Extrinsic allergic alveolitis caused by a cold water humidifier

ATS/JRS/ALAT Hypersensitivity Pneumonitis Guidelines for Diagnosis of humidifier lung and summer-type hypersensitivity pneumonitis

BACKGROUND

The ATS/JRS/ALAT Guidelines for the Diagnosis of Hypersensitivity Pneumonitis (GL for HP) were published in 2020. Humidifier lung and summer-type HP are forms of HP, but it is unclear whether they can be diagnosed using GL for HP. This study examined the level of confidence where humidifier lung and summer-type HP can be diagnosed with GL for HP.

METHODS

Data from 23 patients with humidifier lung and 20 patients with summer-type HP (mean age, 67.3 and 57.4 years, respectively) diagnosed between October 2012 and January 2022 were retrospectively reviewed. We evaluated high resolution computed tomography (HRCT) patterns, bronchoalveolar lavage fluid (BALF) findings, exposures, and histopathological findings to determine the level of confidence where a diagnosis of HP could be made using the GL for HP.

RESULTS

HRCT pattern was classified as typical HP in 5 (22%) and compatible with HP in 18 (78%) patients with humidifier lung and considered as typical HP in 17 (85%) and compatible with HP in 3 (15%) patients with summer-type. The confidence level for diagnosis of HP was definite in 2 (8.7%), moderate in 14 (60.9%), and low in 7 (30.4%) patients with humidifier lung. It was definite in 12 (60%), high in 3 (15%), and moderate in 5 (25%) patients with summer-type HP.

CONCLUSIONS

GL for HP showed utility in diagnosing humidifier lung in many patients with a moderate to low confidence. However, there was a definite to high confidence for patients with summer-type HP.

An update on hypersensitivity pneumonitis: what a clinician wants to know

PURPOSE OF REVIEW

A recent international collaboration has updated the clinical definition and diagnostic recommendations for hypersensitivity pneumonitis, focusing on fibrotic and non-fibrotic phenotypes. However, how these transfer to clinical practice and their impact upon clinical management and prognosis of hypersensitivity pneumonitis is unclear. This review will focus on recent advances in the understanding of the clinical aspects of hypersensitivity pneumonitis, predominantly its epidemiology, diagnosis, classification and treatment.

RECENT FINDINGS

Hypersensitivity pneumonitis is a rare disease within the general population, with variable geographical incidence because of environmental, cultural and occupational factors. Confidence in diagnosis relies upon the presence of clinical features with a temporal relationship to an associated exposure, radiological and histopathological features, bronchiolo-alveolar lavage lymphocytosis and precipitating antibodies/specific immunoglobulin G to antigens. Although emerging evidence regarding nintedanib use in progressive fibrotic interstitial lung disease is promising, the majority of therapies (corticosteroids and immunosuppressive agents) used traditionally in hypersensitivity pneumonitis lack a robust evidence base.

SUMMARY

With a clear definition of fibrotic and nonfibrotic hypersensitivity pneumonitis phenotypes now established, clinical research trials (predominantly randomized controlled trials) should clarify and resolve the discussion regarding antigen avoidance, corticosteroid therapy, immunosuppressive therapy and antifibrotic therapy in fibrotic and nonfibrotic subtypes of hypersensitivity pneumonitis.

Clinical and radiological characteristics of ultrasonic humidifier lung and summer-type hypersensitivity pneumonitis

BACKGROUND

Ultrasonic humidifier lung is a rare form of hypersensitivity pneumonitis (HP), and its clinical and radiological features are unclear. This study examined the clinical and radiological characteristics of humidifier lung.

METHODS

Data from 18 patients with humidifier lung (mean age, 67.3 years) diagnosed during October 2012 through April 2018 were retrospectively reviewed. We compared clinical, laboratory, and CT findings and bronchoalveolar lavage fluid (BALF) characteristics of these patients with those of 19 patients with summer-type HP (mean age, 57.4 years).

RESULTS

Cough and dyspnea were the most common symptoms. White blood cell count and serum C-reactive protein titers were higher for humidifier lung than for summer-type HP. Serum levels of Krebs von den Lungen-6 and surfactant protein D were significantly lower for humidifier lung than for summer-type HP. The most common chest CT findings in humidifier lung were ground-glass opacities (88.9%) and mosaic attenuation (50.0%). Centrilobular ground glass nodules were less common in humidifier lung than in summer-type HP (27.8% vs 63.1%; P = 0.043). Peribronchovascular or subpleural nonsegmental consolidation was more frequent in humidifier lung than in summer-type HP (44.4% vs 5.3%; P = 0.013). Lymphocyte fractions in BALF specimens were significantly lower for humidifier lung than for summer-type HP (37.3% vs 69.0%; P < 0.001). Neutrophil fractions were higher for humidifier lung, but the difference was not significant (22.1% vs 8.1%; P = 0.153). The CD4/8 ratio was higher for humidifier lung than for summer-type HP (1.7 vs 0.8; P = 0.003).

