Exercise Notes
June 1985 -- -- Preplacement work exam before onset
of symptoms
January 1996 -- -- After onset of symptoms; spirometry
before the work week
January 1996 -- -- After shift at end of work week
September 1997 96 96 --
January 1998 -- -- --
April 2000 92 89 More symptomatic
June 2000 -- -- --
Apri12004 -- -- Symptoms stable
Abbreviations: --, not measured; [D.sub.L]CO, diffusing capacity
for carbon monoxide (percent predicted); FE[V.sub.1], forced
expiratory volume in 1 sec in liters (percent predicted); FVC,
forced vital capacity in liters (percent predicted).
REFERENCES Anonymous. 2000. Case records of the Massachusetts General Hospital Massachusetts General Hospital Health care The major teaching hospital for Harvard Medical School, widely regarded as one of the best health care centers in the world . Weekly clinicopathological exercises. Case 27-2000. A 61-year-old with rapidly progressive dyspnea. N Engl J Med 34:642-649. Aksamit TR. 2003. Hot tub lung: infection, inflammation, or both? Semin Respir Infect 18:33-39. Apostolakos M, Rossmoore H, Beckett W. 2001. Hypersensitivity pneumonitis from ordinary residential exposures. Environ Health Perspect 109:979-981. Bernstein D, Lummus Z, Santilli G, Siskosky J, Bernstein I. 1995. Machine operator's lung. A hypersensitivity pneumonitis disorder associated with exposure to metal working fluid aerosols. Chest 108:636-641. Bracker A, Storey E, Yang C, Hodgson MJ. 2003. An outbreak of hypersensitivity pneumonitis at a metalworking plant: a longitudinal assessment of interventional effectiveness. Appl Occup Environ Hyg 18:96-108. Brown-Elliott BA, Wallace RJ Jr. 2002. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria Mycobacteria that form colonies clearly visible to the naked eye in less than 7 days on subculture are termed rapid growers. List of rapidly growing Mycobacteria Nonchromogenic
Cappelluti E, Fraire AE, Schaefer OP. 2003. A case of "hot tub lung" due to Mycobacterium avium complex in an immunocompetent im·mu·no·com·pe·tent adj. Having the normal bodily capacity to develop an immune response following exposure to an antigen. im host. Arch Intern Med 153:845-848. CDC. 1998. Criteria for a Recommended Standard: Occupational Exposure to Metalworking Fluids. NIOSH 98-102. Atlanta, GA:Centers for Disease Control and Prevention. CDC. 2002. Respiratory illness in workers exposed to metalworking fluid contaminated with nontuberculous mycobacteria--Ohio, 2001. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morbid Mortal Wkly Rep 51:349-352. Cullen MR, Balmes JR, Robins JM, Smith GJW. 1981. Lipoid pneumonia caused by oil mist exposure from a steel rolling tandem mill. Am J Indust Med 2:51-58. Embil J, Warren P, Yakrus M, Stark R, Come S, Forrest D, et al. 1997. Pulmonary illness associated with exposure to Mycobacterium-avium complex in hot tub water. Hypersensitivity pneumonitis or infection? Chest 111:813-816. Gordon T. 2004 Metalworking fluid--the toxicity of a complex mixture. J Toxicol Environ Health A 67:209-219. Grimes M, Cole T, Fowler A. 2001. Obstructive granulomatous granulomatous /gran·u·lom·a·tous/ (-lom´ah-tus) containing granulomas. Granulomatous Resembling a tumor made of granular material. bronchiolitis Bronchiolitis Definition Bronchiolitis is an acute viral infection of the small air passages of the lungs called the bronchioles. Description Bronchiolitis is extremely common. due to Mycobacterium avium complex in an immunocompetent man. Respiration 68:411-415. Kahana LM, Kay JM. 1997. Pneumonitis due to Mycobacterium avium complex in hot tub water: infection or hypersensitivity? Chest 112:1713-1714. Kawai T, Tamura M, Murao M. 1884. Summer-type hypersensitivity pneumonitis: a unique disease in Japan. Chest 85:311-317. Kennedy SM, Greaves IA, Kriebel D, Eisen EA, Smith TJ, Woskie SR. 1989. Acute pulmonary responses among automobile workers exposed to aerosols of machining fluids. Am J Indust Med 15:627-641. Khoor A, Leslie KO, Tazelear HD, Helmets RA, Colby TV. 2001. Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung). Am J Clin Pathol 115:755-762. Kreiss K, Cox-Gaenser J. 1997. Metalworking fluid-associated hypersensitivity pneumonitis: a workshop summary. Am J Indust Med 32:423-432. Leigh R, Hargreave FE. 1999. Occupational neutrophilic asthma. Can Respir J 6:194-196. Mangione, E, Huitt G, Lenaway D. 2001. Nontuberculous mycobacterial disease following hot tub exposure. Emerg Infect Dis 7:1039-1042. Mery A, Horan R. 2002. Hot tub-related Mycobacterium avium intracellulare Mycobacterium avium intracellulare is an atypical mycobacterial infection which can occur in the later stages of AIDS. It can also affect women who do not have AIDS and usually first presents as a persistent cough. pneumonitis. Allergy Asthma Proc 23:271-273. OSHA. 1999. Final Report of the OSHA Metalworking Fluids Standards Advisory Committee. Washington, DC:Occupational Safety & Health Administration. Available: http://www.osha.g ov/SLTC/metalworkingfluids/mwf_finalreport.html [accessed 1 April 2005]. Patel AM, Ryu Ryū (竜 or りゅう or リュウ Ryū JH, Reed CE. 2001, Hypersensitivity pneumonitis: current concepts and future questions. J Aller Clin Immunol 108:961-701. Pham R, Vydareny K, Gal A. 2003. High-resolution computed tomography high-resolution computed tomography Imaging CT at slice–collimation scan interval widths of ≤ 4 mm, which is narrower than the usual 1-3 cm interval 'slices' obtained in conventional CT imaging. Cf Spiral computed tomography. appearance of pulmonary Mycobacterium avium complex infection after exposure to hot tub: case of hot-tub lung. J Thorac Imaging 18:48-52. Rickman O, Ryu J, Fidler M, Kalra S. 2002. Hypersensitivity pneumonitis associated with Mycobacterium avium complex and hot tub use. Mayo Clin Proc 77:1233-1237. Rihawi M, Kulkarni P, Sherba L. 2004. Interstitial Lung Disease in a Hot Tub User. General Occupational Lung Disease Clinical Cases. New York:American Thoracic Society American Thoracic Society (ATS ), established in 1905, is an independently incorporated, international, educational and scientific society, serving its 18,000 members world-wide who are dedicated in respiratory and critical care medicine. . Available: http://www.thoracic.org/assemblies/eoh/cases/jan04.asp [accessed accessed 1 April 2005]. Scully RE, Mark EJ, McNeely WF, Ebeting SH, Phillips LD. 1997. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 20-1997. A 74-year-old man with progressive cough, dyspnea, and pleurel thickening. N Engl J Med 336:1995-1903. Wright RS, Dyer Z, Liebhaber MI, Kell DL, Harber P. 1999. Hypersensitivity pneumonitis from Pezizia domiciliana. A case of El Nino lung. Am J Respir Crit Care Med 160:1759-1761. William Beckett, (1) Michael Kallay, (1) Akshay Sood, (2) Zhengfa Zuo, (3) and Donald Milton (3) (1) Pulmonary and Critical Care Division, Occupational Medicine Program and Finger Lakes Occupational Health Services, University of Rochester The University of Rochester (UR) is a private, coeducational and nonsectarian research university located in Rochester, New York. The university is one of 62 elected members of the Association of American Universities. School of Medicine and Dentistry, Rochester, New York This article is about the city of Rochester in Monroe County. For the town in Ulster County, see Rochester, Ulster County, New York. Rochester, once known as The Flour City, and more recently as The Flower City or , USA; (2) Division of Pulmonary and Critical Care Medicine, Southern Illinois University Southern Illinois University, main campus at Carbondale; state supported; coeducational; est. 1869, opened 1874 as a normal school, renamed 1947. It has a center for archaeological investigation and a fisheries research laboratory. There is also a campus at Edwardsville. School of Medicine, Springfield, Illinois, USA; (3) Harvard School of Public Health The Harvard School of Public Health is (colloquially, HSPH) is one of the professional graduate schools of Harvard University. Located in Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill, next to Harvard Medical School and Cambridge, Massachusetts, , Brookline, Massachusetts, USA Address correspondence to W. Beckett, University of Rochester School of Medicine and Dentistry, Environmental Medicine, Room 4-5702, Box EHSC EHSC Engineering and Housing Support Center EHSC Environmental Hazard Safety Classification , 601 Elmwood Ave., Rochester, NY 14642 USA. Telephone: (585) 273-4964. Fax: (585) 256-2591. E-mail: Bill_Beckett@urmc.rochester.edu This work was supported in part by the National Institute of Environmental Health Sciences The National Institute of Environmental Health Sciences (NIEHS) is one of 27 Institutes and Centers of the National Institutes of Health (NIH),which is a component of the Department of Health and Human Services (DHHS). The Director of the NIEHS is Dr. David A. Schwartz. (grant P30 ES01247) and the New York State Network of Occupational Health Clinics, New York State Department of Health. The authors declare they have no competing financial interests. Received 4 November 2004; accepted 10 February 2005. |
|
||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion