[Peculiarities of pulmonary X-ray changes due to exposure to welding aerosol]

The authors first evaluated pulmonary X-ray changes in contemporary pneumoconiosis types and hypersensitivity pneumonoitis, both caused by exposure to welding aerosol.

Chronic hypersensitivity pneumonitis: CT features comparison with pathologic evidence of fibrosis and survival

PURPOSE

To retrospectively compare in patients with chronic hypersensitivity pneumonitis (HP) the computed tomographic (CT) imaging features suggestive of fibrosis with pathologic evidence of fibrosis at surgical lung biopsy and to compare a usual interstitial pneumonia (UIP) pattern at CT with survival.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained for this study, which was HIPAA compliant. Twenty-six patients (15 women, 11 men; age range, 37-76 years) with chronic HP had their surgical lung biopsy results reviewed by two pathologists for the presence of fibrosis. Two radiologists systematically reviewed the CT scans. The two radiologists were blinded to all clinical information, including pathologic diagnosis, patient information, and outcomes. The combination of a subpleural reticular pattern and lower zone predominance was considered a UIP pattern. CT findings were compared with the histopathologic presence of fibrosis, physiologic parameters, symptoms, and survival. The chi(2) or Fisher exact test (each two-tailed) was used to compare nominal and ordinal variables. A t test (with unequal variances) was used to compare continuous variables. The log-rank procedure was used to compare Kaplan-Meier survival curves.

RESULTS

Fifteen patients had fibrotic HP at biopsy, and 11 had nonfibrotic HP. Patients with fibrotic HP had more extensive reticular pattern and were more likely to have traction bronchiectasis, honeycombing, and a UIP pattern than those with nonfibrotic HP (P = .015, P = .007, P = .007, respectively). Although the presence of histologic fibrosis was associated with decreased survival (P = .003), the CT features were not associated with decreased survival.

CONCLUSION

CT findings of extensive reticular pattern, traction bronchiectasis, and honeycombing are closely related to the presence of histologic fibrosis in chronic HP.

Hypersensitivity pneumonitis associated with leflunomide therapy

Disease progression in rheumatoid arthritis is controlled with disease modifying drugs, many of which have toxic side effects. Pulmonary side effects are common and this has resulted in the development of newer medications with less pulmonary toxicity. We observed that even these newer drugs can be associated with potentially very serious pulmonary toxicity, with hypersensitivity pneumonitis developing after the initiation of leflunomide therapy. We urge caution in the use of leflunomide in patients with pulmonary side effects from other drugs or who have underlying pulmonary disease.

[A case of intravascular large cell lymphoma with pulmonary invasion]

A 60-year-old man was admitted to our hospital because of dyspnea, cough, and fever two weeks after participating demolition work. Computed tomography of the chest showed multiple diffuse interstitial shadows. While fibrotic bronchoscopy and transbronchial lung biopsy showed alveolitis. We diagnosed hypersensitivity pneumonitis (HP) and treated with mPSL-pulse therapy then got better soon, and also chest abnormal shadow disappeared. Two month later he was admitted because of the same symptom. His chest CT-scans showed diffuse interstitial shadows and we diagnosed recurrence of HP. Treatment with mPSL pulse-therapy was not effective. Acute respiratory failure appeared and progressed daily. The patient died 3 weeks after admission. The final diagnosis of autopsy is angiotrophic large cell lymphoma, a very rare type of lymphoma (<1% of NHL). It is important to consider angiotrophic large cell lymphoma in the differential diagnosis of diffuse interstitial lung disease.

Hypersensitivity Pneumonitis: Spectrum of High-Resolution CT and Pathologic Findings

OBJECTIVE

The purpose of this article is to illustrate the spectrum of pathologic and high-resolution CT features of hypersensitivity pneumonitis (HP).

CONCLUSION

High-resolution CT plays an important role in the diagnosis of HP. A confident diagnosis of subacute HP is based on the presence of ground-glass opacities, poorly defined centrilobular nodules, and mosaic attenuation on inspiratory images and of air trapping on expiratory CT images. Chronic HP is characterized on high-resolution CT by the presence of reticulation due to fibrosis superimposed on findings of subacute HP. Histologically, subacute HP is characterized by the presence of cellular bronchiolitis, noncaseating granulomas, and bronchiolocentric lymphocytic interstitial pneumonitis. Areas of organizing pneumonia also may be seen. The high-resolution CT and pathologic features of chronic HP frequently overlap with those of nonspecific interstitial pneumonia and usual interstitial pneumonia. Awareness of the various manifestations of HP is important for early diagnosis and management.

