Throw Caution to the Wind Instruments

Abstract

We read with interest the two articles in CHEST (September 2010) from Metzger et al1Metzger F Haccuria A Reboux G Nolard N Dalphin JC De Vuyst P Hypersensitivity pneumonitis due to molds in a saxophone player.Chest. 2010; 138: 724-726Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar and Metersky et al2Metersky ML Bean SB Meyer JD et al.Trombone player's lung: a probable new cause of hypersensitivity pneumonitis.Chest. 2010; 138: 754-756Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar that implicate wind instruments as a possible source of antigens triggering hypersensitivity pneumonitis (HP). We commend these authors for rigorously documenting antigen sensitization in one patient and documenting a classic clinical course of HP in another. Taken together, these articles provide evidence that suggests a causal relationship between microorganisms present in wind instruments and HP. However, we caution that overemphasizing the role of wind instruments not only stigmatizes wind instruments as a cause of lung disease but also creates a pitfall for clinicians that could cause other types of exposure and other types of interstitial lung disease to be overlooked. As a case in point, we consulted on a 62-year-old male music teacher and professional saxophone player who sought care for a low-grade fever associated with fatigue and a dry cough. He had no other significant medical history. Physical examination was notable for bibasilar inspiratory rales. A panel of autoantibody tests was negative. Pulmonary function tests demonstrated normal spirometry, borderline lung volumes (total lung capacity, 81% predicted), and impaired diffusion capacity of the lung for carbon monoxide (62% predicted). High-resolution CT scan revealed subpleural reticulation, mild architectural distortion, and bronchiolectasis within the middle and lower lung zones. A surgical lung biopsy specimen demonstrated patchy interstitial fibrosis around the small airways accompanied by small lymphoid aggregates, multinucleated giant cells, and numerous loosely formed granulomas in a peribronchiolar distribution. This pattern was diagnostic for HP. Upon further questioning, the patient revealed that rotting wood was removed from his home bathroom prior to the onset of symptoms, implying a likely diagnosis of “dry rot lung” that is associated with Merulius.3O'Brien IM Bull J Creamer B et al.Asthma and extrinsic allergic alveolitis due to Merulius lacrymans.Clin Allergy. 1978; 8: 535-542Crossref PubMed Scopus (20) Google Scholar Specific antibodies were not obtained at the time of the initial consultation, yet based on this history, there was little risk of reexposure. The patient was treated with a low dose of oral corticosteroids for several months, and pulmonary function improved. More importantly, he continued to play the saxophone without interruption and without extraordinary measures to clean the instrument. Throw Caution to the Wind Instruments: ResponseCHESTVol. 139Issue 3PreviewWe would like to thank Drs Rackley and Meltzer for their interest in our recent report in CHEST (September 2010)1 of a patient with hypersensitivity pneumonitis (HP) due to use of a trombone colonized with Fusarium sp. and Mycobacterium chelonae/abscessus group organisms. Although we do not think we were guilty of overemphasizing the role of wind instruments in HP, or stigmatizing wind instruments, Drs Rackley and Meltzer correctly caution pulmonologists against assuming that a wind instrument is always the cause of pulmonary symptoms or interstitial lung disease in an exposed patient. Full-Text PDF