214
NOTES
KP, Hung UR, Bouhuys A. Maximum expiratory flow-volume curves and airway conductance in children and adolescents. J Appl Physiol 1969; 25:308-16. 18. Sorbini CA, Grassi V, Solinas E, Muiesan G. Arterial oxygen tension in relation to age in healthy subjects. Respiration 1968; 25:33. 19. Weng T, Levison H . Standards of pulmonary
function in children. Am Rev Respir Dis 1969; 99:879-93. 20. McCormack MK, Dicker L, Katz SH, Caleb M, McDaniels J, Humphrey A, Buchert E, Lubin B. Growth patterns of children with sickle cell disease. H u m Biol 1976; 48:429-37. 21. Ashcroft M T , Serjeant GR. Body habitus of Jamaican adults with sickle cell anemia. South Med J 1972; 65:579-82.
A CLUSTER OF MYCOBACTERIUM GORDONAE ISOLATES FROM BRONCHOSCOPY SPECIMENS'•*
Summary During a 2.5-year period, 52 patients at Yale-New Haven Hospital had Mycobacterium gordonae recovered from specimens obtained by suction at bronchoscopy; 2 of them also had smears positive for acid-fast bacilli. Almost all of the isolates came from patients bronchoscoped by the same physician, one of 4 who performed the procedure during that period. Only this physician added one drop of green dye, stored in a 100-ml bottle, to the cocaine used for topical anesthesia during the procedure; cultures of the dye yielded Mycobacterium gordonae. Contamination with this organism, a cause of positive acid-fast smears, may result in an initial inappropriate diagnosis of Mycobacterium tuberculosis.
In June 1977, members of the microbiology laboratory at Yale-New Haven Hospital told the hospital epidemiologist about the repeated recovery of Mycobacterium gordonae from bronchoscopy specimens. T o evaluate this problem, bacteriology records and patient charts were reviewed. From January 1975 through June 1977, 52 patients had M. gordonae recovered from specimens obtained by suction at bronchoscopy (figure 1). T h e cultures had one to 4 colonies, and in 2 patients smears stained by the fluoro(Received in original form January 9, 1979 and in revised form February 28,1979) 1 Requests for reprints should be addressed to Dr. Allen C. Steere, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar St., New Haven, Conn. 06510. 2 T h e writers thank Ms. Karen Dietz for help with collection of data.
chrome method of T r u a n t and associates (1) showed acid-fast bacilli. T h e median age of the patients was 57 years (range, 19 to 85 years); 33 were men, and 19 were women. In most, the bronchoscopy had been performed for diagnostic evaluation of malignancies or hemoptysis; only one patient had a culture positive for Mycobacterium tuberculosis. Despite culture results, no patient was believed to be infected with M. gordonae, and none had the organism isolated again after the procedure. T h e first M. gordonae isolate from a bronchoscopy specimen was noted during September 1975, and in most months thereafter, one to 6 patients had such isolates (figure 1). During this 2.5-year period, M. gordonae was recovered from 52 of 699 bronchoscopy specimens (7.4 per cent) (table 1). In comparison, only 25 of 944 nonbronchoscopy sputum specimens (2.6 per cent) cultured from January through June 1976 contained this organism (P < 0.0000001). Furthermore, 49 of the 52 bronchoscopy isolates came from patients bronchoscoped by the same physician (physician A), one of 4 who performed the procedure during that period. T h e rate of M. gordonae isolates among his patients was 22.4 per 100 bronchoscopies compared to 1.2 per 100 among those of physician C ( P < 0.00001); physicians B and D had no patients with such isolates. T h e 4 physicians were then observed during bronchoscopy or their written methods were reviewed. Physicians A and B performed bronchoscopies in the same operating room suite, and physicians C and D always used a room in the radiology department. T h e fiberoptic bronchoscopes, other equipment, and personnel were never shared between the 2 areas. All of the physicians used sterile water at 37° C to defog the bronchoscope lens, 5 per cent cocaine or 2 per cent Xylocaine® for topical anesthesia, and sterile saline for irrigation. For disinfection afterward, the outside of the bronchoscope was cleaned with 70 per
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 120, 1979
215
NOTES
thetic and in patient secretions, the concentration of organisms in bronchoscopy specimens was unknown. Mycobacterium gordonae has not been recovered from such specimens since the dye was removed more than 1 year ago.
#
# # #
During a 2.5-year period, 52 patients had M. gordonae recovered from specimens obtained by suction Fig. 1. Number of patients with Mycobacterium gorat bronchoscopy. Except in 4 cases, one patient with donae recovered from bronchoscopy specimens, by meningitis (2), one with prosthetic valve endocardimonth. Forty-nine of the 52 isolates came from patients tis (3), and 2 with malignancies (4), M. gordonae bronchoscoped by physician A, one of 4 who performed has not been reported to cause human disease. None the procedure during that period. of our patients, some of whom were compromised by malignancies or chronic obstructive pulmonary discent isopropyl alcohol and the inside was suctioned ease, was considered to have been infected by M. gorwith povidone-iodine (500 ppm) followed by a rinse donae before bronchoscopy, and even though apwith sterile saline. However, unlike the others, phy- proximately 5 X 105 organisms were inoculated into sician A added one drop of green dye to the topical their respiratory tracts during the procedure, none were believed to have become infected because of anesthetic before use. T h e dye, "Best of All Green" (H. A. Johnson Food that exposure. Mycobacterium gordonae, a scotochromogenic MyCompany, Woodbridge, N.J.), a food dye derived aquae, from coal tars, contains tartrazine, brilliant blue, cobacterium formerly called Mycobacterium citric acid, and sodium benzoate. In the past, the hos- or the "tap water" bacillus, is often present in natural pital pharmacy had added this dye to local anes- water sources (5). In one instance, a large number of thetics used in the operating rooms, but discontinued such isolates were noted from patients who rinsed the practice about 1972. After that time, the phar- their mouths and gargled with tap water before spumacy supplied 100-ml bottles of the dye to physician tum was induced by aerosol (6). Thus, we were first A, and one drop was added to approximately 15 ml suspicious that tap water or deionized water might of cocaine at the time of the procedure. On July 22, have been used before or during bronchoscopies. 1977, the bottle in the operating room, which had However, almost all of the isolates came from patients been there for at least 2.5 years, was removed. Ap- bronchoscoped by the same physician (physician A), proximately 20 ml of dye remained; smears made one of 4 who performed the procedure. This finding from centrifuged sediment of the dye revealed acid- implicated his bronchoscopic methods as the cause of fast bacilli, and cultures yielded M. gordonae. No the outbreak. Observation of the physicians showed that only physician A added one drop of green food bottles were found in the pharmacy. To determine the number of organisms per ml, 4 dye, a nonsterile product, to the cocaine used for top10-fold dilutions were made from 1 ml of dye. T h e ical anesthesia. Mycobacterium gordonae was isofluid from each dilution was passed through a 0.22- lated from that dye, and no isolates have been noted ^m Millipore filter. T h e filter was placed on 7H10 since it was removed. We cannot account for the 3 isolates from patients agar plates, and colony counts were done. By this method, the dye was shown to contain approximately of physician C (L2 per cent of his bronchoscopies) 5 X 105 organisms per drop, the amount usually by this mechanism. Physicians A and C did not share placed in the cocaine. Because of dilution in the anes- bronchoscopy rooms, equipment, medications, pa-
TABLE 1 MYCOBACTERIUM GORDONAE ISOLATES RECOVERED FROM BRONCHOSCOPY SPECIMENS FROM 1975 TO 1977, ANALYZED BY PHYSICIANS RESPONSIBLE FOR THE PROCEDURES
Physician A B C D
Total
Cultures Positive for M. gordonae (no.)
Bronchoscopies Performed (no.)
Rate/100 Bronchoscopies
219 187 253 40
22.4
0 3 0 52
699
7.4
49
0 1.2 0
216
NOTES
tients, or assisting personnel. However, M. gordonae may occasionally colonize the respiratory tract (7) and, in fact, was recovered from 2.6 per cent of nonbronchoscopy sputum specimens in this hospital during a 6-month period. Thus, in the 3 patients of physician C, M. gordonae from their own respiratory tracts might have contaminated the specimens. T h e practice of coloring topical anesthetics was apparently begun to help distinguish topical from oral or injectable medications. Two per cent pontocaine, a potent topical anesthetic, may still be purchased commercially with blue dye added. When our hospital changed to single-dose dispensing of topical anesthetics, the hospital pharmacy discontinued the addition of dyes. However, physician A preferred to continue the practice and was supplied with his own 100-ml, multidose bottles. When removed, the current bottle had been used for at least 2.5 years. We do not know how it became contaminated, but assume that it happened during use in the operating room. T h e experience points out again the hazard of dispensing sterile medications from multidose vials. In this outbreak, 2 of 52 patients had positive smears for acid-fast bacilli; they were assumed to have tuberculosis until cultures yielded M. gordonae. According to hospital policy, the patients were placed on respiratory isolation, and one was also begun on antituberculous therapy. Although approximately 104 to 105 organisms per ml are required before visualization by smear is possible (8), contamination of specimens from either patient or laboratory sources may result in such concentrations of acid-fast bacilli. For example, laboratory contamination has been noted when deionized water was used to prepare the slides (9). Since the frequency of infection with M. tuberculosis has decreased (10), positive acid-fast smears due to M. gordonae may become a more commonly recognized problem. ALLEN C. STEEREI, 2 JOSEFINO CORRALES ALEXANDER VON GRAEVENITZ
Department of Internal Medicine, Hospital demiology, and Laboratory Medicine Yale University School of Medicine New Haven, Conn.