[Actualities in extrinsic allergic alveolities or hypersensitivity pneumonitis]

Significant advances have been noticed in the pathogenesis and the diagnosis of extrinsic allergic alveolitis during the last few years. Indeed the immune mechanism and the enabling conditions have been more precisely defined, the clinical stages and the diagnosis criterias clearly defined, new antigens incriminated and some etiological agents have been reclassified. The present pathogenic explanation insists on the type IV hypersensitivity reaction with sensitization of T lymphocytes, activation macrophages, the formation of IgG type antibodies and immune complexes, activation of complement and secretion of cytokines. The involvement of certain HLA classes (HLA2, DR3, DRB1, DQB1), interaction of genetics and environments factors, the role of infections agents and smoking have been demonstrated in several studies. The development of news clinical and biological diagnosis criteria have led the discovery of new extrinsic allergic alveolitis in the work places, a better knowledge of the prognostic elements and an appropriate adaptation of prevention measures.

Extrinsic allergic alveolitis: comparative study of the bronchoalveolar lavage profiles and radiological presentation

INTRODUCTION

Extrinsic allergic alveolitis (EAA) is an immunologically mediated interstitial lung disease. The abnormalities in the bronchoalveolar lavage (BAL) fluid cell counts are almost always seen in patients with EAA according to the stage of the disease. The aim of this retrospective study was to find out how the BAL lymphocyte count, percentage of lymphocytes expressing HLA-DR, CD4/CD8 T cell ratio in BAL fluid, and the concentration of immunoglobulin G in serum correspond to the inflammatory activity of the disease.

METHODS

The study included 14 patients with EAA. BAL fluid samples were obtained and processed for cytological and cytometric analysis. Immunoglobulin G serum concentrations were measured. High resolution computed tomography (HRCT) scoring system modified by Gay was used for establishing the alveolar and interstitial score in each patient.

CONCLUSIONS

It was found that subjects with normal value of CD4/CD8 ratio in BAL fluid had higher interstitial HRCT score. Clinical presentation, continuous exposure to the causative antigens, and BAL lymphocyte count positively correlated with the alveolar HRCT score. It is proposed that the increased BAL lymphocyte count could be the predictor of the inflammatory activity of the disease, especially in people with lasting exposure to the offending antigen.

Therapeutic effects for hypersensitivity pneumonitis induced by Japanese mushroom (Bunashimeji)

BACKGROUND

Bunashimeji-related hypersensitivity pneumonitis is found among workers who cultivate the mushroom in indoor facilities. An evaluation of protective measures was initiated using the outcomes of clinical, immunological, and radiological findings.

METHODS

Twenty-two patients presented with symptoms of HP; all were employed cultivating Bunashimeji mushrooms in indoor facilities. After hospitalization, 6 of 22 patients quit their job to avoid exposure to spores (Avoidance group). Sixteen patients continued to work used a mask for 3 months, and were then divided into two subgroups: Mask alone (seven patients) and mask plus oral prednisolone (Mask + PSL) (nine patients). The erythrocyte sedimentation rate (ESR), serum Krebs von der Lungen-6 (KL-6), surfactant protein-D (SP-D), lymphocyte stimulation test (LST), ground-glass scores in chest high-resolution computed tomography (HRCT), and bronchoalveolar lavage (BAL) were assessed before and after treatment.

RESULTS

Complete avoidance resulted in a significant decrease in LST. There was a significant decrease after PSL treatment in serum KL-6, SP-D, and total cell counts in the BAL fluid in the Mask + PSL group. In the Mask alone group, serum KL-6, SP-D, ground-glass scores in chest HRCT and total cell counts in BAL fluid showed high levels compared with the other two groups.

