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Lemieszek MK, Chilosi M, Golec M, Skórska C, Dinnyes A, Mashayekhi K, Vierlinger K, Huaux F, Wielscher M, Hofner M, Yakoub Y, Pastena C, Daniele I, Cholewa G, Sitkowska J, Lisowska W, Zwoliński J, Milanowski J, Mackiewicz B, Góra-Florek A, Ziesche R, Dutkiewicz J. Age influence on hypersensitivity pneumonitis induced in mice by exposure to Pantoea agglomerans. Inhal Toxicol 2014; 25:640-50. [PMID: 24044680 DOI: 10.3109/08958378.2013.827284] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Hypersensitivity pneumonitis (HP) represents the immunologically mediated lung disease induced by repeated inhalations of a wide variety of certain finely dispersed organic antigens. In susceptible subjects, these inhalations provoke a hypersensitivity reaction characterized by intense inflammation of the terminal bronchioles, the interstitium and the alveolar tree. The inflammation often organizes into granulomas and may progress to pulmonary fibrosis. Our previous work indicated that cell extract of gram-negative bacteria Pantoea agglomerans (SE-PA) causes, in young C57BL/6J mice, pulmonary changes that are very similar to the clinical manifestations of HP in men. The purpose of presented studies was to describe the response of mice immune system while exposed to SE-PA. Particular attention was paid to examine the age influence on SE-PA induced inflammation and fibrosis in lung tissue. We used 3- and 18-month-old C57BL/6J mice. Lung samples were collected from untreated mice and animals exposed to harmful agent for 7 and 28 days. HP development was monitored by histological and biochemical evaluation. Using ELISA tests, we examined concentration of pro- and anti-inflammatory cytokines in lung homogenates. Our study demonstrated again that SE-PA provokes in mice changes typical for the clinical picture of HP, and that successive stages of disease (acute, subacute and chronic) might be obtained by modulation of time exposure. Furthermore, we found that animals' age at the time of sensitization influences the nature of observed changes (cytokine expression pattern) and the final outcome (reaction intensity and scale of fibrosis).
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102
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Cox CW, Rose CS, Lynch DA. State of the Art: Imaging of Occupational Lung Disease. Radiology 2014; 270:681-96. [DOI: 10.1148/radiol.13121415] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fernández Pérez ER, Swigris JJ, Forssén AV, Tourin O, Solomon JJ, Huie TJ, Olson AL, Brown KK. Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. Chest 2014; 144:1644-1651. [PMID: 23828161 DOI: 10.1378/chest.12-2685] [Citation(s) in RCA: 234] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The cornerstone of hypersensitivity pneumonitis (HP) management is having patients avoid the inciting antigen (IA). Often, despite an exhaustive search, an IA cannot be found. The objective of this study was to examine whether identifying the IA impacts survival in patients with chronic HP. METHODS We used the Kaplan-Meier method to display, and the log-rank test to compare, survival curves of patients with well-characterized chronic HP stratified on identification of an IA exposure. A Cox proportional hazards (PH) model was used to identify independent predictors in time-to-death analysis. RESULTS Of 142 patients, 67 (47%) had an identified IA, and 75 (53%) had an unidentified IA. Compared with survivors, patients who died (n = 80, 56%) were older, more likely to have smoked, had lower total lung capacity % predicted and FVC % predicted, had higher severity of dyspnea, were more likely to have pulmonary fibrosis, and were less likely to have an identifiable IA. In a Cox PH model, the inability to identify an IA (hazard ratio [HR], 1.76; 95% CI, 1.01-3.07), older age (HR, 1.04; 95% CI, 1.01-1.07), the presences of pulmonary fibrosis (HR, 2.43; 95% CI, 1.36-4.35), a lower FVC% (HR, 1.36; 95% CI, 1.10-1.68), and a history of smoking (HR, 2.01; 95% C1, 1.15-3.50) were independent predictors of shorter survival. After adjusting for mean age, presence of fibrosis, mean FVC%, mean diffusing capacity of the lung for carbon monoxide (%), and history of smoking, survival was longer for patients with an identified IA exposure than those with an unidentified IA exposure (median, 8.75 years vs 4.88 years; P = .047). CONCLUSIONS Among patients with chronic HP, when adjusting for a number of potentially influential predictors, including the presence of fibrosis, the inability to identify an IA was independently associated with shortened survival.
