451
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Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e97-e156. [PMID: 33861992 DOI: 10.1016/j.chest.2021.03.066] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/07/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
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Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, UK
| | | | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
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452
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Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Executive Summary: Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:595-615. [PMID: 33865835 DOI: 10.1016/j.chest.2021.03.067] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The purpose of this summary is to provide a synopsis of evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, and Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations, and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
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Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, England
| | - Yuh-Chin Tony Huang
- Department of Environmental and Occupational Medicine, Duke University Medical Center, Durham, NC
| | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
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453
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Interstitial Score and Concentrations of IL-4Rα, PAR-2, and MMP-7 in Bronchoalveolar Lavage Fluid Could Be Useful Markers for Distinguishing Idiopathic Interstitial Pneumonias. Diagnostics (Basel) 2021; 11:diagnostics11040693. [PMID: 33924683 PMCID: PMC8070528 DOI: 10.3390/diagnostics11040693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/28/2023] Open
Abstract
Idiopathic interstitial pneumonia (IIP) entails a variable group of lung diseases of unknown etiology. Idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, interstitial lung diseases related to connective tissue disease (CTD-ILD), and hypersensitivity pneumonitis (HP) can manifest with similar clinical, radiological, and histopathological features. In a differential diagnosis, biomarkers can play a significant role. We assume that levels of specific cyto- or chemokines or their receptors can signal pathogenetic processes in the lungs. Eighty patients with different types of idiopathic interstitial pneumonia were enrolled in this study. Cell counts and concentrations of tumor necrosis factor (TNF)-α, interleukin-4 receptor α, proteinase-activated receptor (PAR)-2, matrix metalloproteinase (MMP)-7, and B cell-activating factor were measured in bronchoalveolar lavage fluid using commercial ELISA kits. High resolution computer tomography results were evaluated using alveolar and interstitial (IS) score scales. Levels of TNF-α were significantly higher in HP compared to fibrosing IIP (p < 0.0001) and CTD-ILD (p = 0.0381). Concentrations of IL-4Rα, PAR-2, and MMP-7 were positively correlated with IS (p = 0.0009; p = 0.0256; p = 0.0015, respectively). Since TNF-α plays a major role in inflammation, our results suggest that HP is predominantly an inflammatory disease. From the positive correlation with IS we believe that IL-4Rα, PAR-2, and MMP-7 could serve as fibroproliferative biomarkers in differential diagnosis of IIP.
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454
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Morán-Mendoza O, Khalil M. Are Ground-Glass Opacities on Chest High-Resolution Computed Tomography a Manifestation of Airway Disease? Am J Respir Crit Care Med 2021; 203:780-781. [PMID: 33434474 PMCID: PMC7958520 DOI: 10.1164/rccm.202011-4276le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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455
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Remy-Jardin M, Wilson KC, Raghu G. Reply to Morán-Mendoza and Khalil: Are Ground-Glass Opacities on Chest High-Resolution Computed Tomography a Manifestation of Airway Disease? Am J Respir Crit Care Med 2021; 203:781-782. [PMID: 33434473 PMCID: PMC7958512 DOI: 10.1164/rccm.202012-4410le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
| | - Kevin C Wilson
- Boston University Boston, Massachusetts.,American Thoracic Society New York, New York and
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456
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Progression in the Management of Non-Idiopathic Pulmonary Fibrosis Interstitial Lung Diseases, Where Are We Now and Where We Would Like to Be. J Clin Med 2021; 10:jcm10061330. [PMID: 33807034 PMCID: PMC8004662 DOI: 10.3390/jcm10061330] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/05/2021] [Accepted: 03/15/2021] [Indexed: 12/19/2022] Open
Abstract
A significant proportion of patients with interstitial lung disease (ILD) may develop a progressive fibrosing phenotype characterized by worsening of symptoms and pulmonary function, progressive fibrosis on chest computed tomography and increased mortality. The clinical course in these patients mimics the relentless progressiveness of idiopathic pulmonary fibrosis (IPF). Common pathophysiological mechanisms such as a shared genetic susceptibility and a common downstream pathway—self-sustaining fibroproliferation—support the concept of a progressive fibrosing phenotype, which is applicable to a broad range of non-IPF ILDs. While antifibrotic drugs became the standard of care in IPF, immunosuppressive agents are still the mainstay of treatment in non-IPF fibrosing ILD (F-ILD). However, recently, randomized placebo-controlled trials have demonstrated the efficacy and safety of antifibrotic treatment in systemic sclerosis-associated F-ILD and a broad range of F-ILDs with a progressive phenotype. This review summarizes the current pharmacological management and highlights the unmet needs in patients with non-IPF ILD.
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457
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Kreuter M, Müller-Ladner U, Costabel U, Jonigk D, Peter Heussel C. The Diagnosis and Treatment of Pulmonary Fibrosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0018. [PMID: 33531115 PMCID: PMC8212400 DOI: 10.3238/arztebl.m2021.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/14/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The different types of pulmonary fibrosis are a subgroup of the interstitial lung diseases (ILDs). They are associated with a chronic and often progressive course. METHODS This review is based on pertinent publications retrieved by a selective search in the EMBASE and PubMed databases, with an emphasis on articles published from 2000 to 2020. RESULTS The most common type of pulmonary fibrosis is idiopathic pulmonary fibrosis (IPF). Among other relevant types, the most important ones are fibrosing hypersensitivity pneumonitis (fHP) and ILDs associated with systemic diseases, all of which are rare and generally carry a poor prognosis. The essential prerequisite to accurate diagnosis is aninterdisciplinary approach, taking account of the clinical, histological, and radiological aspects. The main complications of pulmonary fibrosis are acute exacerbations and pulmonary hypertension; comorbidities are also of prognostic relevance. Treatment of pulmonary fibrosis depends on the subtype and clinical behavior. For IPF, antifibrotic therapy is indicated; fHP, on the other hand, is mainly treated by antigen avoidance and immune modulation. The predominant mode of treatment for systemic disease-associated pulmonary fibrosis is immune suppression. Antifibrotic agents can also be useful in the treatment of other types of progressivepulmonary fibrosis besides IPF. CONCLUSION The differential diagnosis of pulmonary fibrosis, though complex, is clinically essential, as different types of pulmonary fibrosis are treated differently.