CONCLUSIONS

Complete cessation was the best treatment for hypersensitivity pneumonitis. The use of a mask was ineffective for patients with a high serum KL-6 and SP-D concentration and severe ground-glass opacity on chest HRCT. Initial treatment with PSL is recommended for these patients with high levels of total cell counts in BAL fluid.

A woman with cough, fever, and micronodular infiltrates on chest radiograph

Hot tub lung is a form of hypersensitivity pneumonitis (HP) reported to be associated with exposure to large aerosolized inocula of Mycobacterium avium complex (MAC). Although the pathogenesis of the disease is still poorly understood, the pathology of MAC-related HP can be similar to that of sarcoidosis, with well-formed granulomas. We describe a patient with HP featuring well-formed granulomas on transbronchial biopsy specimens, a finding believed to be unique to MAC-related HP, also referred to as "hot tub lung".

A case of acute hypersensitivity pneumonitis associated with an oil fan heater

We report here a case of acute hypersensitivity pneumonitis induced by an oil fan heater. A 57-year-old man was admitted to our hospital because of fever, nonproductive cough, and dyspnea. Paeccilomyces variotii and Paeccilomyces nivea were identified from an oil fan heater in his house. The result of an environmental challenge test was positive. Intradermal reaction and precipitin results to sugar antigen of those fungi were positive only in the patient. This is the first described case of acute hypersensitivity pneumonitis caused by an oil fan heater.

Hypersensitivity pneumonitis induced by spores of Penicillium citrinum in a worker cultivating Enoki mushroom

A 47-year-old Japanese woman was admitted to our hospital with a 2-week history of dry cough and shortness of breath. She had been engaged in Enoki mushroom production for 22 years. Chest X-ray and chest computed tomography (CT) scan showed bilateral fine-nodular shadows and ground glass opacity. Bronchoalveolar lavage fluid demonstrated an increase of total cell counts with predominant lymphocytosis. Pathological specimens obtained by video-assisted thoracoscopic surgery revealed alveolitis and noncaseating granuloma with giant cells. Lymphocyte stimulation test showed positive responses with Enoki mushroom, culture medium, and Penicillium citrinum. On double immunodiffusion test, a precipitation line was observed between patient's serum and Penicillium citrinum antigen. She was found to have hypersensitivity pneumonitis caused by Penicillium citrinum. This is the first report of mushroom worker's lung caused by Penicillium citrinum.

[Radiological methods in the diagnostics of extrinsic allergic alveolitis]

There were 77 patients with EAA under our observation with the following X-ray symptom groups: emphysematous-interstitial; parenchymatous-interstitial; pneumonic. The emphysematous-interstitial X-ray symptom group is the most non-specific for the X-ray diagnostics. The changes indicate to symptoms of impaired bronchial conductance of different expression and are relevant to clinical EAA options characteristic for the obstructive syndrome. The parenchymatous-interstitial X-ray symptom group is more characteristic for occupational EAA. In such cases the most important are changes in the lung parenchyma that have a diffusive character and are accompanied by general symptoms indicating to bronchial impairments of different severity. In pneumatic X-ray symptom group, the major X-ray symptom is presence of local sites of lung tissue consolidation of hypoventilation-infiltrative character that can be bilateral, multiple with a trend to migration.

[Hypersensitivity pneumonitis in budgerigar fanciers. A seldom recognised disease?]

A hypersensitivity pneumonitis (HP) can be easily recognized either in acute manifestations, as in farmer lung syndrome, and in subacute, as bird fancier's lung; the following case shows an insidious HP occurred to a 44 year old, non smoker woman, fancier--during the winter--of 8 budgerigars kept in the kitchen. The authors suppose HP is underestimated, considering Italy's likely high number of bird fanciers, versus only 260 general cases of HP that have been reported every year in Italy (1999-2002).

