Provocation test coupled with bronchoalveolar lavage in diagnosis of propranolol-induced hypersensitivity pneumonitis

A 59-yr-old man was given over a 30-month period a cumulative dose of 36 g of propranolol for treatment of angina pectoris. He then presented with respiratory disease, having all the clinical, radiologic, and functional characteristics of interstitial pneumonitis. No other cause of pneumonitis was found. Bronchoalveolar lavage (BAL) showed a lymphocytic alveolitis with lymphocyte subset inverted ratio. After a 9-wk period of drug withdrawal, clinical and radiologic improvement was observed along with resolution of BAL abnormalities. Propranolol therapy was resumed for 6 wk and induced the recurrence of BAL abnormalities. Propranolol treatment was finally stopped, and 15 wk later, clinical symptoms abated, chest roentgenogram and pulmonary function tests were improved, and BAL data returned to normal. This observation seems to exemplify the possible diagnostic value of coupling provocation test with BAL cell data in some hypersensitivity pneumonitis induced by drugs. In addition, these data support the role of a cell-mediated immunologic mechanism in the pathogenesis of propranolol-induced pneumonitis.

[A comparative evaluation of the results of classical x-ray study and computed tomography in patients with exogenous allergic alveolitis]

A correlative study of the results of x-ray investigation using routine methods and computerized tomography (CT) was conducted to specify the roentgenomorphological substrate of changes in patients with exogenous allergic alveolitis. The established complex of routine methods is informative enough to interpret the revealed changes. However, at early stages CT helps to specify semiotics and permits obtaining additional information, particularly on quantitative, i.e. densitometric changes. In diffuse and disseminated pulmonary lesions CT can be used as an additional method.

Radiation-induced lung injury: a hypersensitivity pneumonitis?

Radiation pneumonitis occurs 6 to 12 weeks after thoracic irradiation, and is thought to be due to direct radiation-induced lung injury. Four patients who developed pneumonitis after unilateral thoracic irradiation for carcinoma of the breast were studied with bronchoalveolar lavage, gallium scan of the lung, and respiratory function tests. On the irradiated side of the chest, all four patients showed an increase in total cells recovered from the lavage fluid and a marked increase in the percentage of lymphocytes. When results for the unirradiated lung were compared with results for the irradiated lung, there was a comparable increase in total cells and percentage of lymphocytes. Gallium scans showed increases for both irradiated and unirradiated lungs. Prompt improvement was seen after corticosteroid therapy in all patients. The fact that abnormal findings occur equally in irradiated and unirradiated lung is inconsistent with simple direct radiation-induced injury and suggests an immunologically mediated mechanism such as a hypersensitivity pneumonitis.

Gallium-67 scanning in the staging of cryptogenetic fibrosing alveolitis and hypersensitivity pneumonitis

Gallium-67 citrate is known to localize within inflammatory sites. Gallium-67 scanning is used for the evaluation of lung inflammation (i.e. alveolitis) during interstitial lung diseases. We investigated 27 patients with cryptogenetic fibrosing alveolitis (n = 17) and hypersensitivity pneumonitis (n = 10) using gallium-67 lung scanning and lung function tests (forced vital capacity, diffusing capacity, resting and exercise blood gases). Investigations were performed before and after one year of methylprednisolone treatment. None of eight healthy volunteers had any abnormal gallium-67 uptake. In all patients with cryptogenetic fibrosing alveolitis an initial abnormal gallium-67 uptake was observed (mean fixation index: 163 +/- 18). In addition, analysis of lung function tests a year after initial evaluation showed that unchanged or improving patients presented initially with a lower gallium-67 index than patients with evidence of deterioration (153.9 +/- 23.7 vs 251.0 +/- 23.3.; p less than 0.01). Similarly, among patients with hypersensitivity pneumonitis the index was lower in unchanged or improving patients than in those with deterioration (74.9 +/- 22 vs 226.7 +/- 4.9; p less than 0.05). Thus gallium-67 scanning is useful in the management of cryptogenetic fibrosing alveolitis and hypersensitivity pneumonitis.

[Radioscintigraphic correlation in interstitial pneumopathy. Case presentations]

Radiological and scintigraphic findings in 82 patients (58 male, 24 female) were compared. The patients were hospitalised in 1981-86 with sarcoidosis (43 cases), silicosis (26), asbestosis (9) extrinsic allergic alveolitis (3), lung disease caused by hard metals (1). Gallium scintigraphy was positive in 61 patients (74.39%). More precisely, the response was positive in 57 cases in both analogic and quantitative terms and in 4 only quantitatively. The radiological (radiography and stratigraphy) finding was significant in 42 of the 61 gallium-positive cases and negative in the remaining 19. In the 21 gallium-negative cases (25.61%) the radiological finding was significant in 9, negative in 12. The study confirms the real value of gallium scintigraphy in the diagnosis and follow-up of interstitial lung disease in line with views presented in the recent literature.

Fansidar hypersensitivity pneumonitis

We report a subject who had Fansidar prescribed to him for the purpose of malaria prophylaxis. This agent is a combination of pyrimethamine and sulphadoxine. He subsequently developed severe hypersensitivity pneumonia and required mechanical ventilation. We believe that sulphadoxine was responsible for his illness.

