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Abstract
PURPOSE OF REVIEW Establishing a diagnosis of hypersensitivity pneumonitis (HP) and distinguishing it from other forms of interstitial lung diseases represents a common challenge in clinical practice. This review summarizes the latest literature and guidelines on HP while integrating some real-life conundrums. RECENT FINDINGS Advances in the understanding of the pathobiology of fibrotic HP and other progressive pulmonary fibrosis have changed how we approach the diagnosis and treatment of interstitial lung disease. Classifications now embrace distinguishing two clinical phenotypes: nonfibrotic and fibrotic HP because of distinct disease behavior and prognosis implications. International guidelines on HP were recently published and proposed a framework and algorithm to guide the diagnostic process. SUMMARY The diagnosis of HP relies on the integration of multiples domains: clinical assessment of exposure, imaging, bronchoalveolar lavage lymphocytosis and histopathological findings. These features are reviewed in multidisciplinary discussion and lead to an estimation of the degree of confidence for HP diagnosis. Further research is warranted to improve knowledge on the pathophysiology of HP and ultimately improve its diagnostic approaches.
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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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Sterclova M, Kremlackova V, Mottlova V, Bruzova M, Sojka P, Vasakova M. Quantitative assessment of specific serum IgGs may verify source of environmental exposure in extrinsic allergic alveolitis (EAA). COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1894688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Martina Sterclova
- Department of Respiratory Medicine of 1st Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Veronika Kremlackova
- Department of Respiratory Medicine of 1st Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Veronika Mottlova
- Department of Biochemistry, Thomayer Hospital, Prague, Czech Republic
| | - Magdalena Bruzova
- Department of Pathology and Molecular Medicine of 3rd Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Pavel Sojka
- Department of Immunology, Thomayer Hospital, Prague, Czech Republic
| | - Martina Vasakova
- Department of Respiratory Medicine, Thomayer Hospital, Prague, Czech Republic
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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: 40] [Impact Index Per Article: 10.0] [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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Page L, Weis P, Müller T, Dittrich M, Lazariotou M, Dragan M, Waaga-Gasser AM, Helm J, Dandekar T, Einsele H, Löffler J, Ullmann AJ, Wurster S. Evaluation of Aspergillus and Mucorales specific T-cells and peripheral blood mononuclear cell cytokine signatures as biomarkers of environmental mold exposure. Int J Med Microbiol 2018; 308:1018-1026. [PMID: 30201279 DOI: 10.1016/j.ijmm.2018.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/10/2018] [Accepted: 09/02/2018] [Indexed: 12/20/2022] Open
Abstract
Mold specific T-cells have been described as a supportive biomarker to monitor invasive mycoses and mold exposure. This study comparatively evaluated frequencies and cytokine profiles of Aspergillus fumigatus and Mucorales reactive T-cells depending on environmental mold exposure. Peripheral blood mononuclear cells (PBMCs) obtained from 35 healthy donors were stimulated with mycelial lysates of A. fumigatus and three human pathogenic Mucorales species. CD154+ specific T-cells were quantified by flow cytometry. In a second cohort of 20 additional donors, flow cytometry was complemented by 13-plex cytokine assays. Mold exposure of the subjects was determined using a previously established questionnaire. Highly exposed subjects exhibited significantly greater CD154+A. fumigatus and Mucorales specific naïve and memory T-helper cell frequencies. Significant correlation (r = 0.48 - 0.79) was found between A. fumigatus and Mucorales specific T-cell numbers. Logistic regression analyses revealed that combined analysis of mold specific T-cell frequencies and selected cytokine markers (A. fumigatus: IL-5 and TNF-α, R. arrhizus: IL-17A and IL-13) significantly improves classification performance, resulting in 75-90 % predictive power using 10-fold cross-validation. In conclusion, mold specific T-cell frequencies and their cytokine signatures offer promising potential in the assessment of environmental mold exposure. The cytokines identified in this pilot study should be validated in the clinical setting, e. g. in patients with hypersensitivity pneumonitis.