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Affiliation(s)
- Evans R Fernández Pérez
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO.
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Anna V Forssén
- Division of Pulmonary and Critical Care Medicine, and the Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO
| | | | - Joshua J Solomon
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Amy L Olson
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
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Travis WD, Costabel U, Hansell DM, King TE, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2013; 188:733-48. [PMID: 24032382 DOI: 10.1164/rccm.201308-1483st] [Citation(s) in RCA: 2622] [Impact Index Per Article: 238.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In 2002 the American Thoracic Society/European Respiratory Society (ATS/ERS) classification of idiopathic interstitial pneumonias (IIPs) defined seven specific entities, and provided standardized terminology and diagnostic criteria. In addition, the historical "gold standard" of histologic diagnosis was replaced by a multidisciplinary approach. Since 2002 many publications have provided new information about IIPs. PURPOSE The objective of this statement is to update the 2002 ATS/ERS classification of IIPs. METHODS An international multidisciplinary panel was formed and developed key questions that were addressed through a review of the literature published between 2000 and 2011. RESULTS Substantial progress has been made in IIPs since the previous classification. Nonspecific interstitial pneumonia is now better defined. Respiratory bronchiolitis-interstitial lung disease is now commonly diagnosed without surgical biopsy. The clinical course of idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia is recognized to be heterogeneous. Acute exacerbation of IIPs is now well defined. A substantial percentage of patients with IIP are difficult to classify, often due to mixed patterns of lung injury. A classification based on observed disease behavior is proposed for patients who are difficult to classify or for entities with heterogeneity in clinical course. A group of rare entities, including pleuroparenchymal fibroelastosis and rare histologic patterns, is introduced. The rapidly evolving field of molecular markers is reviewed with the intent of promoting additional investigations that may help in determining diagnosis, and potentially prognosis and treatment. CONCLUSIONS This update is a supplement to the previous 2002 IIP classification document. It outlines advances in the past decade and potential areas for future investigation.
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Abstract
Asthma is a heterogeneous syndrome of cough, wheeze, dyspnea, and chest tightness. However, in a subset of patients, these symptoms may indicate a different underlying disease process with variable responsiveness to classic asthma therapies. Disease may progress while practitioners attempt conventional asthma therapy. Additionally, some types of asthma may require alternative approaches to relieve symptoms successfully. This article describes the differential diagnosis of asthma and discusses some of the more common asthma variants and asthma mimickers.
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Affiliation(s)
- Patrick R Aguilar
- Department of Internal Medicine, Washington University, 660 Euclid, PO Box 8052, St. Louis, MO 63110, USA
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106
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Abstract
PURPOSE OF REVIEW The diagnosis of hypersensitivity pneumonitis remains a dilemma because of the absence of any characteristic features able to distinguish it from other interstitial lung diseases. We analyze the current role of the specific inhalation challenge (SIC) in the diagnosis of this entity. RECENT FINDINGS Few descriptions of the use of SIC for the diagnosis of hypersensitivity pneumonitis have been published in recent years. In fact, hypersensitivity pneumonitis is still diagnosed on the basis of clinical criteria, as there is no agreement on the diagnostic utility of SIC. Two major reviews carried out in the past year have concluded that this test is not standardized and is usually unnecessary; however, a third study found that the test can indeed recreate the symptoms and functional abnormalities in the laboratory, and may therefore be of considerable use in the diagnosis of hypersensitivity pneumonitis. SUMMARY Hypersensitivity pneumonitis remains a diagnostic challenge. Given that the main cause of the disease is sensitization and hyper-responsiveness to specific antigens in susceptible individuals, SIC is an obvious candidate as the gold standard for diagnosis of this entity. The present review analyzes the reasons for the test's limited use, assesses its diagnostic utility, and proposes a basis for its standardization.