Epi-
References 1. Truant JP, Brett WA, Thomas W Jr. Fluorescence microscopy of tubercle bacilli stained with auramine and rhodamine. Henry Ford Hosp Med Bull 1962; 10:287-96. 2. Gonzales EP, Crosby RMN, Walker SH. Mycobacterium aquae infection in a hydrocephalic child (Mycobacterium aquae meningitis). Pediatrics 1971; 48:974-7. 3. Lohr DC, Goeken JA, Doty DB, Donta ST. Mycobacterium gordonae infection of a prosthetic aortic valve. JAMA 1978; 239:1528-30. 4. Feld R, Bodey GP, Groschel D. Mycobacteriosis in patients with malignant disease. Arch Intern Med 1976; 136:67-70. 5. Goslee S, Wolinsky E. Water as a source of potentially pathogenic mycobacteria. Am Rev RespirDis 1976; 113:287-92. 6. Gangadharam^PRJ, Lockhard J A, Awe RJ, Jenkins DE. Mycobacterial contamination through tap water. Am Rev Respir Dis 1976; 113:894. 7. Wolinsky, E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979; 119:107-59. 8. Bartmann K. Bakteriologische Diagnostik der Tuberkulose. Deutsch Med Wochenschr 1967; 92: 1872. 9. Dizon D, Mihailescu C, Bae HC. Simple procedure for detection of Mycobacterium gordonae: water causing false-positive acid-fast smears. J Clin Microbiol 1976; 3:211. 10. Boyd JC, Marr J. Decreasing reliability of acidfast smear techniques for detection of tuberculosis. Ann Intern Med 1975; 82:489-92.
NOTES
KP, Hung UR, Bouhuys A. Maximum expiratory flow-volume curves and airway conductance in children and adolescents. J Appl Physiol 1969; 25:308-16. 18. Sorbini CA, Grassi V, Solinas E, Muiesan G. Arterial oxygen tension in relation to age in healthy subjects. Respiration 1968; 25:33. 19. Weng T, Levison H . Standards of pulmonary
function in children. Am Rev Respir Dis 1969; 99:879-93. 20. McCormack MK, Dicker L, Katz SH, Caleb M, McDaniels J, Humphrey A, Buchert E, Lubin B. Growth patterns of children with sickle cell disease. H u m Biol 1976; 48:429-37. 21. Ashcroft M T , Serjeant GR. Body habitus of Jamaican adults with sickle cell anemia. South Med J 1972; 65:579-82.
A CLUSTER OF MYCOBACTERIUM GORDONAE ISOLATES FROM BRONCHOSCOPY SPECIMENS'•*
Summary During a 2.5-year period, 52 patients at Yale-New Haven Hospital had Mycobacterium gordonae recovered from specimens obtained by suction at bronchoscopy; 2 of them also had smears positive for acid-fast bacilli. Almost all of the isolates came from patients bronchoscoped by the same physician, one of 4 who performed the procedure during that period. Only this physician added one drop of green dye, stored in a 100-ml bottle, to the cocaine used for topical anesthesia during the procedure; cultures of the dye yielded Mycobacterium gordonae. Contamination with this organism, a cause of positive acid-fast smears, may result in an initial inappropriate diagnosis of Mycobacterium tuberculosis.
