Abstract

hat 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.

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