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107
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Okamoto T, Miyazaki Y, Ogura T, Chida K, Kohno N, Kohno S, Taniguchi H, Akagawa S, Mochizuki Y, Yamauchi K, Takahashi H, Johkoh T, Homma S, Kishi K, Ikushima S, Konno S, Mishima M, Ohta K, Nishioka Y, Yoshimura N, Munakata M, Watanabe K, Miyashita Y, Inase N. Nationwide epidemiological survey of chronic hypersensitivity pneumonitis in Japan. Respir Investig 2013; 51:191-9. [PMID: 23978646 DOI: 10.1016/j.resinv.2013.03.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 1999, a Japanese epidemiological survey of chronic hypersensitivity pneumonitis (HP) showed that summer-type HP was the most prevalent variant of the disease. The number of reported cases of chronic HP has recently been increasing, and the clinical features of the disease seem to have changed. We conducted another nationwide epidemiological survey of chronic HP in Japan to determine better estimates of the frequency and clinical features of the disease. METHODS A questionnaire was sent to qualified hospitals throughout Japan, and data on cases of chronic HP diagnosed between 2000 and 2009 were collected. RESULTS In total, 222 cases of chronic HP from 22 hospitals were studied. Disease subtypes included bird-related HP (n=134), summer-type HP (n=33), home-related HP (n=25), farmer's lung (n=4), isocyanate-induced HP (n=3), and other types (n=23). The median proportion of lymphocytes in bronchoalveolar lavage fluid was high (24.5%). The primary findings of computed tomography of the chest were ground-glass attenuation and interlobular septal thickening. Centrilobular fibrosis was the major pathological finding on examination of surgical lung biopsy specimens from 93 patients. The median survival time was 83 months. CONCLUSIONS The proportion of bird-related HP was higher than that in the previous epidemiological survey, and the proportions of isocyanate-induced HP and farmer's lung were lower. A crucial step in diagnosing chronic HP is to thoroughly explore the possibility of antigen exposure.
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Affiliation(s)
- Tsukasa Okamoto
- Department of Integrated Pulmonology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan.
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Dalphin JC, Didier A. [Environmental causes of the distal airways disease. Hypersensitivity pneumonitis and rare causes]. Rev Mal Respir 2013; 30:669-81. [PMID: 24182653 DOI: 10.1016/j.rmr.2013.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 02/07/2013] [Indexed: 11/16/2022]
Abstract
Hypersensitivity pneumonitis is one of the most frequent causes of distal airways disease. It is associated with inflammation of the bronchioles, predominantly by lymphocytic infiltrates, and with granuloma formation causing bronchial obstruction. This inflammation explains the clinical manifestations and the airways obstruction seen on pulmonary function tests, most often in the distal airways but proximal in almost 20%. CT scan abnormalities reflect the lymphocytic infiltrates and air trapping and, in some cases, the presence of emphysema. Bronchiolitis induced by chronic inhalation of mineral particles or acute inhalation of toxic gases (such as NO2) are other examples of small airways damage due to environmental exposure. The pathophysiological mechanisms are different and bronchiolar damage is either exclusive or predominant. Bronchiolitis induced by tobacco smoke exposure, usually classified as interstitial pneumonitis, is easily diagnosed thanks to broncho-alveolar lavage. Its prognosis is linked to the other consequences of tobacco smoke exposure including respiratory insufficiency. Finally, the complex lung exposure observed in some rare cases (such as the World Trade Center fire or during wars) may lead to a less characteristic pattern of small airways disease.
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Affiliation(s)
- J-C Dalphin
- UMR CNRS 6249 « chrono-environnement », service de pneumologie, hôpital Jean-Minjoz, CHU, 2, boulevard Alexandre-Fleming, 25030 Besançon cedex, France.
