[Hypersensitivity pneumonitis caused by isocyanate exposure during recreational painting]

A 36-year-old man began painting his car as a hobby every weekend in early February 2007 using a paint containing isocyanate. In March, 2007, he developed a dry cough, dyspnea and fever of 40 degrees C. These symptoms appeared repeatedly several hours after engaging in painting activity. His chest X-ray film showed diffuse small granular and reticular shadows in bilateral lung fields. His computed tomogram showed ground glass images in bilateral lung fields. Pulmonary function tests showed significantly decreased DLco. Histological findings of transbronchial lung biopsy revealed cellular interstitial pneumonia. These symptoms improved after cessation of painting and administration of prednisolone. Based on these results, we diagnosed this patient's illness as hypersensitivity pneumonitis due to isocyanate exposure.

[Hypersensitity pneumonitis in a greenhouse rose grower]

A 54-year-old woman presented with chronic cough. She had been engaged in growing roses in plastic greenhouses. Chest CT scan showed bilateral diffuse ground-glass attenuation. Bronchoalveolar lavage fluid demonstrated the increase of total cell counts with predominant lymphocyte cells, and transbronchial lung biopsy specimen revealed lymphocyte alveolitis with granuloma. Precipitating antibody against the extract of the Penicillium species obtained in the greenhouses was detected by the double immunodiffusion test, which led to a diagnosis of hypersensitivity pneumonitis caused by Penicillium species. This case suggests the risk of hypersensitivity pneumonitis caused by fungi in closed spaces with high temperature and humidity such as greenhouses.

[Hypersensitivity pneumonitis induced by Hypsizigus marumoreus]

We present the case of a 53-year-old woman who was employed at a mushroom (Pleurotus eryngii and Hypsizigus marumoreus) cultivation factory for 15 years. She was admitted to our hospital because of fever and dry cough. Chest radiography and CT scanning revealed diffuse ground glass opacity and centrilobular nodules in both lung fields. Serum KL-6 was elevated. In the bronchoalveolar lavage fluid, the CD4/CD8 ratio was reduced, and the lymphocyte fraction was very high. Transbronchial lung biopsy specimens showed lymphocyte alveolitis. After admission, the patient's symptoms improved rapidly without medication. Although these findings are compatible with hypersensitivity pneumonitis, it was difficult to identify a causative antigen. Serum antibody against Trichosporon was positive. A lymphocyte stimulation test of the peripheral blood was positive against extracts of P. eryngii and H. marumoreus. Furthermore, precipitins against the extracts of H. marumoreus were detected by a double immunodiffusion test. Therefore, we decided to conduct a challenge test using H. marumoreus. As an inhalation provocation test with H. marumoreus conducted in a sickroom caused the same clinical symptoms and signs as experienced in the workplace, we diagnosed hypersensitivity pneumonitis caused by H. marumoreus. A provocation test, in which antigen exposure is limited using a closed space, such as a sickroom, was simple, safe and effective for determining the antigen causing hypersensitivity pneumonitis.

Malt can cause both occupational asthma and allergic alveolitis

Specific inhalation challenge can help differentiate occupational asthma from allergic alveolitis caused by malt.

[Extrinsic allergic alveolitis--rarely diagnosed disease]

Extrinsic allergic alveolitis (EAA), known as hypersensitive pneumonitis, causes interstitial lung involvement by inhaled antigen. The clinical presentation of the disease has been defined as acute, subacute and chronic. The most often symptoms of the acute form of the disease are flu-like symptoms, dyspnoe and cough. The progressive dyspnoe in particullary is characterized for the chronic form of EAA. Dyspnoe is worsed, if the disease is combinied with usual respiratory infection or reexposition of inhaled antigen. It seems the diagnostic definition of EAA should be easy and prevalence of EAA relative high. The disease belongs to the group of interstitial lung diseases and it is underestimated as a matter of fact. The clinic, radiographic, laboratory and histologic abnormalities are results of inhaled antigen contact and support the diagnosis of EAA. Specific IgG antibodies against the offending antigen along with them are consedered to be detected (established) of EAA.

