[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 "-".

Suberosis and bird fancier's disease: a comparative study of radiological, functional and bronchoalveolar lavage profiles

Hypersensitivity Pneumonitis (HP) 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 have 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 HP seen in our practice: Suberosis (an HP related to moldy cork dust exposure) 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 HP had lymphocytic alveolitis in BALF: Suberosis - 6.6 +/- 5.7 x 10(5) ml-l cells, 58.8 +/- 18.9% lymphocytes; bird fancier's disease - 9.0 +/- 6.5 x 105 ml-l 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 HP 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.

[Pulmonary fibrosis in young patients with hypersensitivity pneumonitis]

Hypersensitivity pneumonitis (HP) is more common in middle-aged individuals but has been also diagnosed in patients of all ages including infants and children. Host risk factors are poorly characterized. The aim of this paper is presentation of 6 young patients in whom HP was diagnosed at the stage of lung fibrosis. There were 5 females at the age of 16-35 years and 1 male at the age of 28 years. All of them were exposed to organic dust for many years. Three of them were asthenic with scoliosis, 5 had clubbing. All patients were released from sport exercises in school due to fatigue but the diagnostic procedures were started at that time only in 2 patients. One woman had been ill from early childhood (recurrent pneumonia was recognised). In the another girl (16 years old) the spontaneous pneumothorax was the cause of the first chest X-ray examination. In the next woman (21 years old) marked dyspnea was connected with pregnancy and massive fibrotic lesions were recognised after delivery of her child. The only man was diagnosed before change of his job; he had no complaints. Two oldest women (34 and 35 years old) were diagnosed in childhood but avoidance of antigen exposure and corticotherapy were not effective. In all patients precipitins against farmer's lung and pigeon fancier's lung antigens were found. In all patients chest X-ray showed features of advanced lung fibrosis. All patients were treated with steroids without improvement. Two patients died during corticotherapy.

CONCLUSIONS

1) HP could be taken into consideration during differential diagnosis of interstitial lung diseases, 2) Cough and dyspnea on exertion could be the first symptoms of chronic HP in children also.

Ground-glass opacity: interpretation of high resolution CT findings

Ground-glass opacity (GGO) is a common finding on high resolution CT, characterised by areas of hazy increased attenuation of the lung with preservation of bronchial and vascular margins; it is not to be confused with consolidation, in which bronchovascular structures are obscured. It correlates with several pathogenic processes, such as like partial filling of air spaces, inflammatory or fibrotic interstitial thickening, increased capillary blood volume. Infiltrative GGO can representing either interstitial or alveolar processes. GGO is a nonspecific finding; however, the correlation with any of the associated CT findings (nodular lesions, consolidation, septal thickening, fibrosis, vessels or airway calibre alterations, air trapping), and clinical data is helpful in narrowing the range of diagnostic possibilities, or even in suggesting a specific diagnosis. GGO can indicate a potentially treatable disease, help guide the type and location of biopsy and evaluate the effectiveness of therapy. This review discusses the types of lung disease associated with GGO, and the differential diagnosis between GGO caused by infiltrative processes and the mosaic patterns of lung attenuation caused by primary vascular diseases or airway abnormalities. This distinction can be made by evaluating the vessel calibre and air trapping on expiratory scans.

[Chronic hypersensitivity pneumonitis or idiopathic pulmonary fibrosis? Diagnostic role of high resolution Computed Tomography (HRCT)]

PURPOSE

In the diagnosis of extrinsic allergic alveolitis, high-resolution computed tomography (HRCT) is more sensitive and more specific than radiography; however, the accuracy of HRCT is not absolute. The role of HRCT in this field has scarcely been investigated in the literature. The purpose of this paper is to explore the possibilities of HRCT in this field and to analyse the correlations between HRCT and functional parameters.

