Hydrocephalus or "lifeguard lung"?
Troubled water
Hot tubs a harbor for an emerging disease
By Debra Melani
Daily Camera
--------------------------------------------------------------------------------
Kathy Gamble recalls watching her family slowly deteriorate.
Her three boys would struggle to breathe, unable to eat, with one falling to an alarmingly low weight. She and her husband would wake up on midsummer nights drenched in sweat and shivering in their beds. Her heart rate would skyrocket to unacceptable levels when she did simple household tasks. Eventually, she couldn't walk across the room without having to sit down.
She was terrified. And the doctors were stumped. "The scariest part was, they couldn't figure out what it was. We were just on massive doses of antibiotics that didn't seem to do anything," Gamble said.
After three months of countless doctor visits, emergency hospital admissions and lung biopsies, a specialist in Denver finally asked the key question: Did the Gambles have a hot tub in their home?
The answer was "yes." The culprit was found: hypersensitivity pneumonitis, also know as "lifeguard lung."
An emerging disease
Two years ago, when the Gambles' nightmare began, the fact that an indoor tub could have such devastating effects was not well-known. Researchers at National Jewish Medical and Research Center, where the Gambles were finally diagnosed, have begun to study the phenomenon. They say the incidence is on the rise.
"We don't know why we are seeing this more frequently now than we have in the past," said Dr. Cecile Rose of National Jewish, who worked with the Gambles. "Part of it might be that we are recognizing it better, that we are asking the right questions."
The National Spa and Pool Institute, an Alexandria, Va.-based association promoting the use of public and residential swimming pools, spas and hot tubs, did not return telephone calls seeking comment on this article.
Rose was involved in a groundbreaking study published in December 1998 that linked indoor swimming pools to a lung disorder like the Gambles'. The study investigated Westminster Pool, a water park-like indoor area with spraying-water features that had been closed twice in two years because of respiratory complaints from lifeguards.
Boulder Community Hospital's Mapleton Pool remains closed after four employees there complained of respiratory problems. National Jewish has been consulted in the investigation, but a definite link has not been made. Lab results are pending.
"Each year, we have something come up like this," said Ann Bailey, epidemiological nurse at the Boulder County Health Department. "We have seen this more frequently occurring with hot tubs. I think lifeguards and consumers are becoming more aware."
Researchers say probably humidifiers and possibly water heaters could be reservoirs for the responsible organisms as well. But the disease is considered an emerging one, with doctors emphasizing that there are still few certainties.
--------------------------------------------------------------------------------
Guidelines and tips
The Environmental Protection Agency offers these guidelines for using humidifiers, especially ultrasonic and impeller humidifiers:
? Empty tank, wipe all surfaces dry and refill water daily. Use water with low mineral content. Mineral water can can cause scale (breeding ground for micro-organisms) and a white dust, which can induce respiratory problems in some people. Distilled water is recommended.
? Clean portable humidifiers every third day, removing scale, deposits or film on the sides and interior. Wipe all surfaces dry.
? Follow manufacturer directions for cleaning products. If there are none, use a water solution with 3 percent bleach. Rinse thoroughly to avoid dispersal of chemicals. Do not allow water to stand in the tanks for long periods, and keep water clean.
? Do not humidify to indoor relative humidity above 50 percent. Hygrometers are available at hardware stores to measure levels.
? Do not allow surrounding materials to become damp.
? Clean humidifier before storage and ensure that all parts are dry. Throw away used cartridges, cassettes or filters. Store in a dry location. After storage, clean again to remove dust.
? Stop using humidifier immediately and call a doctor if any respiratory problems are noted.
For more information on respiratory disorders, call National Jewish Medical and Research Center 's LINE at (800) 222-LUNG, e-mail lungline@njc.org or visit www.nationaljewish.orgcq.
--------------------------------------------------------------------------------
"We don't know anything about incidence or prevalence rate in that (indoor hot tub, pool, humidifier) population," Rose said. She noted that the lung reaction is the same as one experienced by farmers and bird breeders, two populations that are exposed to airborne bacterial byproducts.
Other organisms from water sources, like fungi or the bacterium responsible for Legionnaires' disease, also can cause respiratory infections.