[A case of hypersensitivity pneumonitis resulting from inhalation of Aspergillus niger in a greenhouse worker who raised roses]

A 57-year-old woman was referred because of exertional dyspnea, fever, and cough in June 2006. She had been employed to culture roses in greenhouses since 1991 and had developed a cough during the summer from 2003. Chest CT scan revealed diffuse centrilobular micronodules. Transbronchial lung biopsy specimens demonstrated alveolitis with lymphocytes and non-necrotizing epithelioid cell granulomas. After admission, both the patient's symptoms and laboratory data improved without medication. However, upon her return to work in the greenhouse, cough and exertional dyspnea reappeared. Aspergillus niger was detected in the greenhouse. Her serum was assayed for precipitating antibodies against various antigens, and precipitating antibodies against Aspergillus fumigatus, Aspergillus flavus, Aspergillus glaucus, and Aspergillus niger were demonstrated. In a double immunodiffusion test, cross-reactivity between Aspergillus niger and other Aspergillus species was indicated. Consequently, she was diagnosed as having hypersensitivity pneumonitis resulting from the inhalation of Aspergillus niger.

A novel inhalation challenge set to study animal model of allergic alveolitis

A novel inhalation challenge set for the study of experimental allergic alveolitis (hypersensitivity pneumonitis) in mice was designed. A finely dispersed aerosol of allergenic extract generated by the commercial ultrasonic nebulizer "TAJFUN MU1" (produced by Medbryt, Warsaw, Poland) was transported to the airtight inhalation chamber. In the chamber were placed 15 perforated containers made of transparent plastic, each containing one mouse. They were coupled in 3 units, each consisted of 5 containers. The constant flow of aerosol through the chamber was assured by commercial vacuum pump "PL 2/3" (AGA LABOR S.C., Warsaw, Poland). The applied set enabled the natural exposure of mice via the inhalation route to known quantities of allergen (usually microbial) suspended in saline, and then dispersed in form of fine aerosol by ultrasonic nebulizer. This method assures the penetration of allergen into the deep parts of lungs, alveoli and bronchioli. The detailed study of histopathological and biochemical changes in the lungs of exposed animals will be the subject of further publications. So far, the retention of endotoxin in the lungs of mice exposed to the extract of a Gram-negative bacterium Pantoea agglomerans and appearance of positive serologic reactions to this extract indicate the effectiveness of the method.

[Familial summer-type hypersensitivity pneumonitis in a husband and wife]

We encountered a family in which two of four members, the husband and his wife, had summer-type hypersensitivity pneumonitis at the same time, about two months after they moved to the residence. A 45-year-old man had cough, fever and exertional dyspnea. Chest computed tomography showed diffuse centriloblar ground-glass attenuation in both lung fields. His 43-year-old wife had chest small nodular shadows and similar symptoms to his husband. Serum anti-Tricosporon cutaneum (T. asahi: serotype II and T. mucoides: serotype I) antibodies of both patients were at the positive level. They were given diagnosis as summer-type hypersensitivity pneumonitis by radiological, serological and histological examinations. The symptoms in both cases were improved immediately after administration of systemic corticosteroid. Summer-type hypersensitivity pneumonitis was assumed to be caused for about two months duration of expousure to antigen.

Mycobacterium immunogenumCauses Hypersensitivity Pneumonitis-Like Pathology in Mice

A surprising number of cases of hypersensitivity pneumonitis have been observed at work sites employing automotive machinists. Because hypersensitivity pneumonitis is not typically associated with exposure to metalworking fluid aerosols, this study examined whether Mycobacterium immunogenum (M. immunogenum), a rapidly growing mycobacterium isolated from several affected work sites, could induce hypersensitivity pneumonitis in mice. Hypersensitivity pneumonitis-like histologic changes occurred in mice treated with heat-killed and lysed M. immunogenum. These lung lesions were characterized by peribronchial and perivascular lymphohistiocytic inflammation and noncaseating granulomas in the parenchyma. The pathologic changes observed in mice instilled with M. immunogenum-contaminated used metalworking fluid were indistinguishable from those observed with M. immunogenum alone. The role of genetic factors in M. immunogenum-induced lung lesions was examined by comparison of the response of eight inbred strains of mice. The observed immunologic changes in the lung were significantly greater in C57Bl/6, 129, and BALB/c mice than in the other strains, suggesting that genetic factor(s) contribute to the susceptibility of workers exposed to M. immunogenum-contaminated metalworking fluid aerosols. Thus, these studies provide indirect evidence that M. immunogenum is an unrecognized class of microorganisms capable of causing hypersensitivity pneumonitis and plays a role in the outbreaks of hypersensitivity pneumonitis in automotive plants.