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109
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Neumonitis por hipersensibilidad a isocianatos. Características clínico-radiológicas y de función pulmonar. Arch Bronconeumol 2013; 49:169-72. [DOI: 10.1016/j.arbres.2012.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 08/27/2012] [Accepted: 08/30/2012] [Indexed: 11/19/2022]
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Uranga A, Sánchez-Ortiz M, Morell F, Cruz MJ, Muñoz X. Hypersensitivity Pneumonitis Due to Isocyanates: Lung Function, Clinical and Radiological Characteristics. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.arbr.2012.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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111
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Abstract
Many home-based and leisure activities can generate hazardous respirable exposures. Routine domestic activities and a variety of hobbies, avocations, and leisure pursuits have been associated with a spectrum of respiratory tract disorders. Indoor environments present a special risk for high-intensity exposures and adverse health effects. There are important knowledge gaps regarding the prevalence of specific health hazards within and across communities, exposure-response effects, population and individual susceptibilities, best management strategies, the adverse health effects of mixed exposures, and long-term clinical outcomes following exposures. The home environment presents special health risks that should be part of the health assessment.
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Affiliation(s)
- Lawrence A Ho
- Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, Division of Pulmonary and Critical Care Medicine, 3801 Miranda Avenue, MC 111P, Palo Alto, CA 94304, USA.
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Cha SI, Ryerson CJ, Lee JS, Kukreja J, Barry SS, Jones KD, Elicker BM, Kim DS, Papa FR, Collard HR, Wolters PJ. Cleaved cytokeratin-18 is a mechanistically informative biomarker in idiopathic pulmonary fibrosis. Respir Res 2012; 13:105. [PMID: 23167970 PMCID: PMC3547729 DOI: 10.1186/1465-9921-13-105] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 11/16/2012] [Indexed: 11/19/2022] Open
Abstract
Background Stress of the endoplasmic reticulum (ER) leading to activation of the unfolded protein response (UPR) and alveolar epithelial cell (AEC) apoptosis may play a role in the pathogenesis of idiopathic pulmonary fibrosis (IPF). Our objectives were to determine whether circulating caspase-cleaved cytokeratin-18 (cCK-18) is a marker of AEC apoptosis in IPF, define the relationship of cCK-18 with activation of the UPR, and assess its utility as a diagnostic biomarker. Methods IPF and normal lung tissues were stained with the antibody (M30) that specifically binds cCK-18. The relationship between markers of the UPR and cCK-18 was determined in AECs exposed in vitro to thapsigargin to induce ER stress. cCK-18 was measured in serum from subjects with IPF, hypersensitivity pneumonitis (HP), nonspecific interstitial pneumonia (NSIP), and control subjects. Results cCK-18 immunoreactivity was present in AECs of IPF lung, but not in control subjects. Markers of the UPR (phosphorylated IRE-1α and spliced XBP-1) were more highly expressed in IPF type II AECs than in normal type II AECs. Phosphorylated IRE-1α and cCK-18 increased following thapsigargin-induced ER stress. Serum cCK-18 level distinguished IPF from diseased and control subjects. Serum cCK-18 was not associated with disease severity or outcome. Conclusions cCK-18 may be a marker of AEC apoptosis and UPR activation in patients with IPF. Circulating levels of cCK-18 are increased in patients with IPF and cCK-18 may be a useful diagnostic biomarker.
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Affiliation(s)
- Seung-Ick Cha
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA 94143-0111, USA
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113
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Recurrent Cough, Fever, and Leukocytosis After Hot Tub Exposure. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2012. [DOI: 10.1097/ipc.0b013e318255d5a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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114
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Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest 2012; 142:208-217. [PMID: 22796841 DOI: 10.1378/chest.11-2479] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an allergen to which the subject has been previously sensitized. The diagnosis of HP most often relies on an array of nonspecific clinical symptoms and signs developed in an appropriate setting, with the demonstration of interstitial markings on chest radiographs, serum precipitating antibodies against offending antigens, a lymphocytic alveolitis on BAL, and/or a granulomatous reaction on lung biopsies. The current classification of HP in acute, subacute, and chronic phases is now challenged, and a set of clinical predictors has been proposed. Nonspecific interstitial pneumonitis, usual interstitial pneumonia, and bronchiolitis obliterans organizing pneumonia may be the sole histologic expression of the disease. Presumably, like in idiopathic interstitial pneumonia, acute exacerbations of chronic HP may occur without further exposure to the offending antigen. New offending antigens, such as mycobacteria causing hot tub lung and metalworking fluid HP, have recently been identified and have stimulated further research in HP.