Measurement of pulmonary epithelial permeability with 99mTc-DTPA aerosol

The rate at which inhaled aerosol of 99mTc-diethylenetriamine pentaacetate (DTPA) leaves the lung by diffusion into the vascular space can be measured with a gamma camera or simple probe. In normal humans, 99mTc-DTPA clears from the lung with a half time of about 80 minutes. Many acute and chronic conditions that alter the integrity of the pulmonary epithelium cause an increased clearance rate. Thus cigarette smoking, alveolitis from a variety of causes, adult respiratory distress syndrome (ARDS), and hyaline membrane disease (HMD) in the infant have all been shown to be associated with rapid pulmonary clearance of 99mTc-DTPA. Rapid clearance is also promoted by increased lung volume and decreased surfactant activity. Although the mechanism of increased clearance in pathological states is not known, the 99mTc-DTPA lung-clearance technique has great potential clinically, particularly in patients at risk from ARDS and HMD and in the diagnosis and follow-up of alveolitis.

[Computed tomographic findings in extrinsic allergic alveolitis. Comparison with conventional x-ray findings]

Seventeen patients with extrinsic allergic alveolitis or bird-fancier's lung were examined by standard radiological techniques and classified after Hapke's classification. In addition, the patients were examined by CT. The CT patterns have been analysed and compared with standard radiological findings. The methodological advantages of CT are discussed. Radiological investigation is of limited value in the diagnosis of extrinsic allergic alveolitis. Conventional radiography remains the standard of initial x-ray examination. In early cases, however, CT may be a valuable addition within the diagnostic strategy of a diagnostic imaging department.

[Exogenous allergic alveolitis in patients at secondary health facilities]

In order to avoid the transition into an irreversible pulmonary fibrosis a diagnosis of the exogenic allergic alveolitis as early as possible is necessary. On the basis of 8 own cases the importance of a correct interpretation of the in detail not specific clinical and radiological symptoms as well as of the with regard to possible inhalative allergen loads directed establishment of the anamnesis is described.

Diffuse peripheral lung disease: evaluation by high-resolution computed tomography

High-resolution computed tomography (HRCT) was performed on 15 patients who had diffuse peripheral lung disease, and the findings were compared with those of conventional chest radiography and histologic examination. Bullae, interstitial fibrosis with honeycombing, and small granulomas were more clearly and specifically demonstrated on HRCT scans than on conventional chest radiographs in all patients. Histologically proved mild alveolar wall thickening due to alveolitis in cases of sarcoidosis and systemic lupus erythematosus was not detected. HRCT is useful for performing detailed morphological analyses of abnormalities of the peripheral portions of the lung.

CT in the diagnosis of interstitial lung disease

The computed tomographic (CT) appearance of interstitial lung disease was assessed in 23 patients with known interstitial disease. These included seven patients with fibrosing alveolitis, six with silicosis, two with hypersensitivity pneumonitis, three with lymphangitic spread of tumor, two with sarcoidosis, one with rheumatoid lung disease, and two with neurofibromatosis. The CT appearance of the interstitial changes in the different disease entities was assessed. Nodules were a prominent CT feature in silicosis, sarcoidosis, and lymphangitic spread of malignancy. Distribution of nodules and associated interlobular septal thickening provided further distinguishing features in these diseases. Reticular densities were the predominant CT change in fibrosing alveolitis, rheumatoid lung disease, and extrinsic allergic alveolitis. A marked peripheral predominance of the interstitial densities was seen in all seven cases of fibrosing alveolitis and in the patient with rheumatoid lung, in marked contrast with the two cases of hypersensitivity pneumonitis in whom a central distribution of the changes was seen. The observed patterns correlate with the pathologic findings and provide information that at times cannot be obtained from the chest radiograph. CT can be useful in the investigation of selected instances of interstitial pulmonary disease.

Radiographic changes in humidifier fever

Images

Penicillium allergic alveolitis: faulty installation of central heating

A married couple presented with an illness typical of allergic alveolitis. A careful search of their home revealed a leak in the central heating system with a heavy fungal growth on wet flooring and linoleum. Two species of Penicillium, P chrysogenum and P cyclopium, were isolated from floorboards, linoleum, and settle plates. Antibodies against both these fungi were demonstrated in the serum of both patients by an enzyme linked immunosorbent assay (ELISA). Allergic alveolitis caused by P chrysogenum and P cyclopium has not been described previously.

[Technique of the x-ray examination of the lungs (author's transl)]

Thorax radiography with high kilovoltage technique in 2 planes is the basis for lung examination. In case of special on-target problems additional x-ray films will be necessary. The aim must always be to obtain an image of the details which are essential for proper diagnosis, showing the fine structures of the relevant area. Among the important image parameters are the visualisation of the fine vessels in the lung periphery and on the costopleural margin from the apex of the lung to the diaphragm; the sharp image of the central pulmonary vessels, of the cardiac margin and the diaphragm; and the recognisability of the retrocardiac vessels. The article discusses the anatomicophysiological conditions, the technical requirements and the demands to be made on the medical assessment of the findings.