[Case of hot tub lung with confirmation of exacerbation following jet bath use]

A 49-year-old woman presented with exertional dyspnea. Chest CT revealed patchy areas of ground-glass attenuation and ill-defined centrilobular nodules scattered in both lungs. Bronchoalveolar lavage (BAL) fluid showed lymphocytosis. Transbronchial lung biopsy revealed bronchiolocentric alveolitis and well-formed non-necrotizing granulomas were present. She had used a jet bath before the onset of symptoms and mycobacterial culture revealed the presence of Mycobacterium avium complex (MAC) in sputum sample, BAL samples and jet bath water. Restriction fragment length polymorphism (RFLP) analysis revealed that the isolated MAC were essentially clonal. She had used the jet bath for the inhalation provocation study, and after the challenge she complained of dyspnea and have body temperature increased. We diagnosed hot tub lung due to Mycobacterium avium complex. Because avoidance of the jet bath caused improvement of her symptoms and reduced her fever and PaO2 increased by 10 Torr but did not improve the CT findings, antimycobacterial drugs were prescribed. The patient recovered fully. This case proves that the cause of hot tub lung is the use of jet bath through the inhalation provocation study.

[Chronic hypersensitivity pneumonitis induced by Shiitake mushroom cultivation: case report and review of literature]

A 72-year-old man, a Shiitake mushroom grower over fifty years, was admitted to our hospital because of bilateral chest interstitial shadow with chronic cough and breathlessness. Chest computed tomography showed traction bronchiectasis, subpleural micro-cystic changes and partial ground-glass opacities in both lungs, and mild mediastinal lymphadenopathy. A diagnosis of chronic hypersensitivity pneumonitis induced by Shiitake mushrooms was comprehensively confirmed by occupational history, radiological findings, and positive findings of an incidental environmental provocation test and lymphocyte stimulation test for Shiitake mushroom extracts. We reviewed the clinical features in five patients with chronic hypersensitivity pneumonitis induced by Shiitake mushrooms reported in Japan. There was a tendency toward increasing lymphocytes and high CD4/CD8 ratio in bronchoalveolar lavage fluids. Treatment with steroids seems to have a limited effect, while avoidance of the antigen is important.

[Health effects of indoor molds]

Molds are found almost everywhere in the environment. Their airborne propagules (conidia, spores, hyphal fragments) can--under certain circumstances--cause a variety of health problems like mycotic infections, allergies, asthma, irritations or toxic syndromes.

Granuloma associated with Trichosporon asahii infection in the lung: Unusual pathological findings and PCR detection of Trichosporon DNA

We describe the first case of a Trichosporon asahii infection of the lung characterized by an epithelioid granuloma with multinucleated giant cells. The patient died of respiratory failure due to lung fibrosis and lung cancer. Autopsy showed primary lung cancer with metastasis, lung fibrosis, and a focal infectious lesion containing the filamentous and yeast forms of a fungus. From its shape the fungus was judged to be Trichosporon, but unusual pathological findings revealed an epithelioid granuloma with multinucleated giant cells surrounding the hyphae and yeast cells. Immunohistochemical staining was performed using the specific Trichosporon spp. monoclonal antibodies and DNA identificationn was done by the PCR. The results showed this case to be a localized Trichosporon asahii infection. Hypersensitivity pneumonitis (HP) due to Trichosporon spp. with its pathological finding of inflammation with granuloma is common, but infections with granulomatous inflammation are extremely rare. This case suggests that Trichosporon infection may develop into granuloma with multinucleated giant cells.