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Affiliation(s)
- Yves Lacasse
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada.
| | - Mélissa Girard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
| | - Yvon Cormier
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
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115
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Herbst JB, Myers JL. Hypersensitivity pneumonia: role of surgical lung biopsy. Arch Pathol Lab Med 2012; 136:889-95. [PMID: 22849736 DOI: 10.5858/arpa.2012-0201-cr] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung biopsy often plays a key role in identifying patients with hypersensitivity pneumonia, especially in the absence of a typical history. A 69-year-old woman with a 2-year history of unexplained dyspnea on exertion underwent surgical lung biopsy for diagnosis of diffuse lung disease thought to represent idiopathic pulmonary fibrosis. Her biopsy showed honeycomb change and fibroblast foci suggestive of usual interstitial pneumonia, but also showed areas of cellular interstitial pneumonia with chronic bronchiolitis and a pattern of granulomatous inflammation typical of hypersensitivity pneumonia. The classic features of hypersensitivity pneumonia in surgical lung biopsy are emphasized, including a bronchiolocentric cellular interstitial pneumonia, chronic bronchiolitis, and poorly formed nonnecrotizing granulomas. As illustrated in our patient, sometimes subtle histologic clues are key in separating hypersensitivity pneumonia from usual interstitial pneumonia and other forms of idiopathic interstitial pneumonia. Making the distinction is important given differences in treatment strategies and natural history.
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Affiliation(s)
- Jonathon B Herbst
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109-5054, USA.
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116
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Peña Irún Á, García Pérez M, González Santamaría A. Alveolitis alérgica extrínseca: forma de presentación inicial como fiebre de origen desconocido. Semergen 2012; 38:456-9. [DOI: 10.1016/j.semerg.2011.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 10/13/2011] [Accepted: 10/19/2011] [Indexed: 11/16/2022]
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119
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Takemura T, Akashi T, Kamiya H, Ikushima S, Ando T, Oritsu M, Sawahata M, Ogura T. Pathological differentiation of chronic hypersensitivity pneumonitis from idiopathic pulmonary fibrosis/usual interstitial pneumonia. Histopathology 2012; 61:1026-35. [PMID: 22882269 DOI: 10.1111/j.1365-2559.2012.04322.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate the histological characteristics differentiating chronic hypersensitivity pneumonitis (chronic HP) with a usual interstitial pneumonia (UIP)-like pattern from idiopathic pulmonary fibrosis (IPF)/UIP. METHODS AND RESULTS Surgical lung biopsy specimens from 22 patients with chronic HP diagnosed as having a UIP-like pattern upon histological examination and 13 patients with IPF/UIP were examined and the incidences of bronchiolitis, perilobular fibrosis, centrilobular fibrosis, bridging fibrosis, organizing pneumonia, fibroblastic foci, honeycombing, granulomas, giant cells, lymphocytic alveolitis and lymphoid follicles were compared. Bronchiolitis, centrilobular fibrosis, bridging fibrosis, organizing pneumonia, granulomas, giant cells and lymphocytic alveolitis were significantly more frequent among patients with chronic HP than among patients with IPF (all P<0.01). CONCLUSIONS Centrilobular fibrosis, bridging fibrosis and organizing pneumonia, in addition to bronchiolitis, granulomas and giant cells, are characteristic features of chronic HP with a UIP-like pattern. These features are therefore important in differentiating chronic HP from IPF/UIP, as management strategies differ for the two disorders.
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Affiliation(s)
- Tamiko Takemura
- Department of Pathology, Japanese Red Cross Medical Center, Tokyo, Japan.