MATERIALS AND METHODS

We performed a retrospective blind evaluation the HRCT scans of 24 patients (19 males and 5 females). Twelve were affected by idiopathic pulmonary fibrosis (IPF); 12 had chronic extrinsic allergic alveolitis (EAA) or hypersensitivity pneumonitis. The HRCT findings were studied by two radiologists, who were not aware of the diagnoses. The possible differences in evaluation were subsequently resolved by consensus. In the presence of interstitial fibrosis, we recorded the prevailing site and the anatomical extension (with the method of the visual percentage score, described in the literature). In all the cases, we recorded the blood gas values (PaO2, PaCO2, and pH), total lung capacity (TLC), forced expiratory volume in 1 second (FEV1), Vital Capacity (VC), Tiffeneau index (FEV1/VC) and monoxide carbon diffusion (DLCO). The statistical significance of the correlations was investigated using the Mann-Whitney and Wilcoxon tests. Student "t"-test and Pearson's chi squared were used to compare the variables of the different groups. A value of p< or =0.05 was considered significant.

RESULTS

Overall, the diagnosis was formulated with a high degree of confidence in 13 of 24 cases (54.1%); in these patients, the result was correct in 84.6% of cases (11 of 13). In the diagnosis of EAA, HRCT sensitivity was 50%, with 91.6% specificity, 70.8% accuracy. In the diagnosis of IPF, HRCT sensitivity was 75%, with 83.3% specificity, 79.1% accuracy. The HRCT signs of interstitial fibrosis were visible in 11 cases of IPF (91.6%) and in 4 cases of EAA (33.3%), with significant statistical difference (p<0.005). In the analysis of the whole series (24 patients) we found a significant inverse correlation between the HRCT score of fibrosis and the extension of the areas with air-trapping (p<0.003). There was no significant difference between IPF and EAA considering age, FEV1, PaO2, PaCO2 and pH. We found inverse correlation (p<0.001) between HRCT extension of the fibrosis and DLCO. There was a significant difference between pulmonary fibrosis and extrinsic allergic alveolitis considering TLC (in average, respectively: 65% and 84.3%; p<0.02), and DLCO (respectively 40.4% and 74.7%; p<0.03).

DISCUSSION AND CONCLUSIONS

HRCT is a reliable and strong method to be used in particularly complex fields. We found signs of interstitial fibrosis more frequently in IPF than in EAA (91.6% versus 33.3%). In IPF cases, the extension of the fibrosis--evaluated with the visual score method--was higher then in EAA (34.7% versus 6%). The presence of fibrosis with basal and peripheral distribution was characteristic of idiopathic pulmonary fibrosis, with good sensitivity and specificity (75%), whereas in chronic extrinsic allergic alveolitis the areas of fibrosis often presented an irregular and heterogeneous distribution, in 91.6% of cases. However, 25% of extrinsic allergic alveolitis cases had a distribution mimicking idiopathic pulmonary fibrosis. The presence of areas with increased ground-glass opacity is more common in EAA than in IPF (66.6% versus 33.3%). Areas of mosaic attenuation, visible in inspiratory CT scans, are not rare in IPF (41.6% of cases), and generally have a basal distribution. The presence of hyperlucent lobules inside the fibrotic areas does not exclude the diagnosis of IPF. The finding of the expiratory air-trapping is more common in chronic EAA than in IPF, and the extension of this areas is greater in EAA (17.3% versus 6.5%). We found an inverse correlation between the extension of the fibrosis and the expiratory trapping. Signs of emphysema were observed in 25% of cases, wiema were observed in 25% of cases, with equal prevalence and the same extension in IPF and in EAA. All patients were smokers or ex-smokers. Smoking has not been demonstrated to have a protective effect against EAA. The areas of mosaic perfusion during inspiration do not represent a sound criterion for the differential diagnosis between IPF and chronic EAA. In fact, they can also be frequently found in IPF. HRCT can be employed in clinical practice for the differential diagnosis between IPF and chronic EAA with good (but not absolute) accuracy.

