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Koschel D, Behr J, Berger M, Bonella F, Hamer O, Joest M, Jonigk D, Kreuter M, Leuschner G, Nowak D, Raulf M, Rehbock B, Schreiber J, Sitter H, Theegarten D, Costabel U. [Diagnosis and Treatment of Hypersensitivity Pneumonitis - S2k Guideline of the German Respiratory Society and the German Society for Allergology and Clinical Immunology]. Pneumologie 2024. [PMID: 39227017 DOI: 10.1055/a-2369-8458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease (ILD) in sensitized individuals caused by a large variety of inhaled antigens. The clinical form of acute HP is often misdiagnosed, while the chronic form, especially the chronic fibrotic HP, is difficult to differentiate from other fibrotic ILDs. The present guideline for the diagnosis and treatment of HP replaces the former German recommendations for the diagnosis of HP from 2007 and is amended explicitly by the issue of the chronic fibrotic form, as well as by treatment recommendations for the first time. The evidence was discussed by a multidisciplinary committee of experts. Then, recommendations were formulated for twelve questions on important issues of diagnosis and treatment strategies. Recently published national and international guidelines for ILDs and HP were considered. Detailed background information on HP is useful for a deeper insight into HP and the handling of the guideline.
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Affiliation(s)
- Dirk Koschel
- Abteilung Innere Medizin und Pneumologie, Fachkrankenhaus Coswig, Lungenzentrum, Coswig, Deutschland
- Bereich Pneumologie, Medizinische Klinik 1, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
- Ostdeutsches Lungenzentrum (ODLZ), Coswig/Dresden, Deutschland
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, LMU Klinikum der Universität München, München, Deutschland
- Deutsches Zentrum für Lungenforschung, Gießen, Deutschland
| | - Melanie Berger
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Köln
- Lehrstuhl für Pneumologie, Universität Witten/Herdecke, Fakultät für Gesundheit, Köln, Deutschland
| | - Francesco Bonella
- Zentrum für interstitielle und seltene Lungenerkrankungen, Ruhrlandklinik, Universitätsmedizin Essen, Essen, Deutschland
| | - Okka Hamer
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Abteilung für Radiologie, Lungenfachklinik Donaustauf, Donaustauf, Deutschland
| | - Marcus Joest
- Praxis für Pneumologie und Allergologie, Bonn, Deutschland
| | - Danny Jonigk
- Deutsches Zentrum für Lungenforschung, Gießen, Deutschland
- Institut für Pathologie, RWTH Aachen, Universität Aachen, Aachen, Deutschland
| | - Michael Kreuter
- Lungenzentrum Mainz, Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Marienhaus Klinikum Mainz und Klinik für Pneumologie, ZfT, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Gabriela Leuschner
- Medizinische Klinik und Poliklinik V, LMU Klinikum der Universität München, München, Deutschland
- Deutsches Zentrum für Lungenforschung, Gießen, Deutschland
| | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München, München, Deutschland
| | - Monika Raulf
- Abteilung Kompetenz-Zentrum Allergologie/Immunologie, Institut für Prävention und Arbeitsmedizin der DGUV, Institut der Ruhr-Universität Bochum (IPA), Bochum, Deutschland
| | - Beate Rehbock
- Privatpraxis für Diagnostische Radiologie und Begutachtung, Berlin, Deutschland
| | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Helmut Sitter
- Institut für Theoretische Chirurgie, Philipps-Universität Marburg, Marburg, Deutschland
| | - Dirk Theegarten
- Institut für Pathologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Ulrich Costabel
- Zentrum für interstitielle und seltene Lungenerkrankungen, Ruhrlandklinik, Universitätsmedizin Essen, Essen, Deutschland
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New Paradigms in Hypersensitivity Pneumonitis. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Aronson KI, O'Beirne R, Martinez FJ, Safford MM. Barriers to antigen detection and avoidance in chronic hypersensitivity pneumonitis in the United States. Respir Res 2021; 22:225. [PMID: 34376172 PMCID: PMC8353836 DOI: 10.1186/s12931-021-01817-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/01/2021] [Indexed: 01/18/2023] Open
Abstract
Background Chronic hypersensitivity pneumonitis (CHP) is an interstitial lung disease (ILD) caused by long term exposure to an offending antigen. Antigen avoidance is associated with improved outcomes. We are unable to identify the antigen source in approximately half of patients. When an antigen is successfully identified, patients have difficulty with avoidance. Methods We conducted three structured group discussions with US based ILD specialists utilizing the nominal group technique (NGT). Participants listed barriers to antigen detection and avoidance in CHP. Each participant ranked what they perceived to be the top three barriers in the list in terms of importance. The master list of barriers was consolidated across the three groups into themes that were prioritized based on receiving the highest rankings by participants. Results Twenty-five physicians participated; 56% had experience caring for CHP patients for ≥ 16 years. Sixty barriers to antigen detection were categorized into seven themes of which the top three were: 1. unclear significance of identified exposures; 2. gaps in clinical knowledge and testing capabilities; 3. there are many unknown and undiscovered antigens. Twenty-eight barriers to antigen avoidance were categorized into five themes of which the top three were: 1. patient limitations, financial barriers and lack of resources; 2. individual patient beliefs, emotions and attachments to the antigen source; and 3. gaps in clinical knowledge and testing capabilities. Conclusions This study uncovered challenges at the individual patient, organizational, and societal levels and ranked them in terms of level of importance. These findings provide information to guide development and validation of multidisciplinary support and interventions geared towards antigen identification and avoidance in CHP. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01817-6.