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120
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Distinct histopathology of acute onset or abrupt exacerbation of hypersensitivity pneumonitis. Hum Pathol 2012; 43:660-8. [DOI: 10.1016/j.humpath.2011.06.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 05/30/2011] [Accepted: 06/01/2011] [Indexed: 11/19/2022]
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121
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Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol 2012; 25 Suppl 1:S58-67. [PMID: 22214971 DOI: 10.1038/modpathol.2011.152] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hypersensitivity pneumonia is a form of diffuse interstitial lung disease resulting from sensitization to an inhaled antigen. Clinical and radiological features are relatively nonspecific, overlapping significantly with other forms of diffuse interstitial lung disease. Establishing the diagnosis in the absence of lung biopsy is challenging and is heavily dependent on being able to identify a specific antigenic exposure. Lung biopsy is especially important in diagnosing hypersensitivity pneumonia in patients for whom no incriminating exposure has been elucidated. Surgical lung biopsies show a classical combination of findings in the majority of patients, which include an airway-centered, variably cellular chronic interstitial pneumonia, a lymphocyte-rich chronic bronchiolitis, and poorly formed non-necrotizing granulomas distributed mainly within the peribronchiolar interstitium. The bronchiolitis may include variable degrees of peribronchiolar fibrosis and hyperplasia of the bronchiolar epithelium ('peribronchiolar metaplasia'), a characteristic but a nonspecific finding. In some patients, granulomatous inflammation may be lacking, resulting in a histological appearance resembling nonspecific interstitial pneumonia. Late-stage fibrotic hypersensitivity pneumonia results in clinical, radiological, and histological findings that closely mimic usual interstitial pneumonia. The presence of established collagen fibrosis, especially when associated with architectural distortion in the form of honeycomb change, is associated with shorter survivals.
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Affiliation(s)
- Jeffrey L Myers
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109-5054, USA.
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122
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Gulati M. Diagnostic assessment of patients with interstitial lung disease. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2011; 20:120-7. [PMID: 21509417 DOI: 10.4104/pcrj.2010.00079] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The diagnosis of interstitial lung disease (ILD) is frequently delayed because clinical clues are neglected and respiratory symptoms are ascribed to more common pulmonary diagnoses such as chronic obstructive pulmonary disease (COPD) in the primary care setting. While ILD cases ultimately require referral to a pulmonologist, general practitioners can play a crucial role in recognising the need for, and initiating, a diagnostic evaluation. An initial assessment hinges upon a structured history and physical examination with careful attention paid to occupational, environmental and drug exposures as well as a history of symptoms suggesting connective tissue disease. Ultimately a surgical lung biopsy may be indicated, but high resolution computed tomography (HRCT) chest scans are essential to the diagnostic workup since each ILD form is characterised by a specific pattern of abnormalities.
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Affiliation(s)
- Mridu Gulati
- Department of Pulmonary & Critical Care, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
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123
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Svensson E, Akerstrom M, Andersson E. Quantitative analyses of mycobacteria in water: Adapting methods in clinical laboratories. J Microbiol Methods 2011; 87:114-5. [DOI: 10.1016/j.mimet.2011.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/05/2011] [Accepted: 07/06/2011] [Indexed: 12/27/2022]
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Hankwitz PE, Cervia JS, Thomas CF, Fink JN, Marras T, Tomic R. Nontuberculous mycobacterial hypersensitivity pneumonitis related to a home shower: treatment and secondary prevention. BMJ Case Rep 2011; 2011:bcr.06.2011.4360. [PMID: 22689847 DOI: 10.1136/bcr.06.2011.4360] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old physician with increasing dyspnoea and hypoxaemia had a high-resolution CT scan of the chest, which disclosed diffuse pulmonary ground glass opacities, more pronounced in the upper lobes with minimal mediastinal lymphadenopathy. Transbronchial biopsy of the right middle and lower lobes was performed, demonstrating varying degrees of well circumscribed organising granulomatous pneumonitis thought to be most consistent with hypersensitivity to nontuberculous mycobacteria. Cultures of water obtained from the patient's home shower were positive for Mycobacterium avium complex. The patient began substituting baths for showers, experiencing some gradual improvement of his symptoms. Subsequently, he installed point-of-use 0.2 micron membrane filters on his shower, and resumed regular showering after installation with continued symptomatic improvement. CT scans at 3 and 18 months revealed improvement and resolution, respectively. Four years later, he continues to shower in filtered home shower water and remains clinically well.
