Findings from a case report published in the BMJ Thorax indicate that musicians who play wind instruments may be at risk of developing “bagpipe lung” – from yeast and mold contamination – which, at the severe end of the scale, can result in death.
The term “bagpipe lung” emerged from a case presentation – led by Dr. Jenny King of University Hospital South Manchester in the United Kingdom – of a 61-year-old man who died from the chronic inflammatory lung condition hypersensitivity pneumonitis (HP) following exposure to breathing in fungi lurking in the moist crevices of his bagpipes.
HP is a disease of the lungs, whereby the lung becomes inflamed from an allergic reaction to inhaled dust, fungus, molds, or chemicals. If detected early and the allergy-producing substance is avoided, the inflammation can be reversed.
However, if HP remains undiagnosed, and the individual continues to be exposed to the allergen, this may lead to some portions of the lung developing scar tissue. Lung scarring – also called pulmonary fibrosis – is permanent and can make breathing normally problematic.
There are more than 300 known substances which, when inhaled as fine dust, may cause a person to develop HP.
Most commonly seen HP problems are given names related to the source of the allergen. For example, “farmer’s lung” is the term for cattle workers where the condition is caused by inhaling mold that grows on hay, straw, and grain, or “bird fancier’s lung” caused by breathing in particles from feathers or droppings of birds, particularly pigeons.
“Bagpipe lung” is the new causal name in this instance.
The cause of HP in the man in the case file was a conundrum; he was not a pigeon fancier, nor did his house harbor mold or show signs of water damage, and he had no symptoms of connective tissue disease. He had also never smoked.
The patient was referred to the interstitial lung disease clinic in 2014 with a 7-year history of a dry cough and progressive breathlessness, diagnosed as HP in 2009. Despite immunosuppressive therapy, he experienced a reduction in exercise tolerance from over 10 kilometers to 20 meters.
Despite his severe restriction in lung function, the man played the bagpipes daily as a hobby. His symptoms were progressive, except a 3-month period in 2011 when he lived in Australia, and his symptoms rapidly improved. On return to the United Kingdom, the man’s breathing quickly deteriorated. He did not take the bagpipes with him to Australia.
With the bagpipes determined as a possible risk factor, samples were taken from the bag, the neck, and the chanter reed protector while the man was in the hospital.
The samples grew numerous fungi including Paecilomyces variotti, Fusarium oxysporum, Penicillium species, Rhodotorula mucilaginosa, Trichosporon mucoides, pink yeast and Exophiala dermatitidis.
In spite of therapy, the man deteriorated and died. Postmortem examination revealed extensive lung damage consistent with acute respiratory distress syndrome and tissue fibrosis (scarring).
The history of daily bagpipe playing coupled with the improvement in symptoms when the man was bagpipe-free in Australia, and the discovery of antigens in the bagpipes, identifies the instrument as the likely cause. Many of the fungi found in this case have been associated with HP.
The authors say that the moist environment of the bagpipes may promote yeast and mold contamination, thereby making the chronic inhalation of offending antigens a likely trigger.
“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 mold, as potential triggers for HP. In a significant proportion of patients, a trigger is not identified,” write the researchers.
“In this case, playing the bagpipes, an important hobby in the history, was not initially realized as a potential trigger in the development of the disease, and subsequently, no serum-precipitating antibodies to molds or fungi were performed,” they add.
While this is an isolated case and the cause of the condition not proven, there have been other reported cases of HP in saxophone and trombone players caused by fungi and yeast.
The authors caution that wind instruments of any type could be contaminated with yeasts and molds that act as a potential trigger for HP. They suggest:
“Cleaning instruments immediately after use and allowing to drip-dry would theoretically reduce the risk of microorganism growth.”
The researchers conclude by noting that physicians should be aware of the potential risk factor for musicians and promote wind instrument hygiene.