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Affiliation(s)
- Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik at Heidelberg University Hospital
- German Center for Lung Research (DZL)
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Campus Kerckhoff, Justus-Liebig-University Giessen, Bad Nauheim
| | - Ulrich Costabel
- Department of Pneumology, Ruhrlandklinik, University Medical Center Essen
| | - Danny Jonigk
- German Center for Lung Research (DZL)
- Institute of Pathology, Hannover Medical School
| | - Claus Peter Heussel
- German Center for Lung Research (DZL)
- Department of Diagnostic and Interventional Radiology, Thoraxklinik at Heidelberg University Hospital
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458
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Rouzet A, Morell F, Reboux G, Villar A, Millon L, Cruz MJ. Pilot Study Using Recombinant Antigens r-PROE and r-IGLL1 for the Serodiagnosis of Feather Duvet Lung. Arch Bronconeumol 2021; 58:S0300-2896(21)00073-9. [PMID: 33771385 DOI: 10.1016/j.arbres.2021.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Feather duvet lung (FDL) is an underestimated form of acute and chronic hypersensitivity pneumonitis. Serological tests for FDL need to be validated. We investigated the ability of recombinant pigeon Proproteinase E (r-PROE) and Immunoglobulin-lambda-like-polypeptide-1 (r-IGLL1) proteins to support the serological diagnosis of FDL, and propose them as a serological tool for clinicians to differentiate cases from FDL and Bird fancier's lung (BFL). METHODS Specific IgG antibodies against r-PROE and r-IGLL1, analyzed with ELISA, were measured in patients diagnosed with FDL (n=31), BFL (n=15) controls exposed (n=15) and unexposed to feathers (n=15). RESULTS The sensitivity and specificity of the r-PROE ELISA for the serological diagnosis of FDL cases versus exposed and unexposed controls were 74.2% and 86.7% respectively, with an index threshold of 0.5 (AUC: 0.89). In addition, this serological test was effective to support the serological diagnosis of FDL and BFL cases with significantly different thresholds. The r-IGLL1 ELISA was only effective for the serological diagnosis of BFL. Also, these two serological tests were useful for the diagnosis of both chronic and acute forms. CONCLUSIONS The new diagnostic test for FDL using r-PROE protein should help to detect overt and hidden cases of FDL. The combination of both test will help the clinician in distinguish between the etiology of birds or feathers duvet.
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Affiliation(s)
- Adeline Rouzet
- Chrono-Environment Research Team UMR/CNRS-6249, University of Bourgogne Franche-Comté, Besançon, France; Parasitology-Mycology Department, University Hospital, Besançon, France.
| | - Ferran Morell
- Pulmonology Department, Hospital Universitari Vall d'Hebron, and VHIR, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Spain; CIBER enfermedades respiratorias (CIBERES), Catalonia, Spain
| | - Gabriel Reboux
- Chrono-Environment Research Team UMR/CNRS-6249, University of Bourgogne Franche-Comté, Besançon, France; Parasitology-Mycology Department, University Hospital, Besançon, France
| | - Ana Villar
- Pulmonology Department, Hospital Universitari Vall d'Hebron, and VHIR, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Spain; CIBER enfermedades respiratorias (CIBERES), Catalonia, Spain
| | - Laurence Millon
- Chrono-Environment Research Team UMR/CNRS-6249, University of Bourgogne Franche-Comté, Besançon, France; Parasitology-Mycology Department, University Hospital, Besançon, France
| | - Maria Jesús Cruz
- Pulmonology Department, Hospital Universitari Vall d'Hebron, and VHIR, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Spain; CIBER enfermedades respiratorias (CIBERES), Catalonia, Spain
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459
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Lacedonia D, Scioscia G, Giardinelli A, Quarato CMI, Sassani EV, Foschino Barbaro MP, Maci F, Sperandeo M. The Role of Transthoracic Ultrasound in the Study of Interstitial Lung Diseases: High-Resolution Computed Tomography Versus Ultrasound Patterns: Our Preliminary Experience. Diagnostics (Basel) 2021; 11:439. [PMID: 33806439 PMCID: PMC8001146 DOI: 10.3390/diagnostics11030439] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Transthoracic ultrasound (TUS) is a readily available imaging tool that can provide a quick real-time evaluation. The aim of this preliminary study was to establish a complementary role for this imaging method in the approach of interstitial lung diseases (ILDs). TUS examination was performed in 43 consecutive patients with pulmonary fibrosis and TUS findings were compared with the corresponding high-resolution computed tomography (HRCT) scans. All patients showed a thickened hyperechoic pleural line, despite no difference between dominant HRCT patterns (ground glass, honeycombing, mixed pattern) being recorded (p > 0.05). However, pleural lines' thickening showed a significant difference between different HRCT degree of fibrosis (p < 0.001) and a negative correlation with functional parameters. The presence of >3 B-lines and subpleural nodules was also assessed in a large number of patients, although they did not demonstrate any particular association with a specific HRCT finding or fibrotic degree. Results allow us to suggest a complementary role for TUS in facilitating an early diagnosis of ILD or helping to detect a possible disease progression or eventual complications during routine clinical practice (with pleural line measurements and subpleural nodules), although HRCT remains the gold standard in the definition of ILD pattern, disease extent and follow-up.
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Affiliation(s)
- Donato Lacedonia
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | - Giulia Scioscia
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | - Angelamaria Giardinelli
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | - Carla Maria Irene Quarato
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | | | - Maria Pia Foschino Barbaro
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | - Federica Maci
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, 71122 Foggia, Italy; (D.L.); (A.G.); (C.M.I.Q.); (M.P.F.B.); (F.M.)
- Institute of Respiratory Diseases, Policlinico “Riuniti” di Foggia, 71122 Foggia, Italy
| | - Marco Sperandeo
- Unit of Interventional and Diagnostic Ultrasound, Department of Internal Medicine, IRCCS Fondazione “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
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460
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Huntley CC, Walters GI. An update on hypersensitivity pneumonitis: what a clinician wants to know. Curr Opin Pulm Med 2021; 27:95-104. [PMID: 33470673 DOI: 10.1097/mcp.0000000000000763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW A recent international collaboration has updated the clinical definition and diagnostic recommendations for hypersensitivity pneumonitis, focusing on fibrotic and non-fibrotic phenotypes. However, how these transfer to clinical practice and their impact upon clinical management and prognosis of hypersensitivity pneumonitis is unclear. This review will focus on recent advances in the understanding of the clinical aspects of hypersensitivity pneumonitis, predominantly its epidemiology, diagnosis, classification and treatment. RECENT FINDINGS Hypersensitivity pneumonitis is a rare disease within the general population, with variable geographical incidence because of environmental, cultural and occupational factors. Confidence in diagnosis relies upon the presence of clinical features with a temporal relationship to an associated exposure, radiological and histopathological features, bronchiolo-alveolar lavage lymphocytosis and precipitating antibodies/specific immunoglobulin G to antigens. Although emerging evidence regarding nintedanib use in progressive fibrotic interstitial lung disease is promising, the majority of therapies (corticosteroids and immunosuppressive agents) used traditionally in hypersensitivity pneumonitis lack a robust evidence base. SUMMARY With a clear definition of fibrotic and nonfibrotic hypersensitivity pneumonitis phenotypes now established, clinical research trials (predominantly randomized controlled trials) should clarify and resolve the discussion regarding antigen avoidance, corticosteroid therapy, immunosuppressive therapy and antifibrotic therapy in fibrotic and nonfibrotic subtypes of hypersensitivity pneumonitis.