CONCLUSIONS

The clinical and radiological characteristics of humidifier lung differ from those of summer-type HP.

Human exposure to polyhexamethylene guanidine phosphate from humidifiers in residential settings: Cause of serious lung disease

Exposure to the humidifier disinfectant, polyhexamethylene guanidine phosphate (PHMG), in mists generated from ultrasonic humidifiers was studied in a simulation chamber and apartment rooms. PHMG is suspected as a causative agent of lung disease in Korea residences. In the simulation-chamber study, the amount of disinfectant discharged from three different ultrasonic humidifiers was measured. Mists generated at 1, 2, and 4 times the recommended amount of disinfectant were sampled with an impinger, and the effect of relative humidity (RH) on airborne disinfectant concentration was studied by changing RH from 60%–70% to 90%–100%. In addition, particle size distribution (PSD) in mists was measured by scanning mobility particle sizer (SMPS), aerodynamic particle sizer (APS), and Mastersizer. In the apartment study, mists generated from ultrasonic humidifiers were sampled for 6 h in small and large rooms during fall ( n = 10) and winter ( n = 15). In the simulation study, the humidifiers discharged 205 ± 24.6 ml/h of mist at maximum capacity. Concentrations of airborne disinfectant increased with increasing concentration of disinfectant. RH affected airborne disinfectant concentration in the chamber, with increasing concentration with increasing RH. Below RH 70%, no airborne PHMG was detected. PHMG-containing mists generated from ultrasonic humidifier showed various sizes ranging from 149–157 nm to 690–740 nm to larger than 5.4 µm by SMPS, APS, and Mastersizer, respectively. Surface area mean diameter measured by Mastersizer ranged from 5.39 µm to 5.72 µm. In the apartment study conducted during the fall, the geometric mean (GM) and geometric standard deviation (GSD) and arithmetic mean (AM) and standard deviation (SD) of airborne PHMG concentration were 3.22 + 5.13 µg/m3 and 8.26 ± 12.18 µg/m3, respectively. In the winter, GM + GSD and AM ± SD of airborne PHMG concentration were 0.21 + 2.11 µg/m3 and 0.35 ± 0.62 µg/m3, respectively. RH and temperature in the apartment rooms for fall and winter were 22.5 ± 1.7°C, 74.5 ± 15.6% and 22.0 ± 2°C, 51.1 ± 12.9%, respectively. Different RHs in the fall and winter resulted in very different airborne concentrations of disinfectant in the apartment rooms. Exposure levels and PSD of mists generated from ultrasonic humidifiers in apartments are not sufficient to conclude that PHMG causes lung disease in Korean residences.

Les pneumopathies d’hypersensibilité en milieu professionnel

INTRODUCTION

Hypersensitivity pneumonitis (HP) is a granulomatous disease of the lungs due to immune reactions following chronic inhalation of organic dusts or chemicals especially encountered in the occupational environment. The main purpose of this review is to report current concepts regarding aetiologies, epidemiology, diagnosis, treatment as well as legal aspects of HP.

STATE OF THE ART

The following aspects will be focused: (1) increase in new etiological circumstances, especially occupational and news antigens, (2) for diagnosis, the major contribution of chest high resolution CT scan which often shows characteristic images but also recent developments in simple diagnostic criteria that may be used for an epidemiological approach, (3) importance of bronchial obstruction and even emphysema as a long term sequelae, finally (4) the possibility of continuing occupational activities in certain circumstances where preventive measures can be used.

PERSPECTIVES

The increasing knowledge of etiological agents and circumstances as well as the development of secondary and especially primary preventive measures should lead to reduce the frequency of this disease and of its medico-social consequences.

Occupational allergic alveolitis

Hypersensitivity pneumonitis is an important occupational pulmonary disease. A variety of antigens including foreign proteins and low molecular weight chemicals have been described as etiologic agents. The immunopathogenesis appears to involve activated CD8+ cells as well as activated macrophages. The clinical disease may be acute, subacute or chronic depending upon the nature and level of exposure. Reducing exposure to known antigens is a strategy that appears promising in terms of prevention of irreversible disease.

