Hypersensitivity pneumonitis among wind musicians - an overlooked disease?

Hypersensitivity pneumonia associated with metallic straw of mate (chimarrão): A case report

This case report describes a 61-year-old male who sought treatment for sudden symptoms of dry cough, chest pain and severe dyspnea. On admission, the patient had hypoxemia and predominantly medullary infiltrate that we could observe on his imaging exams. After hospital discharge, he presented two similar episodes, with clinical and radiological improvement with oxygen therapy alone. He denied exposure to birds, mold or chemical agents. However, the patient noticed the onset of symptoms soon after drinking chimarrão. Given the compatible clinical, radiological and laboratory history, the diagnosis of hypersensitivity pneumonitis was performed. The patient was instructed by the medical team not to consume the drink anymore, remaining asymptomatic for more than two years.

Mold, Mycotoxins and a Dysregulated Immune System: A Combination of Concern?

Fungi represent one of the most diverse and abundant eukaryotes on earth. The interplay between mold exposure and the host immune system is still not fully elucidated. Literature research focusing on up-to-date publications is providing a heterogenous picture of evidence and opinions regarding the role of mold and mycotoxins in the development of immune diseases. While the induction of allergic immune responses by molds is generally acknowledged, other direct health effects like the toxic mold syndrome are controversially discussed. However, recent observations indicate a particular importance of mold/mycotoxin exposure in individuals with pre-existing dysregulation of the immune system, due to exacerbation of underlying pathophysiology including allergic and non-allergic chronic inflammatory diseases, autoimmune disorders, and even human immunodeficiency virus (HIV) disease progression. In this review, we focus on the impact of mycotoxins regarding their impact on disease progression in pre-existing immune dysregulation. This is complemented by experimental in vivo and in vitro findings to present cellular and molecular modes of action. Furthermore, we discuss hypothetical mechanisms of action, where evidence is missing since much remains to be discovered.

Antigen avoidance in people with hypersensitivity pneumonitis: A scoping review

BACKGROUND

Antigen avoidance (AA) is essential for people with hypersensitivity pneumonitis (HP). An intervention programme to promote continuous AA in people with HP will be the focus of future research.

OBJECTIVES

We systematically analysed the AA behaviour of people with HP, interventions of health-care providers to promote AA behaviour, clinical outcomes after AA, and evaluation methods after AA.

METHODS

We conducted a scoping review using six online databases and manual searches. Papers written in English or Japanese that reported cases on AA were selected. The extracted data were classified qualitatively.

RESULTS

In total 205 cases included in 109 eligible papers were examined.

CONCLUSIONS

This review clarified the fundamental evidence of AA in people with HP. These people required the continuous support of health-care providers to continue appropriate AA. This review highlighted four aspects that require further research to design interventions for promoting effective and continuous AA in people with HP.

The association between fungi exposure and hypersensitivity pneumonitis: a systematic review

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.

Exposure assessment in hypersensitivity pneumonitis: a comprehensive review and proposed screening questionnaire

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.

Hypersensitivity pneumonitis

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.

A Nonsmoker Man in His 40s With a Diagnosis of Genetic-Related Idiopathic Pulmonary Fibrosis (Surfactant-Protein C Gene Mutation)

A nonsmoker man in his 40s underwent bilateral lung transplantation with a referral diagnosis of genetic-related idiopathic pulmonary fibrosis (IPF). The patient had no medical history in childhood and early adulthood, nor was there a family history of IPF. His nonsmoker father presented with lung cancer at 59 years of age. The patient was a professional brass instrument player; he had started playing at 9 years of age, and he was recently playing 3 to 4 h per day. He had a 7-year clinical history of chronic cough and shortness of breath. Bilateral fine crackles were present at clinical examination. There was no digital clubbing. Data had been collected since 2015: no clinical or immunologic signs of connective tissue disease were evident, including autoantibodies for myositis or anti-synthetase syndrome. Chest radiograph showed diffuse interstitial lung disease. Results of pulmonary function tests yielded a restrictive pattern with decreased FVC and decreased total lung capacity (69% and 47% of predicted, respectively). The FEV₁/FVC ratio was 86%, and carbon monoxide transfer coefficient was 36% of predicted. BAL cellular analysis consisted of macrophages (66%), lymphocytes (19%; CD4⁺/CD8⁺ ratio, 0.16), neutrophils (10%), and eosinophils (5%).

Fungal contamination of wind instruments: Immunological and clinical consequences for musicians

INTRODUCTION

Playing a wind instrument is an increasingly reported cause of hypersensitivity pneumonitis. However, current knowledge about contamination of wind instruments by fungi and specific fungal sensitization is scarce. Therefore, we aimed: (i) to assess the current prevalence and type of fungal contamination of wind instruments, (ii) to identify potential risk factors associated with instrument contamination, and (iii) to evaluate the prevalence of sensitization to these fungi among musicians.

MATERIAL AND METHODS

Musicians from music schools in eastern France and who played a wind instrument were prospectively recruited (NCT01487850). The mouthpiece and the reed of their instrument were sampled to quantify the magnitude and type of fungi. Each subject had a physical examination, a mycological analysis of saliva and a blood sample in search of serum precipitins against the most frequent fungi isolated from instruments. The results were compared with those of 40 healthy non-exposed controls.

RESULTS

Forty musicians playing a wind instrument (bassoon, clarinet, oboe, saxophone) were included. (i) 95% of wind instruments were colonized by fungi, mainly with Phoma spp., Penicillium spp. and Rhodotorula mucilaginosa; (ii) absence of systematic drying of the instrument was a main contributing factor; (iii) serum precipitins were significantly more present in the musicians' sera than in control sera and were consistent with the fungi present in their instrument.

CONCLUSION

This study reveals a constant and specific fungal contamination among wind reed instruments with a significant sensitization among musicians, pleading in favour of regular instrument cleaning. Physicians should be aware of this possible source of antigenic exposure.

Host Variability in NTM Disease: Implications for Research Needs

Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms that may cause opportunistic infections in susceptible hosts. Lung infections in immunocompetent persons with structural lung disease are most common, while disseminated disease occurs primarily in immunocompromised individuals. Human disease caused by certain species, such as Mycobacterium avium complex, Mycobacterium abscessus, and Mycobacterium kansasii, is increasing in incidence and varies by geographic distribution. The spectrum of NTM disease varies widely in presentation and clinical outcome, but certain patterns can be organized into clinical phenotypes. Treatment options are limited, lengthy, and often toxic. The purpose of this case-based review is to provide non-clinician scientists with a better understanding of human NTM disease with an aim to stimulate more research and development.