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Affiliation(s)
- Kerri I Aronson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine New York, 1305 York Avenue Y-1053, New York, NY, 10021, USA.
| | - Ronan O'Beirne
- Division of Continuing Medical Education, University of Alabama Birmingham, Alabama, USA
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine New York, 1305 York Avenue Y-1053, New York, NY, 10021, USA
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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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: 90] [Impact Index Per Article: 30.0] [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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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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Petnak T, Moua T. Exposure assessment in hypersensitivity pneumonitis: a comprehensive review and proposed screening questionnaire. ERJ Open Res 2020; 6:00230-2020. [PMID: 33015147 PMCID: PMC7520171 DOI: 10.1183/23120541.00230-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/10/2020] [Indexed: 12/24/2022] Open
Abstract
Hypersensitivity pneumonitis is an immune-mediated inflammatory lung disease characterised by the inhalation of environmental antigens leading to acute and chronic lung injury. Along with suggestive clinical and radiological findings, history and timing of suspected antigen exposure are important elements for diagnostic confidence. Unfortunately, many diagnoses remain tentative and based on vague and imprecise environmental or material exposure histories. To date, there has not been a comprehensive report highlighting the frequency and type of environmental exposure that might lead to or support a more systematic approach to antigen identification. We performed a comprehensive literature review to identify and classify causative antigens and their associated environmental contexts or source materials, with emphasis on the extent of the supportive literature for each exposure type. Eligible publications were those that reported unique inciting antigens and their respective environments or contexts. A clinical questionnaire was then proposed based on this review to better support diagnosis of hypersensitivity pneumonitis when antigen testing or other clinical and radiological variables are inconclusive or incomplete.
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Affiliation(s)
- Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Shiroshita A, Jin Z, Tanaka Y, Kataoka Y. Diagnostic accuracy and safety of inhalation challenge tests for bird fancier's lung-Systematic review and meta-analysis. Clin Exp Allergy 2020; 50:1007-1016. [PMID: 32557934 DOI: 10.1111/cea.13685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the diagnostic accuracy of inhalation challenge tests for bird fancier's lung and related adverse reactions. DESIGN We performed a systematic review and meta-analysis for the diagnostic test accuracy of inhalation challenge tests and a systematic review for adverse events of the tests. We evaluated the risk of bias and applicability of the included articles for diagnostic test accuracy with the modified Quality Assessment of Diagnostic Accuracy Studies-2 tool. We used hierarchical summary receiver operating characteristic (HSROC) curve analysis to evaluate the sensitivity and specificity of challenge tests and assessed subjective adverse reactions and steroid treatment use. Sensitivity was calculated by fixing specificity at 99% from the HSROC curve. DATA SOURCES We searched for articles evaluating the diagnostic accuracy of inhalation challenge tests or describing adverse reactions in Medline, Embase, the Cochrane Library, the International Clinical Trials Registry Platform, and Web of Science. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomized control trials, prospective or retrospective cohort studies, or case-control studies assessing the diagnostic test accuracy of inhalation challenge tests for bird fancier's lung. For adverse effects review, we included the same articles, and case series or case reports reporting adverse reactions of inhalation challenge tests. RESULTS In our review of 12 articles, the diagnostic accuracy of inhalation challenge tests was substantially high. Point estimate of sensitivity when calculated with a fixed specificity of 99% was 99%. Among 873 patients, 6 needed steroid treatment for adverse reactions; however, no death occurred due to acute exacerbation following a challenge test. CONCLUSIONS Inhalation challenges for bird fancier's lung could be accurate and safe diagnostic procedures and may be considered both as rule-in and rule-out tests in tertiary care centres. However, caution is required regarding overestimation of diagnostic yield due to risk of bias. Systematic review registration: University hospital Medical Information Network Clinical Trials Registry (UMIN000038799).
