An enthusiastic bagpipe player who developed hypersensitivity pneumonitis from fungi thriving inside the instrument, and eventually died from it, has highlighted the need for careful history-taking when exploring possible causes of the condition.
Doctors at a hospital near Manchester, UK, described the progression of the disease in a man who was aged 61 when he presented with a 7-year history of dry cough and increasing breathlessness despite immunosuppressive therapy. Once able to walk 10 kilometres, his capacity had reduced to just 20 metres.
hypersensitivity pneumonitis (HP) had been diagnosed by high-resolution CT and biopsy five years earlier, but no trigger had ever been identified. He did not have any exposure to common causes such as birds or pigeons, his house had no mould or water damage, and he had no symptoms of connective tissue disease. He had never smoked.
The symptoms were insidious and progressive. His only relief was during a three-month trip to Australia, when the symptoms improved rapidly and he once again could walk 10 km, on the beach. The bagpipes had stayed at home.
Despite the best efforts of his multidisciplinary treating team, including the addition of anti-fungal therapy, the patient died. The cause was reported as an acute exacerbation of interstitial lung disease, but no moulds or fungi were found at post mortem.
Analysis of his bagpipes told a different story, revealing a rich assortment of fungi including Paecilomyces variotti, Fusarium oxysporum, Penicillium species, Rhodotorula mucilaginosa, Trichosporon mucoides, pink yeast and Exophiala dermatitidis.
“This is the first case report identifying fungal exposure from a bagpipe player as a potential trigger for the development of HP,” his doctors reported in Thorax.
“The clinical history of daily bagpipe-playing coupled with marked symptomatic improvement when this exposure was removed and the identification of multiple potential precipitating antigens isolated from the bagpipes make this the likely cause.
“This report highlights the importance of careful clinical history when assessing patients with respiratory symptoms. We often associate exposures to birds and pigeons, or living in environments contaminated with mould, as potential triggers for HP. In a significant proportion of patients, a trigger is not identified.”
Previous case reports had described HP in a saxophone player and a trombone player. The condition of both players improved once they began to regularly clean and disinfect their instruments.
“These isolated case reports highlight that wind instruments of any type could be contaminated with yeasts and moulds that act as a potential trigger for HP and highlight the need for careful history taking in identifying potential triggers,” they said.
“Cleaning instruments immediately after use and allowing them to drip-dry would theoretically reduce the risk of microorganism growth.”