Ventilation system, indoor air quality, and health outcomes in Parisian modern office workers

A cross-sectional study was carried out to determine the effect on health of exposure to different types of ventilation, taking indoor environmental measurements (IEMs) of major contaminants and aeroallergens into account. Three buildings ventilated with heating, ventilating, and air conditioning (HVAC), fan coil units (FCUs), and natural ventilation were selected. One thousand one hundred forty-four workers answered health questionnaires. After adjusting for potential confounders, HVAC and FCU systems were related to a slightly higher risk of nonspecific symptoms (compared with natural ventilation), short-term throat irritation, work-related nasal discharge, nasal blockage on awakening, migraine, and usual coughing induced by cold air. Studying the potential effects of environmental contaminants and aeroallergens on health outcomes, taking the floor and type of ventilation into account, did not explain the observed excess of nonspecific symptoms.

Cross-sectional follow-up of a flu-like respiratory illness among fiberglass manufacturing employees: endotoxin exposure associated with two distinct sequelae

Over a period of 10 years, employees in a manufacturing plant experienced sporadic flu-like episodes after work in a basement containing a recirculated washwater mist. We report a cross-sectional study to define the flu-like illness and bioaerosol exposures. High concentrations of gram-negative bacteria (GNB) (> 10(7) cfu/ml) and endotoxin (range 34-46 micrograms/ml) were found in the water. Mist contained > 10(3) cfu/m3 of GNB, and endotoxin up to 13,900 to 27,800 ng/m3. Few fungi and thermotolerant Bacillus species and no Actinomycetes, Legionella species, or amoeba were found in washwater. Airborne levels of fungi were of the same species and magnitudes as outdoor samples. Subjects volunteered (n = 28) because of a history of flu-like symptoms or were randomly selected (n = 102) from workers with and without current exposure to the basement. No acute cases were examined. Cases did not fulfill criteria for hypersensitivity pneumonitis (HP) and high levels of IgG antibodies to water-borne antigens were not observed. However, among 20 subjects indicating a history of severe flu-like episodes (severe basement flu, SBF), diffusion capacity (DLCO) was significantly lower (p = 0.015) than among other workers. The prevalence of SBF was independent of smoking. Cases occurred in clusters, and SBF was more common among workers with intermittent exposure to the basement (19 cases) than with daily exposure (1 case). These findings suggest that SBF and associated chronically depressed DLCO resulted from toxic injury following high-level endotoxin exposure. Asthma was prevalent in the study population, particularly among employees with daily, rather than intermittent, exposure to endotoxin-containing mist (odds ratio 6.7, p = 0.02). Thus, endotoxin exposure in this study was associated with two distinct sequelae depending on the temporal pattern of exposure.

Hypersensitivity pneumonitis associated with home ultrasonic humidifiers

We describe five patients with hypersensitivity pneumonitis (HP) that was related to using home ultrasonic humidifiers. All patients had micronodular infiltrates on their chest radiograph, and their lung biopsy specimens revealed alveolitis with or without epithelioid cell granulomas. Challenge tests were performed on two patients with the humidifier water and three patients using the humidifier. All patients tested exhibited a positive response. Tests for precipitating antibodies against an extract of the humidifier water gave strongly positive reactions in all patients tested. Precipitins to Cephalosporium acremonium and Candida albicans were also present in all cases, whereas precipitins to thermophilic actinomycetes were not detected. Although cultures of the water grew a variety of fungal and bacterial organisms, thermophilic actinomycetes could not be detected. These findings suggest that thermophilic organisms may not be the causative antigens of HP associated with ultrasonic humidifiers. All five patients had an increase in the bronchoalveolar lavage (BAL) lymphocytes that were predominantly CD4+ lymphocytes. The T helper cell count (CD4) to suppressor T cell count (CD8) ratio was significantly higher than that observed in summer-type HP, and lower than that observed in bird fancier's lung, indicating that the phenotypes of the BAL lymphocytes may vary with the type of HP.

Discriminant analysis of symptom pattern and serum antibody titres in humidifier related disease

BACKGROUND

The heterogeneous patterns of symptoms among factory workers exposed to aerosols from contaminated air humidifiers were analysed to assess the association between specific symptoms and the serum IgG antibody response to the humidifier water contaminants, and to test the ability of specific symptoms to predict this antibody response.

METHODS

Symptoms from 88 factory workers were surveyed by a doctor administered questionnaire and compared with their serum IgG antibody titres to humidifier water contaminants quantified by enzyme immunoassay.