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Affiliation(s)
| | - Gareth I Walters
- Birmingham Regional NHS Occupational Lung Disease Service, Birmingham Chest Clinic
- Occupational and Environmental Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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461
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Hirasawa Y, Nakada TA, Shimazui T, Abe M, Isaka Y, Sakayori M, Suzuki K, Yoshioka K, Kawasaki T, Terada J, Tsushima K, Tatsumi K. Prognostic value of lymphocyte counts in bronchoalveolar lavage fluid in patients with acute respiratory failure: a retrospective cohort study. J Intensive Care 2021; 9:21. [PMID: 33622402 PMCID: PMC7901004 DOI: 10.1186/s40560-021-00536-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/11/2021] [Indexed: 12/26/2022] Open
Abstract
Background Cellular patterns in bronchoalveolar lavage fluid (BALF) are used to distinguish or rule out particular diseases in patients with acute respiratory failure (ARF). However, whether BALF cellular patterns can predict mortality or not is unknown. We test the hypothesis that BALF cellular patterns have predictive value for mortality in patients with ARF. Methods This was a retrospective single-center observational study conducted in a Japanese University Hospital. Consecutive patients (n = 78) with both pulmonary infiltrates and ARF who were examined by bronchoalveolar lavage (BAL) between April 2015 and May 2018 with at least 1 year of follow-up were analyzed. Primary analysis was receiver operating characteristic curve—area under the curve (ROC-AUC) analysis for 1-year mortality. Results Among the final sample size of 78 patients, survivors (n = 56) had significantly increased lymphocyte and eosinophil counts and decreased neutrophil counts in BALF compared with non-survivors (n = 22). Among the fractions, lymphocyte count was the most significantly different (30 [12-50] vs. 7.0 [2.9-13]%, P <0.0001). In the ROC curve analysis of the association of BALF lymphocytes with 1-year mortality, the AUC was 0.787 (P <0.0001, cut-off value [Youden index] 19.0%). Furthermore, ≥20% BALF lymphocytes were significantly associated with increased survival with adjustment for baseline imbalances (1-year adjusted hazard ratio, 0.0929; 95% confidence interval, 0.0147–0.323, P <0.0001; 90-day P =0.0012). Increased survival was significantly associated with ≥20% BALF lymphocytes in both interstitial lung disease (ILD) and non-ILD subgroups (P =0.0052 and P =0.0033, respectively). In secondary outcome analysis, patients with ≥20% BALF lymphocytes had significantly increased ventilator-free days, which represents less respiratory dysfunction than those with <20% BALF lymphocytes. Conclusions In the patients with ARF, ≥20% lymphocytes in BALF was associated with significantly less ventilatory support, lower mortality at both 90-day and 1-year follow-ups.
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Affiliation(s)
- Yasutaka Hirasawa
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yuri Isaka
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masashi Sakayori
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kenichi Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Keiichiro Yoshioka
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takeshi Kawasaki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kenji Tsushima
- Department of Pulmonary Medicine, School of Medicine, International University of Health and Welfare, Kozunomori 4-3, Narita, Chiba, 286-8686, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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462
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Adderley N, Humphreys CJ, Barnes H, Premji ZA, Johannson KA. Reply: BAL lymphocyte percentage is as good as the company it keeps. Eur Respir J 2021; 57:57/2/2100092. [PMID: 33602877 DOI: 10.1183/13993003.00092-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Nicola Adderley
- Dept of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Hayley Barnes
- Dept of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Melbourne, Australia.,Dept of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Zahra A Premji
- Depts of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Kerri A Johannson
- Dept of Medicine, University of Calgary, Calgary, AB, Canada.,Dept of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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463
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Comparison of Clinical Characteristics and Outcomes between Idiopathic and Secondary Pleuroparenchymal Fibroelastosis. J Clin Med 2021; 10:jcm10040846. [PMID: 33670776 PMCID: PMC7922642 DOI: 10.3390/jcm10040846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Pleuroparenchymal fibroelastosis (PPFE) is a unique clinical, radiologic, and histopathologic entity for which several potential etiologies have been reported recently. However, there has been no comprehensive study of secondary PPFE. Objective: Assessment of the clinical characteristics, outcomes, and prognostic factors of secondary and idiopathic PPFE. Methods: We retrospectively reviewed the medical records of consecutive PPFE patients between January 1999 and December 2018. We identified 132 idiopathic PPFE patients and 32 secondary PPFE patients. Results: The incidence of interstitial lung disease (ILD) pattern different from the usual interstitial pneumonia (UIP) pattern in the lower lobes was higher in secondary PPFE patients (38.5%) than in idiopathic PPFE patients (61.5%, p = 0.02). The idiopathic and secondary PPFE groups did not differ significantly in terms of laboratory data, respiratory complications, and survival (median: 5.0 years vs. 4.1 years, p = 0.95). The presence of UIP pattern was independently associated with increased mortality in multivariate analyses in idiopathic PPFE patients, but not in secondary PPFE patients. Conclusions: The frequency and prognostic impact of UIP-pattern ILD differed between idiopathic and secondary PPFE patients. Lung transplantation should be considered in secondary PPFE patients with low diffusing capacity of the lungs for carbon monoxide (DLCO) regardless of lower-lobe ILD pattern.
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464
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Shimoda M, Morimoto K, Tanaka Y, Furuuchi K, Osawa T, Yano R, Kokutou H, Yoshimori K, Ohta K. Features of humidifier lung and comparison with summer-type hypersensitivity pneumonitis. Respirology 2021; 26:394-395. [PMID: 33594737 PMCID: PMC8048899 DOI: 10.1111/resp.14014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Masafumi Shimoda
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Kozo Morimoto
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Yoshiaki Tanaka
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Koji Furuuchi
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Takeshi Osawa
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Ryozo Yano
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Hiroyuki Kokutou
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Kozo Yoshimori
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
| | - Ken Ohta
- Respiratory Disease Center, Japan Anti-Tuberculosis Association (JATA) Fukujuji Hospital, Tokyo, Japan
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465
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Dodia N, Amariei D, Kenaa B, Corwin D, Chelala L, Britt EJ, Sachdeva A, Luzina IG, Hasday JD, Shah NG, Atamas SP, Franks TJ, Burke AP, Hines SE, Galvin JR, Todd NW. A comprehensive assessment of environmental exposures and the medical history guides multidisciplinary discussion in interstitial lung disease. Respir Med 2021; 179:106333. [PMID: 33676119 DOI: 10.1016/j.rmed.2021.106333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/24/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Multidisciplinary discussion (MDD) is widely recommended for patients with interstitial lung disease (ILD), but published primary data from MDD has been scarce, and factors influencing MDD other than chest computed tomography (CT) and lung histopathology interpretations have not been well-described. METHODS Single institution MDD of 179 patients with ILD. RESULTS MDD consensus clinical diagnoses included autoimmune-related ILD, chronic hypersensitivity pneumonitis, smoking-related ILD, idiopathic pulmonary fibrosis, medication-induced ILD, occupation-related ILD, unclassifiable ILD, and a few less common pulmonary disorders. In 168 of 179 patients, one or more environmental exposures or pertinent features of the medical history were identified, including recreational/avocational, residential, and occupational exposures, systemic autoimmune disease, malignancy, medication use, and family history. The MDD process demonstrated the importance of comprehensively assessing these exposures and features, beyond merely noting their presence, for rendering consensus clinical diagnoses. Precise, well-defined chest CT and lung histopathology interpretations were rendered at MDD, including usual interstitial pneumonia, nonspecific interstitial pneumonia, and organizing pneumonia, but these interpretations were associated with a variety of MDD consensus clinical diagnoses, demonstrating their nonspecific nature in many instances. In 77 patients in which MDD consensus diagnosis differed from referring diagnosis, assessment of environmental exposures and medical history was found retrospectively to be the most impactful factor. CONCLUSIONS A comprehensive assessment of environmental exposures and pertinent features of the medical history guided MDD. In addition to rendering consensus clinical diagnoses, MDD presented clinicians with opportunities to initiate environmental remediation, behavior modification, or medication alteration likely to benefit individual patients with ILD.