In June 1977, members of the microbiology laboratory at Yale-New Haven Hospital told the hospital epidemiologist about the repeated recovery of Mycobacterium gordonae from bronchoscopy specimens. T o evaluate this problem, bacteriology records and patient charts were reviewed. From January 1975 through June 1977, 52 patients had M. gordonae recovered from specimens obtained by suction at bronchoscopy (figure 1). T h e cultures had one to 4 colonies, and in 2 patients smears stained by the fluoro(Received in original form January 9, 1979 and in revised form February 28,1979) 1 Requests for reprints should be addressed to Dr. Allen C. Steere, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar St., New Haven, Conn. 06510. 2 T h e writers thank Ms. Karen Dietz for help with collection of data.
chrome method of T r u a n t and associates (1) showed acid-fast bacilli. T h e median age of the patients was 57 years (range, 19 to 85 years); 33 were men, and 19 were women. In most, the bronchoscopy had been performed for diagnostic evaluation of malignancies or hemoptysis; only one patient had a culture positive for Mycobacterium tuberculosis. Despite culture results, no patient was believed to be infected with M. gordonae, and none had the organism isolated again after the procedure. T h e first M. gordonae isolate from a bronchoscopy specimen was noted during September 1975, and in most months thereafter, one to 6 patients had such isolates (figure 1). During this 2.5-year period, M. gordonae was recovered from 52 of 699 bronchoscopy specimens (7.4 per cent) (table 1). In comparison, only 25 of 944 nonbronchoscopy sputum specimens (2.6 per cent) cultured from January through June 1976 contained this organism (P < 0.0000001). Furthermore, 49 of the 52 bronchoscopy isolates came from patients bronchoscoped by the same physician (physician A), one of 4 who performed the procedure during that period. T h e rate of M. gordonae isolates among his patients was 22.4 per 100 bronchoscopies compared to 1.2 per 100 among those of physician C ( P < 0.00001); physicians B and D had no patients with such isolates. T h e 4 physicians were then observed during bronchoscopy or their written methods were reviewed. Physicians A and B performed bronchoscopies in the same operating room suite, and physicians C and D always used a room in the radiology department. T h e fiberoptic bronchoscopes, other equipment, and personnel were never shared between the 2 areas. All of the physicians used sterile water at 37° C to defog the bronchoscope lens, 5 per cent cocaine or 2 per cent Xylocaine® for topical anesthesia, and sterile saline for irrigation. For disinfection afterward, the outside of the bronchoscope was cleaned with 70 per
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 120, 1979
215
NOTES
thetic and in patient secretions, the concentration of organisms in bronchoscopy specimens was unknown. Mycobacterium gordonae has not been recovered from such specimens since the dye was removed more than 1 year ago.
#
# # #
During a 2.5-year period, 52 patients had M. gordonae recovered from specimens obtained by suction Fig. 1. Number of patients with Mycobacterium gorat bronchoscopy. Except in 4 cases, one patient with donae recovered from bronchoscopy specimens, by meningitis (2), one with prosthetic valve endocardimonth. Forty-nine of the 52 isolates came from patients tis (3), and 2 with malignancies (4), M. gordonae bronchoscoped by physician A, one of 4 who performed has not been reported to cause human disease. None the procedure during that period. of our patients, some of whom were compromised by malignancies or chronic obstructive pulmonary discent isopropyl alcohol and the inside was suctioned ease, was considered to have been infected by M. gorwith povidone-iodine (500 ppm) followed by a rinse donae before bronchoscopy, and even though apwith sterile saline. However, unlike the others, phy- proximately 5 X 105 organisms were inoculated into sician A added one drop of green dye to the topical their respiratory tracts during the procedure, none were believed to have become infected because of anesthetic before use. T h e dye, "Best of All Green" (H. A. Johnson Food that exposure. Mycobacterium gordonae, a scotochromogenic MyCompany, Woodbridge, N.J.), a food dye derived aquae, from coal tars, contains tartrazine, brilliant blue, cobacterium formerly called Mycobacterium citric acid, and sodium benzoate. In the past, the hos- or the "tap water" bacillus, is often present in natural pital pharmacy had added this dye to local anes- water sources (5). In one instance, a large number of thetics used in the operating rooms, but discontinued such isolates were noted from patients who rinsed the practice about 1972. After that time, the phar- their mouths and gargled with tap water before spumacy supplied 100-ml bottles of the dye to physician tum was induced by aerosol (6). Thus, we were first A, and one drop was added to approximately 15 ml suspicious that tap water or deionized water might of cocaine at the time of the procedure. On July 22, have been used before or during bronchoscopies. 1977, the bottle in the operating room, which had However, almost all of the isolates came from patients been there for at least 2.5 years, was removed. Ap- bronchoscoped by the same physician (physician A), proximately 20 ml of dye remained; smears made one of 4 who performed the procedure. This finding from centrifuged sediment of the dye revealed acid- implicated his bronchoscopic methods as the cause of fast bacilli, and cultures yielded M. gordonae. No the outbreak. Observation of the physicians showed that only physician A added one drop of green food bottles were found in the pharmacy. To determine the number of organisms per ml, 4 dye, a nonsterile product, to the cocaine used for top10-fold dilutions were made from 1 ml of dye. T h e ical anesthesia. Mycobacterium gordonae was isofluid from each dilution was passed through a 0.22- lated from that dye, and no isolates have been noted ^m Millipore filter. T h e filter was placed on 7H10 since it was removed. We cannot account for the 3 isolates from patients agar plates, and colony counts were done. By this method, the dye was shown to contain approximately of physician C (L2 per cent of his bronchoscopies) 5 X 105 organisms per drop, the amount usually by this mechanism. Physicians A and C did not share placed in the cocaine. Because of dilution in the anes- bronchoscopy rooms, equipment, medications, pa-
TABLE 1 MYCOBACTERIUM GORDONAE ISOLATES RECOVERED FROM BRONCHOSCOPY SPECIMENS FROM 1975 TO 1977, ANALYZED BY PHYSICIANS RESPONSIBLE FOR THE PROCEDURES
Physician A B C D
Total
Cultures Positive for M. gordonae (no.)