[Granulomatous diseases and pathogenic microorganism]

Granuloma formation is a chronic inflammatory reaction where macrophage system and other inflammatory cells are involved. After some antigen exposure and processing, T cells, macrophages, epithelioid cells, and giant cell are activated, and granulomas are formed. Granuloma is considered as a defense mechanism against antigens, which stay in the organs without inactivation. Granulomas including fibroblasts extra-cellular matrix surround and isolate the antigens. Granulomas are classified to noninfectious granulomas and infectious granulomas. However recent studies revealed pathogenic microorganism are suspected to be a cause of granuloma in non-inflammatory diseases. Balance between pathogenic microorganisms and defense mechanisms of the host might be important in the special immunologic reaction. In some cases, it is hard to clearly classify infectious and noninfectious granulomas. Recently, Eishi et al. reported that latent infection of Propionibacterium acnes might be cause of sarcoidosis. Several hypersensitivity pneumonias are considered to be caused by exogenous microorganisms. The symposium was organized to know and clarify the new mechanisms of non-infectious granulomatous lung diseases and pathogenic microorganisms. This report is a summary of a symposium entitled "Granulomatous Diseases and Pathogenic Microorganism", organized in the 82nd Japanese Society for Tuberculosis (president Dr. Mitsunori Sakatani, M.D.). 1. Imaging of Granulomatous Lung Diseases: Masanori AKIRA (Department of Radiology, National Hospital Organization Kinki-chuo Chest Medical Center) High-resolution computed tomography (HRCT) is a useful tool in the evaluation of parenchymal changes in patients with a granulomatous lung disease. In sarcoidosis, the HRCT findings include small, well-defined nodules in relation to lymphatic roots, lymph node enlargement, and middle or upper lobe predominance. The appearances of subacute hypersensitivity pneumonitis include ill-defined centrilobular nodules, ground-glass opacity, and air trapping especially on expiratory CT scan. Those of Langerhans cell histiocytosis include bizarre thin-walled lung cysts, centrilobular nodules and upper lobe predominance. Each of granulomatous lung disease has some characteristic HRCT appearances, but they all are non-specific for diagnosis. HRCT is also useful for grading of parenchymal changes in granulomatous lung diseases. 2. Histopathology of granulomatous lung diseases with special reference to differential diagnosis of infectious disease: Tamiko TAKEMURA (Department of Pathology, Japanese Red Cross Medical Center) The lung is commonly involved by various granulomatous diseases of various etiology. It is difficult to pathologically differentiate these granuloumatous diseases to conduct appropriate therapy, because of morphological similarity of epithelioid cell granuloma, variable etiology, and difficulty of identification of causative agents. Granulomatous diseases generally are divided into infectious and non-infectious ones for treatment. Although infectious granulomas usually reveal necrosis and abscess, non-infectious ones occasionally also reveal necrosis. In cases with granulomas in the lung, it is necessary to explore the etiologic agents including environmental ones. 3. Sarcoidosis and Propionibacterium acnes: Yoshinobu EISHI (Department of Pathology, Tokyo Medical and Dental University) P. acnes can cause latent infection in peripheral lung tissue and the mediastinal lymph nodes and persist intracellularly in a cell-wall-deficient form. This dormant form of P. acnes can be activated endogenously under certain environmental conditions (hormones, stress, living habits, etc.) and proliferate in cells at the sites of latent infection. Granulomatous inflammation occurs in sarcoidosis patients with hypersensitivity to intracellular proliferation of the cell-wall-deficient bacteria, which can infect other cells or organs when spread via the lymphatic or blood streams. The timely use of antibiotics may not only kill the bacteria proliferating at the site of disease activity, but also prevent endogenous activation of P. acnes. If long term administration of antibiotics eradicates dormant forms of the bacteria persistent in organs, it may lead to complete remission of sarcoidosis. 4. Farmer's lung and thermophilic actinomycetes: Takashi MOURI (Pulmonary Division, Iwate Prefectural Kitakami Hospital), Kohei YAMAUCHI, Hiroshi INOUE (Third Department of Internal Medicine, Iwate Medical University, School of Medicine), Kazuki KONISHI (Morioka Tsunagi Onsen Hospital) Farmer's lung is caused by the allergic reaction to inhalation of thermophilic actinomycetes. Acute symptoms are chill, fever, cough and dyspnea. Fine crackles is characteristic. Pathologically, alveolitis with lymphocytes infiltration and epithelioid cell granuloma and Masson's body are characteristics. Bronchoalveolar lavage analysis shows elevated lymphocytes and diverse CD4/8 ratio (high in average). Isolation from the environment improves the symptoms. Sometimes patients need steroid therapy, 0.5 to 1.0 mg/kg of predonisolone. Pulse therapy can be applied for severe cases. SLX analogue can prevent lymphocytes infiltration and granuloma formation in mice model. Some of acute farmer's lung show poor long term prognosis, showing emphysematous, fine granular or small nodules in chest CT. These chronic farmer's lung might be diagnosed as IIPs. 5. Hot tub lung: Takashi OGURA (Kanagawa Cardiovascular and Respiratory Center) Hot Tub Lung (HTL) is a disorder caused by exposure to Mycobacterium avium complex (MAC) organisms contaminating hot tub water. Whether this disease represents true infection or hypersensitivity pneumonitis is contoroversial. Recent reports support the theory that this disease represents a hypersensitivity pneumonitis rather than infection. The physicians should suspect a hypersensitivity pneumonitis reaction to MAC in the investigation of patients with hypersensitivity pneumonitis of unknown cause.