Aspergillus in the lung: diverse and coincident forms

Pulmonary disease caused by the fungus Aspergillus has traditionally been regarded as belonging to one of the following, apparently distinct, entities: saprophytic aspergilloma; allergic bronchopulmonary aspergillosis (ABPA); and invasive aspergillosis (IPA); which may be further categorised as angioinvasive, acute or chronic airway invasive) [1]. It is not always obvious that there is overlap between these entities, and that in any given patient more than one Aspergillus-related pathological process can co-exist [2]. The aim of this article is to review the clinical and imaging features of the main categories of Aspergillus-related pulmonary disease and, in particular, to highlight the overlap between them.

Hypersensitivity pneumonitis. High resolution CT findings with pathological correlations. A pictorial essay

The diagnosis of HP is based upon the association of antigen exposure history, compatible clinical and radiological findings and high titres of precipitating serum antibodies to specific antigens. The manifestations of HP are usually divided into three typesacute, sub-acute and chronicbut a significant overlap exists. The clinical spectrum probably reflects different factors, specific to the subject, as well as the frequency and degree of exposure. The aim of this pictorial essay is to present the more common presentations of HP.

Lung cysts in subacute hypersensitivity pneumonitis

PURPOSE

To determine the frequency of cystic lesions on high-resolution computed tomography (CT) in patients with subacute hypersensitivity pneumonitis.

METHODS

High-resolution CT scans in 182 patients with proven subacute hypersensitivity pneumonitis were retrospectively evaluated for the presence of lung cysts. Patients with CT evidence of emphysema or interstitial fibrosis and patients with connective tissue disease were excluded from the study. Two thoracic radiologists reviewed the thoracic CT scans for the presence and location of lung cysts.

RESULTS

Thin-walled lung cysts were identified in 24 (13%) of 182 patients and ranged in size from 3 to 25 mm in maximal diameter. The patients included 16 men and 8 women (age range, 30-79 years; mean age, 48 years). The cysts ranged from 1 to 15 in number (mean, 4 cysts) and had a random distribution. Sixteen of the 24 patients also had areas of decreased attenuation and vascularity consistent with air trapping.

CONCLUSIONS

Thin-walled cysts can be seen in a small percentage of patients with subacute hypersensitivity pneumonitis. The cysts resemble those seen in lymphocytic interstitial pneumonia, and their pathogenesis is uncertain.

[Asthma, alveolitis, aspergillosis, berylliosis. What to do when there is allergic reaction of the lung?]

Among the major allergic pulmonary disorders are bronchial asthma, extrinsic allergic alveolitis, allergic aspergillosis and berylliosis. Asthma is diagnosed on the basis of clinical symptoms (wheezing, respiratory distress, tight chest, coughing) and lung function tests possibly supplemented by allergic and provocative testing. Asthma treatment is differentiated into long-term medication and as-required medication. Specific immunotherapy is considered the sole causal therapy. Extrinsic allergic alveolitis is work- or hobby-related (farmer's/cheese worker's/bird-fancier's lung) and manifests as diffuse pneumonitis with dyspnea, coughing and fever. For the diagnosis, the antigen provocative test in particular plays a major role. In the main, treatment comprises strict avoidance of allergens. The diagnosis of allergic pulmonary aspergillosis is based on the history, clinical findings, skin tests, serology and radiography. Treatment is stage-related by means of immunosuppressive agents. In terms of radiographic and pulmonary function findings, berylliosis is similar to sarcoidosis. Here, too, immunosuppressive agents are to the fore.

Clinical and radiologic manifestations of hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is an inflammatory interstitial lung disease caused by recurring exposure to a variety of occupational and environmental antigens. It features widely variable clinical, radiologic, and histopathologic findings. Because the clinical findings of HP mimic multiple other diseases, a high degree of clinical suspicion and a thorough occupational and environmental history are essential for accurate diagnosis. There is no single pathognomonic feature for HP; rather, diagnosis relies on a constellation of clinical, radiologic, and pathologic findings. The radiologic manifestations, particularly the high-resolution computed tomography (HRCT) pattern, provide important clues and frequently point clinicians towards the correct diagnosis. The HRCT findings in HP may include ground-glass opacification, centrilobular nodules, air trapping (mosaic pattern), fibrosis, emphysema, or more frequently a combination of these. The combination of a mosaic pattern with ground-glass opacification and centrilobular nodules is particularly suggestive of the diagnosis. The best long-term prognosis is achieved with early diagnosis and removal from exposure.