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Affiliation(s)
- Neal Dodia
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Diana Amariei
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Blaine Kenaa
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Doug Corwin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lydia Chelala
- Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E James Britt
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashutosh Sachdeva
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Irina G Luzina
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Jeffrey D Hasday
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Nirav G Shah
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sergei P Atamas
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Teri J Franks
- Department of Defense, The Joint Pathology Center, USA
| | - Allen P Burke
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stella E Hines
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey R Galvin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nevins W Todd
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA.
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466
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Selman M, Pardo A. When things go wrong: exploring possible mechanisms driving the progressive fibrosis phenotype in interstitial lung diseases. Eur Respir J 2021; 58:13993003.04507-2020. [PMID: 33542060 DOI: 10.1183/13993003.04507-2020] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
Interstitial lung diseases (ILDs) comprise a large and heterogeneous group of disorders of known and unknown aetiology characterised by diffuse damage of the lung parenchyma. In recent years it has become evident that patients with different types of ILD are at risk of developing progressive pulmonary fibrosis, known as progressive fibrosing ILD (PF-ILD). This is a phenotype that behaves similar to idiopathic pulmonary fibrosis, the archetypical example of progressive fibrosis. PF-ILD is not a distinct clinical entity but describes a group of ILDs with similar clinical behaviour. This phenotype may occur in diseases displaying distinct aetiologies and different biopathology during their initiation and development. Importantly, these entities may have the potential for improvement or stabilisation prior to entering the progressive fibrosing phase. The crucial questions are: 1) why does a subset of patients develop a progressive and irreversible fibrotic phenotype even with appropriate treatment? and 2) what are the possible pathogenic mechanisms driving progression? Here, we provide a framework highlighting putative mechanisms underlying progression, including genetic susceptibility, ageing, epigenetics, structural fibrotic distortion, aberrant composition and stiffness of the extracellular matrix, and the emergence of distinct pro-fibrotic cell subsets. Understanding the cellular and molecular mechanisms behind PF-ILD will provide the basis for identifying risk factors and appropriate therapeutic strategies.
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Affiliation(s)
- Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de Mexico, Mexico City, Mexico
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467
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Hypersensitivity pneumonitis in a patient with pulmonary alveolar proteinosis. Pulmonology 2021; 27:464-466. [PMID: 33551268 DOI: 10.1016/j.pulmoe.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 11/21/2022] Open
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468
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The association between fungi exposure and hypersensitivity pneumonitis: a systematic review. Porto Biomed J 2021; 6:e117. [PMID: 33532658 PMCID: PMC7846411 DOI: 10.1097/j.pbj.0000000000000117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 12/13/2022] Open
Abstract
A systematic review of published studies focused on the association between hypersensitivity pneumonitis (HP) and fungi exposure was conducted on PubMed, following PRISMA guidelines for systematic reviews. A total of 14 studies met the inclusion criteria but only 6 of these studies were eligible, as the remaining 8 represented case reports that were separately included for further discussion. HP is an interstitial lung disease (ILD) characterized by a hypersensitization response to inhalable antigens and represents 1.5% to 12% of all ILD in the European population. Several fungi species that populate the indoor environment have been associated with the incidence of HP upon cumulative exposure, with Penicillium spp and Aspergillus spp being the fungi species most frequently associated with the onset of disease. Although some studies have shown that avoiding exposure to causative HP fungi tends to improve patients’ symptoms, other studies were unable to identify the source of sensitization. More microbial exposure studies are needed to properly estimate the risk of HP development in the built environment.
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469
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Molyneaux PL, Smith JJ, Saunders P, Chua F, Wells AU, Renzoni EA, Nicholson AG, Fahy WA, Jenkins RG, Maher TM. BAL Is Safe and Well Tolerated in Individuals with Idiopathic Pulmonary Fibrosis: An Analysis of the PROFILE Study. Am J Respir Crit Care Med 2021; 203:136-139. [PMID: 32857629 DOI: 10.1164/rccm.202004-1138le] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Philip L Molyneaux
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom
| | - Jonathan J Smith
- National Heart and Lung Institute, Imperial College London London, United Kingdom
| | - Peter Saunders
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom
| | - Felix Chua
- Royal Brompton Hospital London, United Kingdom
| | - Athol U Wells
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom
| | - Elisabetta A Renzoni
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom
| | - Andrew G Nicholson
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom
| | | | | | - Toby M Maher
- Royal Brompton Hospital London, United Kingdom.,National Heart and Lung Institute, Imperial College London London, United Kingdom.,University of Southern California Los Angeles, California
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470
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Braun M, Klingelhöfer D, Groneberg DA. Sooty bark disease of maples: the risk for hypersensitivity pneumonitis by fungal spores not only for woodman. J Occup Med Toxicol 2021; 16:2. [PMID: 33478566 PMCID: PMC7819180 DOI: 10.1186/s12995-021-00292-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/13/2021] [Indexed: 11/10/2022] Open
Abstract
In the middle of the twentieth century, the from North America sooty bark disease (SBD) of maples was first discovered in England and has spread in the last decades in Central Europe, in particular. The trigger of SBD is the mould fungus Cryptostroma (C.) corticale. The most common infested maple is the sycamore, Acer pseudoplatanus, a common tree in woods and parks. The disease is characterised by peeling of the outer layer of the bark and brownish-black spores under the peeled off bark. These spores can cause maple bark disease (MBD) in humans, a hypersensitivity pneumonitis (HP) with similar symptoms like COPD, allergic asthma, influenza or flu-like infections and interstitial pneumonia. Persons who have intensive respectively occupational contact with infested trees or wood, e.g., woodman, foresters, sawyers or paper mill workers, are at risk in particular. Since C. corticale favours hot summers and host trees weakened by drought, SBD will increasingly spread in the future due to ongoing climate change. Consequently, the risk of developing MBD will increase, too. As with all HPs, e.g., farmer's lung and pigeon breeder's disease, the diagnosis of MBD is intricate because it has no clear distinguishing characteristics compared to other interstitial lung diseases. Therefore, the establishment of consistent diagnosis guidelines is required. For correct diagnosis and successful therapy, multidisciplinary expertise including pulmonologists, radiologists, pathologists and occupational physicians is recommended. If MBD is diagnosed in time, the removal of the triggering fungus or the infested maple wood leads to complete recovery in most cases. Chronic HP can lead to lung fibrosis and a total loss of lung function culminating in death. HP and, thus, MBD, is a disease with a very high occupational amount. To avoid contact with spores of C. corticale, persons working on infested wood or trees have to wear personal protective equipment. To protect the public, areas with infested maples have to be cordoned off, and the trees should be removed. This is also for impeding further spreading of the spores.