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Affiliation(s)
- Paul E Hankwitz
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Otera H, Tada K, Sakurai T, Hashimoto K, Ikeda A. Hypersensitivity Pneumonitis Associated with Inhalation of Catechin-Rich Green Tea Extracts. Respiration 2011; 82:388-92. [DOI: 10.1159/000324450] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 01/17/2011] [Indexed: 11/19/2022] Open
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126
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Hirschmann JV, Pipavath SNJ, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics 2010; 29:1921-38. [PMID: 19926754 DOI: 10.1148/rg.297095707] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most cases of hypersensitivity pneumonitis develop only after many years of inhaling allergens, which include microbes, animal or plant proteins, and certain chemicals that form haptens. The initial clinical presentation is either episodes of acute illness with dyspnea and prominent constitutional symptoms, such as fever, or an insidious onset of dyspnea, coughing, and weight loss, sometimes with superimposed acute episodes. The histopathologic process consists of chronic inflammation of the bronchi and peribronchiolar tissue, often with poorly defined granulomas and giant cells in the interstitium or alveoli. Fibrosis and emphysema may develop. The radiologic findings include diffuse ground-glass opacification, centrilobular ground-glass opacities, air trapping, fibrosis, lung cysts, and emphysema. The histologic and radiologic features in some cases may resemble those of usual interstitial pneumonia or nonspecific interstitial pneumonia. The diagnosis usually rests on a variable combination of findings from history, serology, radiography, lung biopsy, and bronchoalveolar lavage, which characteristically reveals a lymphocyte content of more than 30%, often with an increased CD4-to-CD8 ratio of T cells. Treatment includes avoiding the allergen, if possible, and, in severe cases, systemic corticosteroids. The long-term prognosis is usually good, but some patients develop severe respiratory insufficiency, and a few die of the disease.
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Kim M, Cha SI, Shin KM, Yoon GS, Bae J, Yoon WK, Lee SY, Kim CH, Park JY, Jung TH. A Case of Hot Tub Lung. Tuberc Respir Dis (Seoul) 2010. [DOI: 10.4046/trd.2010.68.4.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Min Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung-Ick Cha
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung-Min Shin
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ghil-Suk Yoon
- Department of Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Junghyun Bae
- Department of Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Won-Kyung Yoon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Shin-Yup Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chang-Ho Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae-Yong Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Hoon Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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128
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Borderías L, Morell F, Vera J, Briz H, Muñoz X, Cruz MJ. [Starling-induced hypersensitivity pneumonitis: minimal but persistent antigen exposure]. Arch Bronconeumol 2009; 46:607-9. [PMID: 20044195 DOI: 10.1016/j.arbres.2009.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 10/01/2009] [Accepted: 10/10/2009] [Indexed: 11/27/2022]
Abstract
A 51-year old woman developed hypersensitivity pneumonitis (HP) after inhaling the excrement of starlings that populated a park adjacent to her home. The clinical symptoms consisted of a non-productive cough and grade II dyspnea and radiological interstitial micronodular involvement. The respiratory function tests showed a restrictive pattern with desaturation on effort and a biopsy using videothorascopy was highly suggestive of HP. After taking a very detailed clinical history the patient mentioned an increase in cough when she crossed a park near her home, where a high population of starlings lived in its trees. Specific antigen extracts were prepared and skin tests were performed, precipitins measured, and bronchial provocation tests specific to this antigen were all positive. This observation identified a species of bird capable of causing the disease and shows a lung disease secondary to the exposure of a not very large but persistent antigen load.