High-resolution CT in the evaluation of occupational and environmental disease

The most common of the pneumoconioses are silicosis, CWP, and asbestosis. The former two are characterized by the presence of small nodular opacities predominantly distributed in the upper zones of the lung. The small nodular opacities are classified into two patterns on HRCT: (1) ill-defined fine branching lines and (2) well-defined discrete nodules. Asbestosis demonstrates thickened interlobular and intralobular lines, subpleural dot-like or curvilinear opacities, and honeycombing on HRCT, predominantly distributed in the bases of the lungs. Although HRCT findings of other pneumoconioses are variable and nonspecific, there are predominant and characteristic findings for each type of pneumoconiosis. HRCT is useful in achieving more accurate categorization of the parenchymal changes in each type of pneumoconiosis.

Sulfasalazine-induced extrinsic allergic alveolitis in a patient with psoriatic arthritis

We report the first case of a well defined extrinsic allergic alveolitis as a complication of sulfasalazine therapy in a patient treated for psoriatic arthritis. CT of the chest showed small nodular densities over both lungs, BAL demonstrated a highly active lymphocytic alveolitis and transbronchial biopsies revealed lymphoplasmocytic interstitial infiltration. Sulfasalazine as causative agent was proven by an inadvertent rechallenge three years later and a positive lymphocyte transformation test. sulfasalazine; psoriatic arthritis; extrinsic allergic alveolitis

[Hypersensitivity pneumonitis in a patient taking pravastatin]

A 41-year-old man who had been taking pravastatin for two years developed hypersensitivity pneumonitis. The initial examination found intestinal pneumonitis and hypereosinophilia. The patient's syndromes gradually resolved with withdrawal of pravastatin. As HMG coenzyme A reductase inhibitors are commonly prescribed, any respiratory symptoms in this setting should be considered with special attention.

[Isocyanate-induced alveolitis in a furniture manufacture worker]

A 41-year-old woman who worked in a furniture plant was admitted to hospital for acute dyspnea that had developed a few hours she marked pieces of "Alcantara" material with a heated metallic blade. The chest x-ray showed a restrictive syndrome. The lymphocyte count was high in the bronchioalveolar lavage fluid with a CD4/CD8 ratio of 0.11, leading to the diagnosis of alveolitis. Investigations at the work place allowed identification and evaluation of the causal agent. Alcantara is a synthetic fabric composed of 70% polyurethane fibers, which when burned produces isocyanate monomers. After eliminating exposure and institution of corticosteroid therapy, the outcome was good with complete recovery. The risk was eliminated by changing the work procedure. This risk has not been reported earlier for furniture manufacture.

Mixed infiltrative and obstructive disease on high-resolution CT: differential diagnosis and functional correlates in a consecutive series

Fourteen of 400 consecutive patients having high-resolution computed tomography (HRCT) with expiratory images showed findings of infiltrative lung disease on inspiratory HRCT and air trapping on expiratory CT. Diagnoses included hypersensitivity pneumonitis, sarcoidosis, atypical infection, and pulmonary edema. The extent of infiltrative abnormalities and air trapping were correlated with pulmonary function tests (PFT) in 11 patients. PFT indicated a mixed pattern in five, an obstructive pattern in three, and a restrictive pattern in three. Forced expiratory volume (FEV) in 1 second/forced vital capacity (FVC) correlated significantly with the extent of air-trapping (r = 0.60; p = 0.05). The extent of infiltrative abnormalities correlated significantly and negatively with forced vital capacity (r = -0.82, p = 0.002), FEV1 (r = -0.59, p = 0.05), total lung capacity (TLC) (r = -0.67, p = 0.05), and DLCO (r = -0.75, p = 0.02). Findings of lung infiltration on inspiratory HRCT scans and air trapping on expiratory CT correlated respectively with PFT measures of restrictive and obstructive lung disease.