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Affiliation(s)
- Markus Braun
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, D-60590, Frankfurt am Main, Germany.
| | - Doris Klingelhöfer
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, D-60590, Frankfurt am Main, Germany
| | - David A Groneberg
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, D-60590, Frankfurt am Main, Germany
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471
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Aronson KI, Ali M, Reshetynak E, Kaner RJ, Martinez FJ, Safford MM, Pinheiro LC. Establishing content-validity of a disease-specific health-related quality of life instrument for patients with chronic hypersensitivity pneumonitis. J Patient Rep Outcomes 2021; 5:9. [PMID: 33443657 PMCID: PMC7809073 DOI: 10.1186/s41687-020-00282-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Chronic Hypersensitivity Pneumonitis (CHP) is caused by an immune mediated response in the lung tissue after exposure to an inhaled environmental antigenic stimulant. We previously documented the ways in which CHP impacts patients’ lives and have now developed a disease-specific instrument, the CHP-HRQOL instrument, to measure health-related quality of life (HRQOL). The objective of this study was to assess content validity for the CHP-HRQOL. Methods Cognitive interviews were conducted among adults with CHP. The instrument was revised and refined between each round of interviews. Feedback was obtained on the instructions, items, response options, and recall period. Items where participants had difficulty with comprehension, wording, or misinterpretation were marked by the interviewer and participant feedback was reviewed to make revisions, add or delete items when appropriate. Readability statistics were calculated using Flesch-Kincaid grade level and reading ease scores. Results Ten participants were interviewed over three rounds, with revisions made to the questionnaire in an iterative process. In the initial 39 item instrument, we identified 7 items where two or more participants reported difficulty. Participants preferred a four-week recall period (compared to a two-week recall period) and response options with a 5-point response scale. The final version of the CHP-HRQOL includes 40 items with a median reading level between 6th and 7th grade. Conclusion The CHP-HRQOL instrument demonstrated high content validity and is ready for psychometric testing in further validation studies. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-020-00282-x.
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Affiliation(s)
- Kerri I Aronson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine New York, New York, USA.
| | - Maha Ali
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Evgeniya Reshetynak
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert J Kaner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine New York, New York, USA.,Department of Genetic Medicine, Weill Cornell Medicine New York, New York, USA
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine New York, New York, USA
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Laura C Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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472
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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473
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Gandhi CK, Chen C, Amatya S, Yang L, Fu C, Zhou S, Wu R, Buendía-Roldan I, Selman M, Pardo A, Floros J. SNP and Haplotype Interaction Models Reveal Association of Surfactant Protein Gene Polymorphisms With Hypersensitivity Pneumonitis of Mexican Population. Front Med (Lausanne) 2021; 7:588404. [PMID: 33469544 PMCID: PMC7813780 DOI: 10.3389/fmed.2020.588404] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/07/2020] [Indexed: 01/21/2023] Open
Abstract
Background: Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by inhalation of common environmental organic particles. Surfactant proteins (SPs) play a role in innate immunity and surfactant function. We hypothesized that single nucleotide polymorphisms (SNPs) or haplotypes of the SP genes associate with HP. Methods: Seventy-five HP patients caused by avian antigen and 258 controls, asymptomatic antigen exposed and non-exposed were enrolled. SNP association was performed using logistic regression analysis and SNP-SNP interaction models. Results: Based on odds ratio, regression analyses showed association of (a) rs7316_G, 1A3 (protective) compared to antigen exposed; (b) male sex, smoking, rs721917_T and rs1130866_T (protective) compared to non-exposed controls with HP; (c) compared to antigen exposed, 25 interactions associated with HP in a three-SNP model; (d) compared to non-exposed, (i) rs1136451 associated with increased, whereas rs1136450 and rs1130866 associated with lower HP risk, (ii) 97 interactions associated with HP in a three-SNP model. The majority of SNP-SNP interactions associated with increased HP risk involved SNPs of the hydrophilic SPs, whereas, the majority of interactions associated with lower HP risk involved SNPs of both hydrophilic and hydrophobic SPs; (e) haplotypes of SP genes associated with HP risk. Conclusions: The complexity of SNPs interactions of the SFTP genes observed indicate that the lung inflammatory response to avian antigens is modulated by a complex gene interplay rather than by single SNPs.
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Affiliation(s)
- Chintan K. Gandhi
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Chixiang Chen
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Shaili Amatya
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Lili Yang
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Chenqi Fu
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Shouhao Zhou
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Rongling Wu
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Ivette Buendía-Roldan
- Unidad de Investigación, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
| | - Moisés Selman
- Unidad de Investigación, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
| | - Annie Pardo
- Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Joanna Floros
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
- Department of Obstetrics & Gynecology, Pennsylvania State University College of Medicine, Hershey, PA, United States
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474
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Zhang F, Yang T, Liu Z, Jia X, Yang L, Wu L, Tang L. Clinical Features of Hypersensitivity Pneumonitis in Children: A Single Center Study. Front Pediatr 2021; 9:789183. [PMID: 35127590 PMCID: PMC8811457 DOI: 10.3389/fped.2021.789183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Hypersensitivity pneumonia (HP) is an interstitial lung disease (ILD) mainly involving small airways and lung parenchyma that is caused by the inhalation of antigens in susceptible people to stimulate the body's immune response. METHODS A total of 6 Chinese children with HP treated in our center from July 2017 to July 2021 were included in our study. RESULTS Among the children, there were 4 males and 2 females, ranging in age from 4 to 14 years. Three cases had chest tightness and shortness of breath, 2 cases had cough, 1 case had chest pain, and 1 case had fever. Two cases of children had a history of close contact with pet dogs, 1 case had a history of contact with pigeons, 2 cases lived in a moldy house recently, and 1 case recently played a saxophone that had been idle for more than 2 years. The parents of two cases also had similar symptoms recently. The specific signs of chest HRCT of 6 cases all were in line with the characteristics of HP. After avoiding the sensitization environment, 2 children quickly recovered, 4 patients received low-dose glucocorticoid oral treatment, and after symptom control the dose was gradually reduced. The course of treatment was about 3-6 months. CONCLUSIONS Exposure to a potential antigen has been found in all 6 HP children. The clinical manifestations are heterogeneous and easy to confuse with other diseases. A clear history of exposure to the antigens, respiratory symptoms associated with HP, signs of HP on HRCT, and improvement after removal from the antigenic environment constitute the cornerstone of the diagnosis of HP children in our unit. Avoiding exposure to antigenic environment is the first step in treatment, and glucocorticoid use is necessary in children with persistent symptoms.
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Affiliation(s)
- Feizhou Zhang
- Department of Pulmonology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
| | - Tongyu Yang
- Department of Pulmonology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
| | | | - Xuan Jia
- Department of Radiology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
| | - Li Yang
- Department of Radiology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
| | - Lei Wu
- Department of Pulmonology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
| | - Lanfang Tang
- Department of Pulmonology, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, The Children's Hospital, Hangzhou, China
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475
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Nambiar AM, Walker CM, Sparks JA. Monitoring and management of fibrosing interstitial lung diseases: a narrative review for practicing clinicians. Ther Adv Respir Dis 2021; 15:17534666211039771. [PMID: 34477452 PMCID: PMC8422822 DOI: 10.1177/17534666211039771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Close monitoring of patients with fibrosing interstitial lung diseases (ILDs) is important to enable prompt identification and management of progressive disease. Monitoring should involve regular assessment of physiology (including pulmonary function tests), symptoms, and, when appropriate, high-resolution computed tomography. The management of patients with fibrosing ILDs requires a multidisciplinary approach and should be individualized based on factors such as disease severity, evidence of progression, risk factors for progression, comorbidities, and the preferences of the patient. In this narrative review, we discuss how patients with fibrosing ILDs can be effectively monitored and managed in clinical practice.
