“Hot tub” lung: Is it on your list of respiratory ailments?

The steam and bubbles generated by the hot tub efficiently aerosolize the organism and facilitate easy inhalation. When hot tubs are outdoors, the mist simply disperses. But in an indoor setting, the aerosol is more likely to be contained and subsequently inhaled. Placement of a hot tub in an enclosed or poorly ventilated environment should be discouraged.

Get cultures of hot tub water. We did not obtain cultures of the hot tub water in this case, but some authors have reported positive results from water cultures that correspond to results of lung cultures.⁸ Most patients will improve with antigen avoidance, which is more suggestive of a hypersensitivity reaction than an infection—particularly when symptoms resolve without antibiotics or antifungals. However, after review of the literature, we recommend obtaining a culture of the water in suspicious hot tubs, as it may uncover an infectious source.⁸

Our recommendation. As hot tubs become more popular in the United States, illnesses associated with improperly maintained units are likely to increase. Skin lesions,¹³ external otitis,¹³ genital herpes,¹⁴ and Legionnaire’s disease^16-20 have all been associated with hot tub use. In routine reviews of patients with respiratory problems, consider hypersensitivity pneumonitis in your differential diagnosis and include questions about hot tub use.

CORRESPONDENCE
Kevin N. Waninger, MD, MS, FAAFP, FACEP, FACSM, Department of Family Medicine, Family Medicine Residency Program, St. Luke’s Hospital, Bethlehem, PA 18017-4206. E-mail: knwaninger@aol.com