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References [1] Sood A et al. Environ Health Perspect, 2007;115;262-6 [2] Falkinham J O III, Emerg Infect Dis, 9(7), 763-7, 2003 [3]Hanak V, et al, Mayo Clin Proc, 82/7), 812-6, 2007 Figure 3: Filter stored in water with hydrogen peroxide before the next use. Visible microbial growth on surfaces. Conclusion • Whirlpool spas may be an occupational health problem • The way the facility is cleansed may increase the risk for development of hot tub lung • M. avium in cultures taken from water, filters and patients supports the diagnosis of hot tub lung • After conversion to sand filter the hotel techni- cian’s exposure has decreased but the growth of M. avium in the whirlpool system remains • Quantitative culture may be useful to monitor levels of mycobacteria Figure 4: Washing a filter with a water hose Figure 5: Filtered (left) and spread (right) water sample Figure 1: One of the hotel spa whirlpools Results Table 1: Summary of the seven cases Resp. Hotel Employee Alveolitis Symtoms a culture A 1 Yes Yes M. avium 2&3 Suspected Yes Not done B 4&5 No Yes M. avium C 6 No No b M. avium 7 No No M. avium a Fever, chills and dyspnea related to cleansing b One patient, though, had flu like symptoms shortly after bathing in the pool Table 2: Differences between the three facilities Hotel A Hotel B Hotel C Use of high pressure washer Yes No No Sufficient ventilation No No Yes Visible growth on surfaces Yes Yes Yes Presence of M. avium in whirlpool Yes Yes Yes Presence of other mycobacteria No Yes No Presence of M. avium in fresh water No Yes No Dry storage of filter between use No No Yes Figure 2: The cleaning system of the whirlpools; filter and UV- light Introduction Hotel technicians cleaning spa whirlpools and fil- ters became ill with fever, chills and dyspnea re- lated to cleansing spa whirlpools (Table 1). In to- tal seven employees at three hotels in Western Sweden were involved. Three of them devel- oped so-called hot tub lung, which is an allergic alveolitis-like granulomatous lung disease [1–3]. Mycobacterium avium was suspected to be the cause. Methods Investigation of the workplaces Inspections of the sites were carried out by an occupational hygienist. The three whirlpools (36 ◦ C ) were from the same manufacturer and designed for 5-10 persons. The water was cleaned by 1-2 nylon membrane filters and disinfected with 50 ppm hydrogen per- oxide and UV-light. The filters was exchanged and cleaned once a week by the hotel techni- cians. One filter was always being out of use and kept in a separate container (Table 2) . The spa whirlpools at the three hotels were, as soon as the problems were recognized, con- verted to water purification by sand filter and hy- drogen peroxide and UV-light. Sampling Respiratory samples from the patients were sputum or obtained using bronchoscopy Water samples were taken from pool water, filter water and scrapings from filter surfaces Microbiological analyses • Direct microscopy was done on filter scrapings • Water was decontaminated with standard methods for contaminated samples • The concentrated samples were then incu- bated for eight weeks on Löwenstein-Jensen medium • A quantitive method was developed. 200 mL water was centrifuged and decontaminated. The concentrated sample was then diluted to 10 mL, from which 0.1 mL was spread on Mid- dlebrook 7H10 agar and the rest was filtered through a 0.45 μm filter, which was incubated on 7H10 agar for eight weeks. • Identification was done with GenoType Assay (Hain Lifescience, Germany) and AccuProbe M. avium kit (GenProbe, California, USA) Mycobacterium avium alveolitis after cleansing hotel spa whirlpools Erik Svensson a , Malin Ridell a , Magnus Åkerström b , and Eva Andersson b a Institute of Biomedicine, and b Department of Occupational and Environmental Medicine, University of Gothenburg, Sweden 30 th Annual Congress of the European Society of Mycobacteriology, 5-8 July 2009, Oporto, Portugal