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Affiliation(s)
- Anoop M. Nambiar
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, University of Texas Health San Antonio,
7703 Floyd Curl Drive, MC 7885, San Antonio, TX 78229, USA
| | - Christopher M. Walker
- Cardiothoracic Imaging Division, Department of
Radiology, The University of Kansas Medical Center, Kansas City, KS,
USA
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and
Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
USA
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476
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Cardoso A, Gonçalves L, Inácio JR, Cunha F, Freitas JV, Soares R, Branco C, Branco T, Jacinto N, Santos LR, Alvoeiro L, Lacerda APD. Bird Fancier's Lung Diagnosis in Times of COVID-19. Arch Bronconeumol 2021; 57:90-91. [PMID: 34629679 PMCID: PMC7577872 DOI: 10.1016/j.arbres.2020.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ana Cardoso
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Lisa Gonçalves
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - João R Inácio
- Department of Imagiology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Francisco Cunha
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - João Victor Freitas
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Raquel Soares
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Carolina Branco
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Tiago Branco
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Nuno Jacinto
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Liliana R Santos
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Lourdes Alvoeiro
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - António Pais de Lacerda
- Department of Medicine 2, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculty of Medicine of the University of Lisbon, Lisbon
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477
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Kang EY. Preface for Special Issue on Updates in Chest Radiology. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:767-769. [PMID: 36238064 PMCID: PMC9514413 DOI: 10.3348/jksr.2021.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Eun-Young Kang
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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478
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Erratum: Diagnosis of Hypersensitivity Pneumonitis in Adults: An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2021; 203:150-151. [PMID: 33385222 PMCID: PMC7781139 DOI: 10.1164/rccm.v203erratum1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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479
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Park S, Oh YW, Kang EY, Yong HS, Kim C, Lee KY, Hwang SH. Diagnosis of Hypersensitivity Pneumonitis: 2020 Clinical Practice Guideline. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:817-825. [PMID: 36238061 PMCID: PMC9514409 DOI: 10.3348/jksr.2021.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Soojung Park
- Department of Radiology, Korea University Anam Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Yu-Whan Oh
- Department of Radiology, Korea University Anam Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Eun-Young Kang
- Department of Radiology, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
| | - Cherry Kim
- Department of Radiology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Ki Yeol Lee
- Department of Radiology, Korea University Ansan Hospital, College of Medicine, Korea University, Ansan, Korea
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, College of Medicine, Korea University, Seoul, Korea
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480
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[Fibrotic hypersensitivity pneumonia: focus on pathology-relevant aspects of the new ATS/JRS/ALAT clinical guideline for the diagnosis of hypersensitivity pneumonia in adults]. DER PATHOLOGE 2020; 42:48-54. [PMID: 33355704 PMCID: PMC7858214 DOI: 10.1007/s00292-020-00885-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 10/26/2022]
Abstract
Hypersensitivity pneumonia (HP), also called exogenous allergic alveolitis, is a chronic interstitial pneumonia induced by a hypersensitivity reaction to an identified or unidentified antigen in exposed and susceptible individuals that may progress to terminal lung fibrosis. The diagnosis of HP presents a diagnostic challenge. Though therapeutically important, it may be particularly difficult to differentiate fibrotic HP, historically termed chronic HP, from idiopathic pulmonary fibrosis (IPF) or interstitial lung disease associated with connective tissue diseases (CTD-ILD). Multidisciplinary discussion and thus a synoptic evaluation of all findings is firmly established as the gold standard diagnostic approach in interstitial lung diseases including HP. Nonetheless, the high interobserver variability between experts from the individual disciplines (pulmonology, radiology, and pathology) and between experienced multidisciplinary teams in assessing the diagnostic probability of HP has highlighted the need for widely accepted guidelines.The present review summarizes pathology-relevant aspects of the new ATS/JRS/ALAT clinical practice guideline for the diagnosis of HP in adults.
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481
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Üçsular F, Polat G, Karadeniz G, Ayranci A, Keskin M, Buyukşirin M, Güldaval F, Yalniz E. Predictive value of platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in patients with hypersensitivity pneumonia. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2020; 37:e2020012. [PMID: 33597799 PMCID: PMC7883515 DOI: 10.36141/svdld.v37i4.9966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 11/15/2020] [Indexed: 11/13/2022]
Abstract
Aim: To evaluate Platelet-to-Lymphocyte Ratio (PLR) and Neutrophil-to-Lymphocyte Ratio (NLR) in patients with HP. Method: A sample of 140 total patients, 50 having chronic HP and 20 having acute HP, and a control group of 70 more patients were included in this retrospective study conducted with hospital Ethical Committee approval. Results: PLR and NLR values were significantly higher in all HP patients than in the control group ( p <0.001). In addition, these biomarkers were significantly higher in patients with acute HP than in the chronic HP group (p = 0.017 and p = 0.044, respectively). The cutoff values for PLR and NLR were: (1) 177 (p = 0.020) and 2.76 (p <0.0001) between the HP patients and the control group, and, (2) 110 (p = 0.0054) and 2.15 (p = 0.03), between the acute and chronic HP groups. Conclusion: PLR and NLR values are inexpensive and easy parameters that can guide in diagnosing hypersensitivity pneumonia in combination with clinical, radiological and pathology findings.and the acute-chronic differentiation of the disease. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020012)
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Affiliation(s)
- Fatma Üçsular
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Gülru Polat
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Gülistan Karadeniz
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Aysu Ayranci
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Merve Keskin
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Melih Buyukşirin
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Filiz Güldaval
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Enver Yalniz
- Department of Pulmonology, Health Siences University Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
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482
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Moldoveanu B, Gearhart AM, Jalil BA, Saad M, Guardiola JJ. Pulmonary Aspergillosis: Spectrum of Disease. Am J Med Sci 2020; 361:411-419. [PMID: 33563417 DOI: 10.1016/j.amjms.2020.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/22/2020] [Accepted: 12/10/2020] [Indexed: 01/17/2023]
Abstract
Aspergillus species are ubiquitous in the environment. Aspergillosis is acquired by inhalation of Aspergillus spores. In normal hosts, spore inhalation rarely causes lung disease. Pulmonary Aspergillosis covers a wide spectrum of clinical syndromes depending on the interaction between Aspergillus and the host (immune-status, prior bronchopulmonary disease). It runs the gamut from invasive Aspergillosis to Aspergillus bronchitis. Invasive Aspergillosis usually occurs in severely immunocompromised patients, typically in neutropenic but also in non-neutropenic patients. Chronic pulmonary Aspergillosis affects patients with chronic structural lung disease such as COPD or previous mycobacterial lung disease, but without other significant immunocompromise. Aspergillus bronchitis affects patients with bronchial disease such as bronchiectasis. Allergic bronchopulmonary Aspergillosis affects patients with bronchial asthma or cystic fibrosis, and is due to an allergic response to Aspergillus.
