'Lifeguard lung': Endemic granulomatous pneumonitis in an indoor swimming pool

Objectives. Two sequential outbreaks of respiratory disease among lifeguards at an indoor swimming pool with water spray features were investigated. Methods. Questionnaires were administered to recreation center employees following each outbreak. Respondents reporting 2 or more pool- related symptoms were offered clinical evaluation, including bronchoscopy with bronchoalveolar lavage and trans-bronchial biopsy. Pool air and water were sampled for fungi, bacteria, amoebae, endotoxin, and respirable particulates. Results. Thirty-three lifeguards had noncaseating granulomas on biopsy and/or bronchoalveolar lavage lymphocytosis. Attack rates for the outbreaks were 27% and 65%. Case patients had higher cumulative hours of work and tended to work more hours per week. Analyses indicated increased levels of endotoxin in pool air and water (relative to control pools) and gram- negative bacterial colonization of water sprays. Use of water spray features generated a 5.2-fold increase in the number of respirable particles and up to an 8-fold increase in air endotoxin levels. Conclusions. Lifeguards in this indoor swimming pool developed granulomatous lung disease associated with endotoxin-containing respirable bioaerosols from water spray features, which ventilation system improvements did not prevent.