RESULTS

The strength of association between individual symptoms and antibody showed that fever, shivering or chills, influenza-like symptoms, or headache were individually significantly associated with the presence and higher titres of antibody. This was also true for those subjects whose symptoms were most pronounced during the first day of the working week. Within each subject's full symptom profile there were significant associations between the description of chest tightness, breathlessness, and wheeze; between headache and influenza like symptoms; between fever and shivering or chills; and between intermittent onset and general tiredness. Discriminant analysis of the full symptom profiles showed that there was maximum information content in five independent parameters, namely, the descriptions of fever, headache, and chest tightness, the timing of their onset, and the readiness to describe miscellaneous symptoms in addition to those in the questionnaire. On the basis of these criteria 72% of subjects could be classified according to their antibody state. Cluster analysis with these five independent parameters described four symptom clusters: one associated with high median antibody levels, one with low, and two with zero median levels. These were, respectively: (1) fever with headache and chest tightness; (2) either no or few symptoms; (3) chest tightness and headache with intermittent onset; (4) headache and miscellaneous symptoms with intermittent onset.

CONCLUSIONS

The association between serum antibody titres and specific symptom patterns may identify different categories of disease which constitute the spectrum known as humidifier related disease, and strengthens the hypothesis that antibody may be involved in the pathogenesis of some components of the disease.

Hypersensitivity pneumonitis

The lung is constantly exposed to a wide variety of environmental insults. In its defense against these environmental challenges, however, the lung responds through a limited number of pathophysiologic mechanisms. This is well illustrated by a group of diseases which are collectively referred to as hypersensitivity pneumonitis. This syndrome includes a very large number of different diseases. However, in the United States, only farmer's lung, bird-breeder's lung, and ventilation hypersensitivity pneumonitis occur with any significant frequency. Each of these is characterized by flu-like symptoms, in conjunction with a pneumonitis consisting of lymphocytic granulomatous infiltration of the alveoli and terminal bronchioles. This disease is caused by the inhalation of antigenic material which usually originates from the dusts of organic material. A host of different dusts and antigens have been described in conjunction with hypersensitivity pneumonitis but each leads to the same characteristic clinical syndrome. Thus, each of the diseases shares similar clinical features but differs primarily with respect to the nature of the exposure and causative antigens. The clinical features, pathogenesis, course, prognosis, and treatment of these related diseases are reviewed.

Association of fever with late-onset pulmonary hypersensitivity responses in the guinea pig

The guinea pig model of pulmonary hypersensitivity, developed in this laboratory, was used to study the relationship of fever with late-onset airway responses (LAR). The preceding paper M. H. Karol, J. A. Hillebrand, and P. S. Thorne. (1989). Toxicol. Appl. Pharmacol. 100, 234-246 described production of immediate-onset responses (IAR) to ovalbumin (OA) with infrequent production of LAR (Karol et al., 1989). In the current study, LAR was produced on each of two occasions in the same animals using a sensitization regimen consisting of ip injection with 1 mg OA followed by exposure to 63 mg/m3 OA aerosol on Day 8. On Days 15 and 29, pyrilamine maleate was administered prior to inhalation challenges to block H1 receptors and to allow exposure for 20 min to 63 mg/m3 OA without histamine shock and fatal anaphylactic reactions. Each of the seven guinea pigs demonstrated IAR; four of seven additionally underwent LAR on both occasions. Late-onset responses were maximal at 4-5 hr postchallenge. Febrile responses of approximately 1 degree C (maximum 1.6 degrees C) accompanied the LAR in six of seven cases. Histopathology performed at the height of response revealed peribronchiolar eosinophilia. Pulmonary function determination indicated airflow disturbance during exhalation. These results are consistent with LAR being an airway response which is accompanied by fever and demonstrate the applicability of the guinea pig animal model to the study of mechanisms underlying IAR and LAR hypersensitivities.

Occupational biohazards: a review

There are at least 193 important biological agents that show infectious, allergenic, toxic, or carcinogenic activities in the working population. These agents are viruses, bacteria, fungi, plant substances, invertebrate animals (mostly arthropods), and substances derived from vertebrate animals. At least 20 large occupational groups are exposed to these biohazards. The risk is greatest among health care and laboratory workers who are threatened by human pathogens and among agricultural workers who are at risk from dust-borne biological allergens and toxins and by parasitic worms in warm climates. There is growing evidence that biohazards are also important risk factors for many other professions, including woodworkers, workers of textile plants, sewage and compost workers, miners and renovators. Some suggestions for research and prevention for reducing the occupational risks from biohazards are discussed.