[Suberosis and bird fancier's disease: comparative study of radiological, functional and bronchoalveolar characteristics profile]

Extrinsic Allergic Alveolitis (EAA) is an immunologically mediated interstitial lung disease that may result from repeated inhalation of many different environmental agents. Heterogeneity of the clinical presentation and bronchoalveolar lavage profiles has been described, possibly related to different occupational exposures. The aim of our study was to compare bronchoalveolar lavage fluid (BALF), clinical, functional and radiological characteristics of the two most frequent forms of EAA seen in our practice: Suberosis and Bird Fancier's Disease (BFD). We included 81 patients with Suberosis, with a mean age of 38.8+/-11.3 years and a mean exposure of 20.0 +/- 10.5 years and 32 patients with BFD, with a mean age of 46.3+/-11.8 years and mean exposure of 10.5 +/- 1.0 years. Patients with BFD had more acute forms, while subacute and chronic presentations predominated in Suberosis. Restrictive defect was the most frequent pattern of lung function impairment, and more severe in BFD. Ground glass opacities were the most frequent pattern in high-resolution computed tomography. A normal chest x-ray was more frequently seen in Suberosis. Both types of EAA had lymphocytic alveolitis in BALF: Suberosis - 6.6 +/- 5.7 x 105 ml-1 cells, 58.8 +/- 18.9% lymphocytes; bird fancier's disease - 9.0 +/- 6.5 x 105 ml-1 cells, 61.7 +/- 22.2% lymphocytes. Although BALF CD8+ lymphocytes predominated in both diseases, the proportion of CD4+ and CD4/CD8 ratios were significantly higher in Bird Fancier's Disease (Suberosis: 0.47 +/- 0.33 versus BFD: 1.1 +/- 1.5; p <0.005). Moreover, BALF cellularity and mast cell counts were also significantly higher in BFD. In conclusion, Suberosis and bird fancier's disease are EAA with different clinical and laboratory profiles, suggesting that despite their pathophysiological similarities, different antigenic exposures may cause different immune and inflammatory response dynamics in the lung.

High-resolution computed tomography in hypersensitivity pneumonitis - correlation with pulmonary function

In 20 patients with chronic form of hypersensitivity pneumonitis (HP) pulmonary function tests (FEV(1), FVC, DCO) and high resolution computed tomography (HRCT) scans were obtained. Extent of pathological changes, i.e. nodularity, lines, honeycombing but not ground-glass estimated by HRCT and expressed as a score correlated significantly with lung function abnormalities.

Characterization of Functional, Radiologic and Lung Function Recovery Post-Treatment of Hot Tub Lung. A Case Report and Review of the Literature

Hot tub lung is described as an acute pulmonary illness that is characterized by fever, dyspnea and interstitial nodular infiltrates. Although not entirely clear, the etiology may be a hypersensitivity pneumonitis, an infection secondary to Mycobacterium avium intracellulare (MAC), or possibly both. Herein we describe the most well-characterized physiologic, radiographic, and functional recovery from hot tub lung reported in the literature to date. Pulmonary function testing and CT scans of the chest were obtained after each therapeutic intervention, and the patient had the most dramatic improvement with simply avoiding the hot tub. Prednisone therapy offered minimal further improvement while anti-MAC therapy provided no further improvement. These results are suggestive of a hypersensitivity pneumonitis rather than an infectious etiology.

Clues for the differential diagnosis of hypersensitivity pneumonitis as an expectant variant of diffuse parenchymal lung disease

Hypersensitivity pneumonitis, also called extrinsic allergic alveolitis, a type of diffuse parenchymal lung disease (DPLD), is an immunologically mediated pulmonary disease induced by inhalation of various antigens. As data on the frequency of hypersensitivity pneumonitis are lacking in Turkey, a retrospective analyses was performed in 43 patients with DPLD, followed up over seven years. The objective was to discover cases fulfilling the diagnostic criteria for hypersensitivity pneumonitis, to determine the frequency and/or the new characteristics of the disease, and to pick up clues for differentiating it from other DPLDs. The four subjects with hypersensitivity pneumonitis (9%) who lived in an urban area were studied in detail. The most common symptoms were dry cough and dyspnoea. According to the symptom duration, clinical features, radiological and pathological findings, three were diagnosed with chronic and one with subacute hypersensitivity pneumonitis. Patients with hypersensitivity pneumonitis and those with DPLD were compared by means of age, sex, smoking status, symptom duration, haematology, erythrocyte sedimentation rate, peripheral cell count, spirometric parameters, blood gases, and diffusion capacity. No statistically significant difference was detected in these parameters except for forced expiratory volume in one second (FEV(1)) and forced vital capacity (FVC). In conclusion, patients with a history of antigen exposure, with mild symptoms such as dry cough and dyspnoea, and who have diffuse interstitial lung involvement on radiology should be carefully evaluated for hypersensitivity pneumonitis. Moreover, among other DPLDs, stable FEV(1) or FVC values may be the clues for establishing the diagnosis of hypersensitivity pneumonitis. However, further studies are needed in larger series of patients.