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Affiliation(s)
- Lukas Page
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Philipp Weis
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Tobias Müller
- University of Wuerzburg, Biocenter, Department of Bioinformatics, Am Hubland, 97074 Wuerzburg, Germany
| | - Marcus Dittrich
- University of Wuerzburg, Biocenter, Department of Bioinformatics, Am Hubland, 97074 Wuerzburg, Germany
| | - Maria Lazariotou
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Mariola Dragan
- University Hospital of Wuerzburg, Department of Surgery I, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany
| | - Ana Maria Waaga-Gasser
- University Hospital of Wuerzburg, Department of Surgery I, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany
| | - Johanna Helm
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Thomas Dandekar
- University of Wuerzburg, Biocenter, Department of Bioinformatics, Am Hubland, 97074 Wuerzburg, Germany
| | - Hermann Einsele
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Jürgen Löffler
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Andrew J Ullmann
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Sebastian Wurster
- University Hospital of Wuerzburg, Department of Internal Medicine II, Division of Infectious Diseases, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany; The University of Texas MD Anderson Cancer Center, Department of Infectious Diseases, 1515 Holcombe Boulevard, Houston, Texas, 77030, United States.
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Wurster S, Weis P, Page L, Helm J, Lazariotou M, Einsele H, Ullmann AJ. Intra- and inter-individual variability of Aspergillus fumigatus reactive T-cell frequencies in healthy volunteers in dependency of mould exposure in residential and working environment. Mycoses 2017; 60:668-675. [PMID: 28786508 DOI: 10.1111/myc.12643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 01/08/2023]
Abstract
Invasive aspergillosis remains a deadly disease in immunocompromised patients, whereas the combination of an exaggerated immune response and continuous exposure lead to various hyperinflammatory diseases. This pilot study aimed to gain an overview of the intra- and inter-individual variability in Aspergillus fumigatus reactive T-helper cells in healthy adults and the correlation with environmental mould exposure. In this flow cytometric study, the frequencies of CD154+ A. fumigatus reactive T cells were evaluated in 70 healthy volunteers. All subjects completed a standardised questionnaire addressing their mould exposure. Subjects with intensive mould exposure in their professional or residential surrounding demonstrated considerably higher mean frequencies of A. fumigatus reactive T-helper and T-memory cells. Comparative evaluation of multiple measurements over time demonstrated relatively conserved reactive T-cell frequencies in the absence of major changes to the exposure profile, whereas those frequently exposed in professional environment or with changes to their risk score demonstrated a marked dependency of antigen reactive T-cell frequencies on recent mould exposure. This pilot study was the first to provide data on the intra-individual variability in A. fumigatus reactive T-cell frequencies and its linkage to mould encounter. Fungus reactive T cells are to be considered a valued tool for the assessment of environmental mould exposure.
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Affiliation(s)
- Sebastian Wurster
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Philipp Weis
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Lukas Page
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Johanna Helm
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Maria Lazariotou
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Andrew J Ullmann
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital of Wuerzburg, Wuerzburg, Germany
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Agache IO, Rogozea L. Management of hypersensivity pneumonitis. Clin Transl Allergy 2013; 3:5. [PMID: 23374544 PMCID: PMC3585806 DOI: 10.1186/2045-7022-3-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 02/01/2013] [Indexed: 12/28/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to a combined type III and IV reaction with a granulomatous inflammation, caused by cytotoxic delayed hypersensitivity lymphocytes, in a Th1/Th17 milieu, chaperoned by a deficient suppressor function of T regulatory cells. Skewing toward a Th2 phenotype is reported for chronic HP. Phenotypic expression and severity depends on environmental and/or host genetic and immune co-factors. The wide spectrum of causative antigens is continuously up-dated with new sources of airborne organic particles and drug-induced HP. The diagnosis requires a detailed history, measurement of environmental exposure, pulmonary function tests, imaging, detection of serum specific antibodies, broncho-alveolar lavage, antigen-induced lymphocyte proliferation, environmental or laboratory-controlled inhalation challenge and lung biopsy. Complete antigen avoidance is the best therapeutic measure, although very difficult to achieve in some cases. Systemic steroids are of value for subacute and chronic forms of HP, but do not influence long term outcome. Manipulation of the immune response in HP holds future promise.
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Affiliation(s)
- Ioana O Agache
- Theramed Medical Center, Spatarul Luca Arbore 16, 500112, Brasov, Romania.
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