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Affiliation(s)
| | - Zhuan Jin
- Post Graduate Education Center, Kameda Medical Center, Kamogawa, Japan
| | - Yu Tanaka
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan.,Department of Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
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Hypersensitivity pneumonitis: Antigen diversity and disease implications. Pulmonology 2018; 25:97-108. [PMID: 30126802 DOI: 10.1016/j.pulmoe.2018.07.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is an immune-mediated syndrome triggered by inhalation of a wide variety of allergens, to which an individual has previously been sensitized. More than 200 agents responsible for the disease have already been identified; however, HP occurs only in a small number of individuals exposed to causal antigens. The present report provides an overview of the role of antigen role in HP, highlighting its diversity, research methods, and prevention strategies, as well as the impact on disease prognosis following elimination of antigen. HP is an underdiagnosed disease and, therefore, it is difficult to accurately estimate its incidence. Triggering antigens can be divided into six broad categories: bacteria, fungi, mycobacteria, animal and plant proteins, chemicals, and metals, represented by disease prototypes. The identification of causal antigen is a major challenge; it is impossible to obtain in about 30-60% of cases. The acute form of HP, with early detection and immediate eviction of causal antigen, tends to have an excellent prognosis. In the chronic form, partial recovery of disease is still possible; however, some cases tend to progress to fibrosis, even after removal from exposure. In conclusion, HP diagnosis should be based on a proactive search for potential antigen sources, although their identification is hampered by the lack of standardized methods of demonstrating the specific antigen sensitization. Antigen avoidance is a critical determinant in disease prognosis.
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Sema M, Miyazaki Y, Tsutsui T, Tomita M, Eishi Y, Inase N. Environmental levels of avian antigen are relevant to the progression of chronic hypersensitivity pneumonitis during antigen avoidance. IMMUNITY INFLAMMATION AND DISEASE 2017; 6:154-162. [PMID: 29168324 PMCID: PMC5818447 DOI: 10.1002/iid3.202] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/24/2017] [Accepted: 09/29/2017] [Indexed: 11/11/2022]
Abstract
Background In chronic hypersensitivity pneumonitis (chronic HP), antigen avoidance is critical for disease management; however, complete avoidance is difficult because of unrecognized exposure to antigens. Recently, we revealed that the amount of avian antigen (AAA) in household dust at the time of diagnosis predicted the progression of chronic bird‐related HP. The purpose of this study is to evaluate the relationship between the prognosis of chronic bird‐related HP and the AAA that remained in the environment during antigen avoidance. Methods First, we measured the AAA in household dust of 28 consecutive patients (22 with chronic bird‐related HP and 6 with acute bird‐related HP) and 12 healthy volunteers. Second, we measured the AAA and collected questionnaires on the environmental conditions of the homes of 53 patients with various lung diseases, including bird‐related HP, to investigate the environmental parameters related to a higher AAA. Finally, we prospectively recruited 14 consecutive patients with chronic bird‐related HP, measured the AAA periodically, and collected clinical data. Results The AAA was higher in patients with chronic bird‐related HP at the time of diagnosis compared to healthy volunteers and was highest in patients with acute bird‐related HP. Logistic regression analysis showed that birds frequenting a residence was the only significant factor for a higher AAA (odds ratio, 5.686; 95%CI, 1.263–25.59; P = 0.024). There was a correlation between the mean AAA and decline of vital capacity for 1 year (r = −0.55; 95%CI −0.84 to −0.01; P = 0.043). Conclusion Measurements of the AAA after diagnosis predict the progression of chronic bird‐related HP. Avian antigen can exist in the indoor environment regardless of antigen avoidance. The presence of avian antigen in the indoor environment can be attributed to wild birds found outdoors.
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Affiliation(s)
- Manabu Sema
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshiharu Tsutsui
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Makoto Tomita
- Department of Clinical Research Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yoshinobu Eishi
- Department of Human Pathology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Naohiko Inase
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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