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Affiliation(s)
- Luis Borderías
- Servicio de Neumología, Hospital San Jorge, Huesca, Spain
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129
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Wang P, Xu ZJ, Xu WB, Shi JH, Tian XL, Feng RE, Zhu YJ. Clinical Features and Prognosis in 21 Patients with Extrinsic Allergic Alveolitis. ACTA ACUST UNITED AC 2009; 24:202-7. [DOI: 10.1016/s1001-9294(10)60002-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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130
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Ohshimo S, Guzman J, Bonella F, Costabel U. To BAL or Not to BAL: Is This a Problem in Diagnosing IPF? Am J Respir Crit Care Med 2009. [DOI: 10.1164/ajrccm.180.4.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Ulrich Costabel
- University of Duisburg-Essen
and
Ruhrlandklinik
Essen, Germany
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131
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Chiba S, Okada S, Suzuki Y, Watanuki Z, Mitsuishi Y, Igusa R, Sekii T, Uchiyama B. Cladosporium species-related hypersensitivity pneumonitis in household environments. Intern Med 2009; 48:363-7. [PMID: 19252363 DOI: 10.2169/internalmedicine.48.1811] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Home-related chronic hypersensitivity pneumonitis (HP) is sometimes difficult to discriminate because patients do not have an obvious history of antigen exposure. We report two HP cases which developed in an office area and in a home: a 47-year-old woman with acute-onset HP and a 72-year-old woman with chronic HP followed up as idiopathic pulmonary fibrosis following isolation of Cladosporium cladosporioides and Cladosporium herbarum, respectively. Lymphocyte stimulating activity and antibody titer to these fungi were increased in these patients. Since Cladosporium spp. and several other fungi are present ubiquitously in our living environment, it is difficult to eliminate the antigen from the patients' environment to control the disease. Cladosporium spp. can be key antigens in inducing chronic HP in the home environment.
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132
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Abstract
PURPOSE OF REVIEW Hypersensitity pneumonitis, caused by inhalation of various antigens, is characterized by interstitial mononuclear cell infiltration, nonnecrotizing granulomas, cellular bronchiolitis, and fibrosis. The pathological picture of chronic hypersensitivity pneumonitis is, however, complicated; it is sometimes difficult to differentiate chronic hypersensitivity pneumonitis from idiopathic pulmonary fibrosis/usual interstitial pneumonia, nonspecific interstitial pneumonia, and connective-tissue-related lung disease. The clinical, radiological, and pathological features of chronic hypersensitivity pneumonitis have recently been described. This study reviews the previously reported information and provides new insights into the pathological features of chronic hypersensitivity pneumonitis. RECENT FINDINGS The pathological features of chronic hypersensitivity pneumonitis comprise overlapping usual interstitial pneumonia-like pattern with subpleural patchy fibrosis, alternating normal alveoli and fibroblastic foci, a nonspecific interstitial pneumonia-like pattern, and centrilobular fibrosis. In contrast to pathological features of acute and subacute hypersensitivity pneumonitis, epithelioid cell granulomas are sparse or absent, but giant cells are seen in the interstitium. Bridging fibrosis between peribronchiolar area and perilobular areas is an outstanding feature of chronic hypersensitivity pneumonitis. Autopsy cases of chronic hypersensitivity pneumonitis have demonstrated not only upper lobe contraction but also lower lobe contraction, mimicking usual interstitial pneumonia pattern and diffuse alveolar damage. SUMMARY The present review focuses on the pathological features of chronic hypersensitivity pneumonitis and presents that centrilobular fibrosis and bridging fibrosis are the important hallmarks of chronic hypersensitivity pneumonitis, even with a usual interstitial pneumonia-like pattern.
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133
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Reply. J Allergy Clin Immunol 2008. [DOI: 10.1016/j.jaci.2008.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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134
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Jacobs RL. Hypersensitivity pneumonitis may be home-induced by common domestic mold spores. J Allergy Clin Immunol 2008; 122:428; author reply 428-9. [DOI: 10.1016/j.jaci.2008.05.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 05/23/2008] [Indexed: 11/26/2022]
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135
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Teirstein AS. Help for the diagnosis of some, but not all cases of Mycobacterium avium-complex pulmonary disease. Am J Respir Crit Care Med 2008; 177:677-9. [PMID: 18362117 DOI: 10.1164/rccm.200801-018ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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