Extrinsic allergic alveolitis from a proteolytic enzyme

BACKGROUND

Subtilisins are proteolytic enzymes of bacterial origin found in detergents. They are high-molecular-weight antigens and have been implicated in allergic rhinitis and asthma.

OBJECTIVE

This report describes a case of extrinsic allergic alveolitis due to subtilisins in a liquid cleaner.

METHODS

Clinical, radiologic, and serologic information were used to make the diagnosis.

CASE REPORT

A 53-year-old woman developed respiratory symptoms while working with a cleaner containing subtilisins. Her symptoms intensified in the work environment and improved away from work. A computed tomography scan demonstrated alveolar and interstitial infiltrates with subsequent scarring. A pulmonary function study revealed a restrictive pattern with diminished diffusion capacity. Bronchoalveolar lavage showed lymphocytosis and all cultures were negative. Precipitating antibodies to the enzyme were found in the patient's serum. Her symptoms improved once she changed her occupation.

CONCLUSIONS

The combination of the patient's clinical history, physical, laboratory, and radiologic findings support the diagnosis of extrinsic allergic alveolitis from the enzyme contained in the cleaner.

Hypersensitivity pneumonitis with normal high resolution computed tomography scans

A case of symptomatic hypersensitivity pneumonitis with normal high resolution computed tomography (CT) scans is presented. The patient, a 32-year-old man with systemic lupus erythematosus, had a chronic, progressive history of respiratory symptoms, abnormal findings on examination and abnormal pulmonary function tests but normal high resolution CT scans of the chest. Diagnosis was made through open lung biopsy. Clinical improvement was seen on removal of the offending antigen. The literature on the utility of high resolution CT scans in hypersensitivity pneumonitis is reviewed.

[Value of multiplanar reformations (MPR)in multi-slice spiral CT of the lung]

PURPOSE

To evaluate the quality of multiplanar reformations (MPR) of multidetector spiral-CT (MD-CT) data sets of the chest based on anatomic criteria.

METHODS

90 patients with suspected or known diseases of the lung parenchyma underwent thoracic MD-CT with 1-mm collimation. Axial scans were reconstructed with 1-mm slice width and 0.6-mm reconstruction increment. Coronal and sagittal MPRs were reconstructed with 3, 5 and 8 mm thickness from the axial scans. Three blinded readers rated image quality based on several anatomic criteria and the presence of different artifacts using a 5-point scale. The scores for MPRs were compared with those of 5-mm thick axial scans.

RESULTS

All anatomical structure were equally well depicted on MPRs as on axial scans with very good interobserver correlation (kappa 0.69-0.76). Only the lung parenchyma directly adjacent to the heart and the great vessels were visualized with limited quality due to cardiac pulsation artifacts. Advantages of sagittal MPRs include the sharper delineation of interlobar fissures and thus improved anatomic localization of a lesion. Coronal reformations also offer improved anatomic orientation in comparison with 5-mm axial scans. A slice thickness of 5 mm for MPRs yielded best results.

CONCLUSIONS

MPRs allow an unrestricted assessment of the lung. Sagittal and coronal reformations improve the topographical visualization of chest anatomy.

Hydroxyurea-induced hypersensitivity pneumonitis: A case report and literature review

Hydroxyurea is a cytotoxic agent indicated in the treatment of a variety of malignant and nonmalignant conditions. Apart from dose-related bone marrow suppression, this antineoplastic agent is generally well tolerated. This report describes a patient with chronic myeloid leukemia who developed severe pneumonitis within four weeks of beginning therapy with hydroxyurea. Pathological examination of a lung specimen obtained by video-assisted thoracoscopic lung biopsy revealed extensive active alveolar and interstitial inflammation, and poorly formed granulomas. After the cessation of hydroxyurea and treatment with systemic corticosteroids, both clinical and radiological resolution of pneumonitis occurred. Physicians using hydroxyurea must be aware of its potentially life-threatening pulmonary toxicity.