[A case of hypersensitity pneumonitis due to the contamination of a dehumidifier by Thermoactinomyces vulgaris]

A 22-year-old man was admitted to our hospital because of high fever and shortness of breath. A chest CT showed centrilobular nodules and ground-glass attenuation in both lungs. Transbronchial lung biopsy specimens showed alveolitis including the infiltration of mononuclear cells and granulomas. He responded to treatment, but upon returning home the radiological findings and clinical symptoms reappeared. We focused on a dehumidifier because it had been used continuously in his room. Thermoactinomyces vulgaris presented in the air filter of the dehumidifier. The test of precipitation in response to Thermoactinomyces vulgaris was positive. The condition inside the dehumidifier of a high temperature and high humidity were suitable for the proliferation of Thermoactinomyces vulgaris. We diagnosed hypersensitity pneumonitis due to a dehumidifier contaminated by Thermoactinomyces vulgaris.

Airborne biological hazards in different pig fattening systems

In this research project two organic and two conventional housing systems for fattening pigs are assessed in regard to the emission of microorganisms, endotoxins and dust. The concentrations of microorganisms and endotoxins varied between the different housing systems while no distinct differences for the dust concentrations were observed. Endotoxins concentrations reached up to 14 495 EU/cubic meter median) in deep litter stable, indicating the high exposure with biological agents during farm work. The differences between the stables could not be assigned to the organic or conventional kind of husbandry but to the management of the systems.

Hypersensitivity pneumonitis caused by Penicillium citrinum, not Enoki spores

BACKGROUND

Flammulina velutipes is called the Enoki mushroom in Japanese and is cultivated indoors. Mushroom workers face occupational exposure to a tremendous number of fungi and organic antigens capable of causing hypersensitivity pneumonitis (HP). One worker employed at an Enoki farm developed HP due to Penicillium citrinum. This study investigated new cases of HP among the workers cultivating Enoki.

METHODS

Serum Krebs von der Lungen-6 (KL-6), surfactant protein (SP)-A and SP-D were measured. Lymphocyte stimulation tests (LST) and double immunodiffusion tests (DIT) were performed to identify P. citrinum. Workers showing high levels of KL-6, SP-A, or SP-D and a high LST value or positive DIT were identified and then were further examined by chest computed tomography, bronchoalveolar lavage and transbronchial lung biopsy. The initial patient and new HP patients were defined as the HP group and the other participants were defined as the non-HP group.