Bronchoscopies Performed (no.)
Rate/100 Bronchoscopies
219 187 253 40
22.4
0 3 0 52
699
7.4
49
0 1.2 0
216
NOTES
tients, or assisting personnel. However, M. gordonae may occasionally colonize the respiratory tract (7) and, in fact, was recovered from 2.6 per cent of nonbronchoscopy sputum specimens in this hospital during a 6-month period. Thus, in the 3 patients of physician C, M. gordonae from their own respiratory tracts might have contaminated the specimens. T h e practice of coloring topical anesthetics was apparently begun to help distinguish topical from oral or injectable medications. Two per cent pontocaine, a potent topical anesthetic, may still be purchased commercially with blue dye added. When our hospital changed to single-dose dispensing of topical anesthetics, the hospital pharmacy discontinued the addition of dyes. However, physician A preferred to continue the practice and was supplied with his own 100-ml, multidose bottles. When removed, the current bottle had been used for at least 2.5 years. We do not know how it became contaminated, but assume that it happened during use in the operating room. T h e experience points out again the hazard of dispensing sterile medications from multidose vials. In this outbreak, 2 of 52 patients had positive smears for acid-fast bacilli; they were assumed to have tuberculosis until cultures yielded M. gordonae. According to hospital policy, the patients were placed on respiratory isolation, and one was also begun on antituberculous therapy. Although approximately 104 to 105 organisms per ml are required before visualization by smear is possible (8), contamination of specimens from either patient or laboratory sources may result in such concentrations of acid-fast bacilli. For example, laboratory contamination has been noted when deionized water was used to prepare the slides (9). Since the frequency of infection with M. tuberculosis has decreased (10), positive acid-fast smears due to M. gordonae may become a more commonly recognized problem. ALLEN C. STEEREI, 2 JOSEFINO CORRALES ALEXANDER VON GRAEVENITZ
Department of Internal Medicine, Hospital demiology, and Laboratory Medicine Yale University School of Medicine New Haven, Conn.
Epi-
References 1. Truant JP, Brett WA, Thomas W Jr. Fluorescence microscopy of tubercle bacilli stained with auramine and rhodamine. Henry Ford Hosp Med Bull 1962; 10:287-96. 2. Gonzales EP, Crosby RMN, Walker SH. Mycobacterium aquae infection in a hydrocephalic child (Mycobacterium aquae meningitis). Pediatrics 1971; 48:974-7. 3. Lohr DC, Goeken JA, Doty DB, Donta ST. Mycobacterium gordonae infection of a prosthetic aortic valve. JAMA 1978; 239:1528-30. 4. Feld R, Bodey GP, Groschel D. Mycobacteriosis in patients with malignant disease. Arch Intern Med 1976; 136:67-70. 5. Goslee S, Wolinsky E. Water as a source of potentially pathogenic mycobacteria. Am Rev RespirDis 1976; 113:287-92. 6. Gangadharam^PRJ, Lockhard J A, Awe RJ, Jenkins DE. Mycobacterial contamination through tap water. Am Rev Respir Dis 1976; 113:894. 7. Wolinsky, E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979; 119:107-59. 8. Bartmann K. Bakteriologische Diagnostik der Tuberkulose. Deutsch Med Wochenschr 1967; 92: 1872. 9. Dizon D, Mihailescu C, Bae HC. Simple procedure for detection of Mycobacterium gordonae: water causing false-positive acid-fast smears. J Clin Microbiol 1976; 3:211. 10. Boyd JC, Marr J. Decreasing reliability of acidfast smear techniques for detection of tuberculosis. Ann Intern Med 1975; 82:489-92.