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Affiliation(s)
- Bogdan Moldoveanu
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine - Department of Medicine, University of Louisville, Pulmonary, Critical Care and Sleep Division, Louisville, KY, USA.
| | - Alessandra Morello Gearhart
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine - Department of Medicine, University of Louisville, Pulmonary, Critical Care and Sleep Division, Louisville, KY, USA
| | - Bilal A Jalil
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine - Department of Medicine, University of Louisville, Pulmonary, Critical Care and Sleep Division, Louisville, KY, USA
| | - Mohamed Saad
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine - Department of Medicine, University of Louisville, Pulmonary, Critical Care and Sleep Division, Louisville, KY, USA
| | - Juan J Guardiola
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine - Department of Medicine, University of Louisville, Pulmonary, Critical Care and Sleep Division, Louisville, KY, USA
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483
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BAL for ILD. Respir Investig 2020; 59:3-4. [PMID: 33262064 DOI: 10.1016/j.resinv.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 11/23/2022]
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484
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Johannson KA, Barnes H, Bellanger AP, Dalphin JC, Fernández Pérez ER, Flaherty KR, Huang YCT, Jones KD, Kawano-Dourado L, Kennedy K, Millerick-May M, Miyazaki Y, Morisset J, Morell F, Raghu GR, Robbins C, Sack CS, Salisbury ML, Selman M, Vasakova M, Walsh SLF, Rose CS. Exposure Assessment Tools for Hypersensitivity Pneumonitis. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17:1501-1509. [PMID: 33258669 PMCID: PMC7706597 DOI: 10.1513/annalsats.202008-942st] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This report is based on proceedings from the Exposure Assessment Tools for Hypersensitivity Pneumonitis (HP) Workshop, sponsored by the American Thoracic Society, that took place on May 18, 2019, in Dallas, Texas. The workshop was initiated by members from the Environmental, Occupational, and Population Health and Clinical Problems Assemblies of the American Thoracic Society. Participants included international experts from pulmonary medicine, occupational medicine, radiology, pathology, and exposure science. The meeting objectives were to 1) define currently available tools for exposure assessment in evaluation of HP, 2) describe the evidence base supporting the role for these exposure assessment tools in HP evaluation, 3) identify limitations and barriers to each tool's implementation in clinical practice, 4) determine which exposure assessment tools demonstrate the best performance characteristics and applicability, and 5) identify research needs for improving exposure assessment tools for HP. Specific discussion topics included history-taking and exposure questionnaires, antigen avoidance, environmental assessment, specific inhalational challenge, serum-specific IgG testing, skin testing, lymphocyte proliferation testing, and a multidisciplinary team approach. Priorities for research in this area were identified.
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485
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Making Sense of Bronchoalveolar Lavage Lymphocytosis in Fibrotic Interstitial Lung Disease. Ann Am Thorac Soc 2020; 17:1382-1383. [PMID: 33124908 PMCID: PMC7640718 DOI: 10.1513/annalsats.202007-818ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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486
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Hayashi F, Kido T, Sakamoto N, Zaizen Y, Ozasa M, Yokoyama M, Yura H, Hara A, Ishimoto H, Yamaguchi H, Miyazaki T, Obase Y, Ishimatsu Y, Eishi Y, Fukuoka J, Mukae H. Pneumoconiosis with a Sarcoid-Like Reaction Other than Beryllium Exposure: A Case Report and Literature Review. ACTA ACUST UNITED AC 2020; 56:medicina56110630. [PMID: 33266389 PMCID: PMC7700418 DOI: 10.3390/medicina56110630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 01/18/2023]
Abstract
Background: Chronic beryllium disease (CBD) is a granulomatous disease that resembles sarcoidosis but is caused by beryllium. Clinical manifestations similar to those observed in CBD have occasionally been reported in exposure to dusts of other metals. However, reports describing the clinical, radiographic, and pathological findings in conditions other than beryllium-induced granulomatous lung diseases, and detailed information on mineralogical analyses of metal dusts, are limited. Case presentation: A 51-year-old Japanese man with rapidly progressing nodular shadows on chest radiography, and a 10-year occupation history of underground construction without beryllium exposure, was referred to our hospital. High-resolution computed tomography showed well-defined multiple centrilobular and perilobular nodules, and thickening of the intralobular septa in the middle and lower zones of both lungs. No extrathoracic manifestations were observed. Pathologically, the lung specimens showed 5–12 mm nodules with dust deposition and several non-necrotizing granulomas along the lymphatic routes. X-ray analytical electron microscopy of the same specimens revealed aluminum, iron, titanium, and silica deposition in the lung tissues. The patient stopped smoking and changed his occupation to avoid further dust exposure; the chest radiography shadows decreased 5 years later. Conclusion: The radiological appearances of CBD and sarcoidosis are similar, although mediastinal or hilar lymphadenopathy is less common in CBD and is usually seen in the presence of parenchymal opacities. Extrathoracic manifestations are also rare. Despite limited evidence, these findings are similar to those observed in pneumoconiosis with a sarcoid-like reaction due to exposure to dust other than of beryllium. Aluminum is frequently detected in patients with pneumoconiosis with a sarcoid-like reaction and is listed as an inorganic agent in the etiology of sarcoidosis. It was also detected in our patient and may have contributed to the etiology. Additionally, our case suggests that cessation of dust exposure may contribute to improvement under the aforementioned conditions.
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Affiliation(s)
- Fumiko Hayashi
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
- Correspondence: ; Tel.: +81-95-819-7273; Fax: +81-95-849-7285
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Yoshiaki Zaizen
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan; (Y.Z.); (J.F.)
| | - Mutsumi Ozasa
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan; (Y.Z.); (J.F.)
| | - Mitsuru Yokoyama
- Department of Anatomy, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu City, Fukuoka 807-8555, Japan;
| | - Hirokazu Yura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Atsuko Hara
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Hiroyuki Yamaguchi
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Taiga Miyazaki
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan;
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan;
| | - Yoshinobu Eishi
- Department of Human Pathology, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan;
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan; (Y.Z.); (J.F.)
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; (F.H.); (N.S.); (M.O.); (H.Y.); (A.H.); (H.I.); (H.Y.); (Y.O.); (H.M.)
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Tibana RCC, Soares MR, Storrer KM, de Souza Portes Meirelles G, Hidemi Nishiyama K, Missrie I, Coletta ENAM, Ferreira RG, de Castro Pereira CA. Clinical diagnosis of patients subjected to surgical lung biopsy with a probable usual interstitial pneumonia pattern on high-resolution computed tomography. BMC Pulm Med 2020; 20:299. [PMID: 33198708 PMCID: PMC7670778 DOI: 10.1186/s12890-020-01339-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/04/2020] [Indexed: 12/01/2022] Open
Abstract
Background Usual interstitial pneumonia can present with a probable pattern on high-resolution computed tomography (HRCT), but the probability of identifying usual interstitial pneumonia by surgical lung biopsy in such cases remains controversial. We aimed to determine the final clinical diagnosis in patients with a probable usual interstitial pneumonia pattern on HRCT who were subjected to surgical lung biopsy. Methods HRCT images were assessed and categorized by three radiologists, and tissue slides were evaluated by two pathologists, all of whom were blinded to the clinical findings. The final clinical diagnosis was accomplished via a multidisciplinary discussion. Patients with a single layer of honeycombing located outside of the lower lobes on HRCT were not excluded. Results A total of 50 patients were evaluated. The most common final clinical diagnosis was fibrotic hypersensitivity pneumonitis (38.0%) followed by idiopathic pulmonary fibrosis (24.0%), interstitial lung disease ascribed to gastroesophageal reflux disease (12.0%) and familial interstitial lung disease (10.0%). In the group without environmental exposure (n = 22), 10 patients had a final clinical diagnosis of idiopathic pulmonary fibrosis (45.5%). Irrespective of the final clinical diagnosis, by multivariate Cox analysis, patients with honeycombing, dyspnoea and fibroblastic foci on surgical lung biopsy had a high risk of death. Conclusions The most common disease associated with a probable usual interstitial pneumonia pattern on HRCT is fibrotic hypersensitivity pneumonitis followed by idiopathic pulmonary fibrosis and interstitial lung disease ascribed to gastroesophageal reflux disease. In patients without environmental exposure, the frequencies of usual interstitial pneumonia and a final clinical diagnosis of idiopathic pulmonary fibrosis are not sufficiently high to obviate the indications for surgical lung biopsy. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-020-01339-9.