RESULTS

Forty-eight Enoki workers participated in the study. Four of nine workers who met the criteria for further examinations were diagnosed as having HP due to P. citrinum. In comparison between non-HP group and HP group, KL-6, SP-D and LST values were significantly higher in HP group. There was a strong correlation between KL-6 and SP-D. DIT had high sensitivity and high specificity.

CONCLUSIONS

KL-6, SP-D, LST, and DIT were useful for detecting HP patients. KL-6 was the most useful predictor of HP in this study. DIT was useful not only as a predictor of HP but also as a detector of the causative antigen.

Overexpression of GATA-3 Protects against the Development of Hypersensitivity Pneumonitis

RATIONALE

Hypersensitivity pneumonitis (HP) is mediated by a Th1 immune response. Transcription factor GATA binding protein-3 (GATA-3) is believed to be a key regulator of Th2 differentiation and thus might play regulatory roles in the pathogenesis of hypersensitivity pneumonitis (HP).

OBJECTIVES

We examined the effect of GATA-3 overexpression on the development of HP in mice.

METHODS

Wild-type C57BL/6 mice and GATA-3-overexpressing mice of the same background were used in this study. HP was induced by repeated exposure to Saccharopolyspora rectivirgula, the causative antigen of farmer's lung.

MEASUREMENTS AND MAIN RESULTS

Antigen exposure resulted in a marked inflammatory response with enhanced pulmonary expression of T-bet and the Th1 cytokine interferon (IFN)-gamma in wild-type mice. The degree of pulmonary inflammation was much less severe in GATA-3-overexpressing mice. The induction of T-bet and IFN-gamma genes was suppressed, but a significant induction of Th2 cytokines, including IL-5 and IL-13, was observed in the lungs of GATA-3-overexpressing mice after antigen exposure. Supplementation with recombinant IFN-gamma enhanced lung inflammatory responses in GATA-3-overexpressing mice to the level of wild-type mice. Because antigen-induced IFN-gamma production predominantly occurred in CD4+ T cells, nude mice were transferred with CD4+ T cells from either wild-type or GATA-3-overexpressing mice and subsequently exposed to antigen. Lung inflammatory responses were significantly lower in nude mice transferred with CD4+ T cells from GATA-3-overexpressing mice than in those with wild-type CD4+ T cells, with a reduction of lung IFN-gamma level.

CONCLUSIONS

These results indicate that overexpression of GATA-3 attenuates the development of HP by correcting the Th1-polarizing condition.

[Allergic lung diseases]

Allergic lung diseases present with either lung diseases developed as a result of inhalation of allergens (bronchial asthma) and antigens (hypersensitivity pneumonitis) of as a manifestation of systemic diseases including sarcoidosis and collagen vascular diseases. A limited space is available, therefore only hypersensitivity pneumonitis. bronchial asthma, sarcoidosis. and eosinophilic pneumonia were briefly summarized although a list of the allergic lung diseases is extensive. As a video-assisted lung biopsy has presently been popular, thoracic surgeons should perform surgery with a correct understanding of the pathophysiology of the disease.

[Hypersensitivity pneumonitis in a chicory worker]

INTRODUCTION

We report a case of occupational hypersensitivity pneumonitis in a patient handling chicory leaves.

CASE REPORT

The diagnosis was based symptoms of broncho-alveolitis with pyrexia, positive precipitins to moulds present on chicory, especially Fusarium, and the disappearance of the clinical and radiological manifestations following cessation of exposure to chicory.

CONCLUSION

"Chicory worker's lung" is an occupational disease which should be considered in cases of respiratory symptoms suggestive of hypersensitivity pneumonitis and chronic exposure to chicory leaves.

[Humidifier fever: and unusual variant of hypersensitivity pneumonitis]

A case of a patient suffering three episodes consistent in fever, lung infiltrates, lymphocitosis in bronchoalveolar lavage and non-caseificant granulomata in transbronchial biopsy is reported.A relationship between exposition to the air conditioner in the office and the clinical picture was stablished, and the patient was finally diagnosed from humidifiers fever. We enfatize the manifestations of this uncommon disease, probably infradiagnosed, and the patogenic mechanisms are reviewed.