A matter of exposure
"These types of organisms like to hang out in standing water, and they are not killed by certain types of cleaning mechanisms," said Dr. Gwen Huitt of National Jewish, considered a premier U.S. hospital in respiratory research. When the bacteria or their byproducts reach a high enough level and begin to circulate in the air ? such as through hot-tub bubbles or water-park mist ? they are inhaled, Huitt said.
The resulting lung inflammation can be mild or serious and even fatal, depending on the person's immune system and ? what doctors consider the primary concern ? the extent of exposure.
At the Westminster Pool, some of the full-time lifeguards became very ill. A few, including Mitch Trujillo, now a Boulder police officer, were exposed for more than a year before the source was pinpointed, leaving them with permanent asthma-like problems. The Gambles managed to escape without permanent symptoms.
Trujillo, whose symptoms lasted longer than the Gambles', said the disease profoundly affected his life: "I was very athletic. I was a competitive cyclist. I had some very high goals. I thought that I was going to do some very good things athletically. When I got sick, I had to come to the realization that that wasn't going to happen."
A bike-patrol officer for the city, Trujillo is still active and fit, but his lung capacity isn't what it used to be. He struggles with exercise-induced asthma, which he has to treat with medication.
While as many as 65 percent of the employees were affected, visitors to Westminster Pool interviewed for the study had no symptoms of hypersensitivity pneumonitis.
The same is likely to hold true at the Mapleton Pool, Rose said, where complaints come from therapists who are in the pool with clients for hours every day.
A need for air
Another key to exposure is the level of bacteria in the air, which is why the problem seems to occur almost exclusively in indoor pools and hot tubs. Pools with spraying-water features seem even more likely to cause problems.
Airborne bacterial byproducts at the Westminster Pool measured 27 to 162 times higher than levels at two control pools with no water sprayers. A $600,000 overhaul of the ventilation system failed to fix the problem, and the pool was closed again. It took a $1.2 million upgrade to eliminate the respiratory complaints.
Lack of ventilation gives rise to the problem, which is why more pool-related lung complaints are reported in the winter, Rose said.
"When it's cold outdoors in Colorado, one of the biggest struggles is to keep the ambient temperature comfortable for the users. And it's expensive to have outside air supply and re-warm it, so they recirculate the air," Rose said. In the summertime, doors are open and air can be pumped in, she said.
In the Gambles' case, the hot tub was in a sunroom in the center of their air-conditioned, tightly sealed home. Gamble's husband, who was at work all day, didn't become as sick as she and her sons did, she said. When the hot tub was found to be responsible, it was drained and cleaned and the house was opened for three days before the family was allowed to return, Gamble said.
But the ordeal was far from over.
The road to recovery
It took nearly a year of powerful antibiotic treatment before the Gambles recovered. The boys had to be pulled from school, and every family member had to be on continual oxygen. Their illness had been induced by an organism called nontuberculosis mycobacteria, and infection had developed.
"We had a home-care nurse who came in once a week. It was absolutely horrendous," Gamble said. "We were so physically exhausted. We had to travel to National Jewish twice a week for six months. All of this because of a hot tub."
For some victims of "lifeguard lung," treatment can be even more devastating, with doctors periodically forced to remove parts of lung to control the infection.
But frequently, hypersensitivity pneumonitis can be treated with steroids and removal from exposure, Rose said, explaining that it is often an inflammatory reaction with no infection.
Although research is incomplete, doctors say it's important that consumers be aware of the potential problem. Quick identification can lead to more successful treatment, and good sanitation and ventilation can prevent disorders.
In her recent interview, Huitt said National Jewish was expecting another patient who cleaned hot tubs at a ski resort. "This gal clearly has hypersensitivity pneumonitis. I think this is becoming a bigger and bigger problem, and hot-tub sales are on the rise with so many high-end houses being built," she said. "If it were me, I wouldn't own an indoor hot tub."
Gamble wouldn't hesitate to second that. Her hot tub is "long gone," she said. "I never want to see one again."
Contact Debra Melani at (303) 473-1333 or melanid@thedailycamera.com.
May 9, 2000
|