Zimmerspringbrunnen-Alveolitis

A 22-year-old woman developed recurrent episodes of fever, cough and dyspnea after repeated exposure to a misting fountain at home. A diagnosis of extrinsic allergic alveolitis (EAA) was made by detection of serum antibodies against the fountain water, by culture of Bacillus subtilis, Mucor racemosus, Mucor mucedo, and Saccharomyces cerevisiae from the water, and by detection of specific IgG antibodies against Bacillus subtilis and the Mucores. The diagnosis was confirmed by a restrictive lung function pattern, and a highly increased total cell count with a lymphocytosis of 39 % in the bronchoalveolar lavage. An inhalation challenge with the misting fountain resulted in a positive reaction. Because this humidifier system has recently become widespread at home, clinicians should be aware of this specific type of EAA which may be called "misting fountain alveolitis".

Imaging of interstitial lung disease

This article provides a comprehensive summary of typical imaging features of common interstitial lung diseases with an emphasis on high-resolution computed tomography (HRCT). The classification of interstitial lung disease that is used is in accordance with the consensus statement of the American Thoracic Society. The secondary pulmonary lobule is the basic anatomic unit that is used for standard description of findings on HRCT. Sarcoidosis, Langerhans' cell histiocytosis, lymphangioleiomyomatosis, collagen vascular diseases, and hypersensitivity pneumonitis are some of the common interstitial lung diseases that are addressed.

Hypersensitivity Pneumonitis Caused by Esparto Dust in a Young Plaster Worker:A Case R eport and Review of the Literature

We report a case of a 25-year-old, white, male plaster worker who started developing fever, severe dyspnea and cough during the manipulation of esparto fibers. The functional lung study showed restrictive lung disease and decreased single-breath carbon monoxide transfer lung capacity. High-resolution computed tomography revealed a diffuse 'ground-glass' pattern. The histopathological findings were interstitial inflammation with a marked predominance of lymphocytes and microgranulomas. Bronchoalveolar lavage showed a significant predominance of lymphocytes, with an increase in the level of CD8. Serum precipitins against fungal antigens confirmed that Aspergillus fumigatus was the cause of the patient's hypersensitivity pneumonitis.

[Hypersensitivity pneumonitis recognised by open lung biopsy in patients at the Institute of Tuberculosis and Lung Diseases]

Diagnosis of hypersensitivity pneumonitis (HP) is made on the basis of a combination of clinical features connected with the exposition to organic dusts, radiographic abnormalities, lung function tests and immunological tests. Open lung biopsy (OLB) and histological examination is not necessary and is indicated mainly in chronic and subacute form of HP. In the chronic form of HP symptoms often do not show a temporal relationship with antigen exposure and errors occur especially if specific questions are not asked about exposure to antigen if HP. The aim of this paper was to analyse whether OLB was necessary in all patients in whom HP was recognised just after this procedure. Material included 21 patients in whom microscopic examination suggested HP among 258 pts in whom OLB was performed in the period of 1998-2003. There were 13 men and 8 women at the age of 18 to 65 years, mediana 42 years.

RESULTS

We found 3 groups of pts. Group "+" included 9 exposed pts. They were asked and confirmed contact with birds, hay and 7 of them observed correlation between exposition and symptoms. The second Group "-" included 7 pts who were asked about exposition and who answered in the negative. In all of them HRCT scans suggested HP. Restriction was below 70% of VC in 3 pts. The third Group "0" included 5 pts who were not asked about exposition and correlation with symptoms. Two from them lived in the rural area.

CONCLUSIONS

Open lung biopsy was not necessary for 6 patients in Group "+", because then had enough symptoms to recognise HP. In 3 patients of Group "+" and in 5 of Group "0" OLB could be not necessary because specific anamnesis and additional examinations were not collected. OLB was necessary method for 7 patients in Group "-".