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Affiliation(s)
- Regina Celia Carlos Tibana
- Pulmonary Department, Federal University of Sao Paulo, R. Botucatu, 740 - Vila Clementino, São Paulo, SP, 04023-062, Brazil.
| | - Maria Raquel Soares
- Pulmonary Department, Federal University of Sao Paulo, R. Botucatu, 740 - Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Karin Mueller Storrer
- Pulmonary Department, Federal University of Sao Paulo, R. Botucatu, 740 - Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | | | | | - Israel Missrie
- Radiology Department, Federal University of Sao Paulo, Sao Paulo, Brazil
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488
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Assessment and Management of Occupational Hypersensitivity Pneumonitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3295-3309. [PMID: 33161960 DOI: 10.1016/j.jaip.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
The diagnosis and treatment of occupational hypersensitivity pneumonitis (OHP) remain complex and challenging in the absence of diagnostic gold standards or clinical guidelines. This review provides an update of the recent literature regarding the different presentations of OHP and the diagnostic yield and value of the diagnostic tests currently available, which include occupational and medical history, laboratory tests (serum-specific immunoglobulins, environmental sampling), imaging, bronchoalveolar lavage, transbronchial biopsy, transbronchial cryobiopsy, surgical lung biopsy, and specific inhalation challenges. These tools provide a precise differential diagnosis within the framework of interstitial lung diseases. However, among the chronic fibrotic forms, distinguishing OHP from sarcoidosis, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis remains a diagnostic challenge. Avoidance of exposure is pivotal for OHP management, whereas corticosteroids are fundamental in the pharmacological approach to this disease. In addition, studies describing the long-term benefits of immunosuppressive and antifibrotic agents have increased the use of these treatments in OHP.
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489
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Okuda R, Takemura T, Mikami Y, Hagiwara E, Iwasawa T, Baba T, Kitamura H, Komatsu S, Okudela K, Ohashi K, Ogura T. Inhalation challenge test using pigeon eggs for chronic hypersensitivity pneumonitis. Clin Exp Allergy 2020; 50:1381-1390. [PMID: 33010071 DOI: 10.1111/cea.13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic hypersensitivity pneumonitis (CHP) remains a diagnostic challenge. The process of collecting and extracting serum and droppings from causative animals for the inhalation challenge test is complicated and the risk of inducing disease progression exists. OBJECTIVE To investigate the utility and safety of an inhalation challenge test using pigeon eggs. METHODS Pigeon eggs were pasteurized and mixed with a saline solution to produce an inhalation fluid. An inhalation challenge test was conducted on 19 patients with bird-related CHP and 17 patients with interstitial lung disease other than bird-related CHP. To identify antigens in pigeon eggs, the antigen-antibody responses of the pigeon eggs and serum from patients were evaluated using Western blotting. RESULTS The mean changes in C-reactive protein, alveolar-arterial oxygen difference, erythrocyte sedimentation rate, and lactate dehydrogenase significantly increased by 0.32 mg/dL (P = .014), 7.8 Torr (P = .002), 1.4 mm/h (P = .012), and 5.4 U/mL (P = .0019), respectively, in bird-related CHP group compared to the control 24 hours after the inhalation challenge test. Furthermore, within 24 hours of the inhalation test, the mean forced vital capacity decreased by 2.3% in the bird-related CHP group compared with a decline of 0.05% in the control group (P = .035). Serum collected from seven bird-related CHP patients who underwent the inhalation challenge test and reacted to antigens with molecular weights of 37-75 KDa, and these molecular weights were consistent with egg albumin and globulin. CONCLUSION Since a mild response was observed after the inhalation challenge test using pigeon eggs, this test was an obvious candidate for diagnosing bird-related CHP.
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Affiliation(s)
- Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan.,Department of Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Yu Mikami
- Department of Respiratory Medicine, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Koji Okudela
- Department of Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Kenichi Ohashi
- Department of Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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490
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Affiliation(s)
- Marlies Wijsenbeek
- From the Center for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (M.W.); and the Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, and Claude Bernard University - both in Lyon, France (V.C.)
| | - Vincent Cottin
- From the Center for Interstitial Lung Diseases and Sarcoidosis, Department of Respiratory Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands (M.W.); and the Department of Respiratory Medicine, National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, and Claude Bernard University - both in Lyon, France (V.C.)
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491
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Costabel U, Miyazaki Y, Pardo A, Koschel D, Bonella F, Spagnolo P, Guzman J, Ryerson CJ, Selman M. Hypersensitivity pneumonitis. Nat Rev Dis Primers 2020; 6:65. [PMID: 32764620 DOI: 10.1038/s41572-020-0191-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 02/06/2023]
Abstract
Hypersensitivity pneumonitis (HP) is a complex syndrome caused by the inhalation of a variety of antigens in susceptible and sensitized individuals. These antigens are found in the environment, mostly derived from bird proteins and fungi. The prevalence and incidence of HP vary widely depending on the intensity of exposure, the geographical area and the local climate. Immunopathologically, HP is characterized by an exaggerated humoral and cellular immune response affecting the small airways and lung parenchyma. A complex interplay of genetic, host and environmental factors underlies the development and progression of HP. HP can be classified into acute, chronic non-fibrotic and chronic fibrotic forms. Acute HP results from intermittent, high-level exposure to the inducing antigen, usually within a few hours of exposure, whereas chronic HP mostly originates from long-term, low-level exposure (usually to birds or moulds in the home), is not easy to define in terms of time, and may occur within weeks, months or even years of exposure. Some patients with fibrotic HP may evolve to a progressive phenotype, even with complete exposure avoidance. Diagnosis is based on an accurate exposure history, clinical presentation, characteristic high-resolution CT findings, specific IgG antibodies to the offending antigen, bronchoalveolar lavage and pathological features. Complete antigen avoidance is the mainstay of treatment. The pharmacotherapy of chronic HP consists of immunosuppressive drugs such as corticosteroids, with antifibrotic therapy being a potential therapy for patients with progressive disease.
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Affiliation(s)
- Ulrich Costabel
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany.
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Dirk Koschel
- Department of Internal Medicine and Pneumology, Fachkrankenhaus Coswig, Centre for Pulmonary Diseases and Thoracic Surgery, Coswig, Germany.,Division of Pneumology, Medical Department I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Josune Guzman
- General and Experimental Pathology, Ruhr-University, Bochum, Germany
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
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