Hypersensitivity pneumonitis in peat moss processing plant workers

Case report: Rare pulmonary fungal infection caused by Penicillium digitatum: the first clinical report in China

Penicillium digitatum is a common plant pathogen that causes citrus rot, which is extremely rare in humans. We report a case of a 66-year-old man with a history of consuming large amounts of citrus fruits, smoking for 30 years, and a history of emphysema. He had experienced intermittent coughing with sputum for more than 10 years and was admitted to the hospital due to worsening of symptoms over the past month. Despite antibiotic treatment, his condition did not improve. Subsequently, bronchoalveolar lavage fluid (BALF) was detected by metagenomic next-generation sequencing (mNGS), which showed the presence of P. digitatum. The fungal culture of BALF also indicated the presence of the Penicillium genus. The diagnosis was lung infection caused by P. digitatum, and the patient was treated with itraconazole. The lung infection was controlled. This is the third reported case of invasive pulmonary fungal infection caused by P. digitatum worldwide at the genus level, and the first reported case in China. Although human infections caused by P. digitatum are rare, as an emerging opportunistic pathogen, the detection of this fungus in immunocompromised patients should still be clinically important.

Clinical Manifestations of Human Exposure to Fungi

Biological particles, along with inorganic gaseous and particulate pollutants, constitute an ever-present component of the atmosphere and surfaces. Among these particles are fungal species colonizing almost all ecosystems, including the human body. Although inoffensive to most people, fungi can be responsible for several health problems, such as allergic fungal diseases and fungal infections. Worldwide fungal disease incidence is increasing, with new emerging fungal diseases appearing yearly. Reasons for this increase are the expansion of life expectancy, the number of immunocompromised patients (immunosuppressive treatments for transplantation, autoimmune diseases, and immunodeficiency diseases), the number of uncontrolled underlying conditions (e.g., diabetes mellitus), and the misusage of medication (e.g., corticosteroids and broad-spectrum antibiotics). Managing fungal diseases is challenging; only four classes of antifungal drugs are available, resistance to these drugs is increasing, and no vaccines have been approved. The present work reviews the implications of fungal particles in human health from allergic diseases (i.e., allergic bronchopulmonary aspergillosis, severe asthma with fungal sensitization, thunderstorm asthma, allergic fungal rhinosinusitis, and occupational lung diseases) to infections (i.e., superficial, subcutaneous, and systemic infections). Topics such as the etiological agent, risk factors, clinical manifestations, diagnosis, and treatment will be revised to improve the knowledge of this growing health concern.

Risk factors associated with mortality in hypersensitivity pneumonitis: a meta-analysis

BACKGROUND

Hypersensitivity pneumonitis (HP) related deaths have increased substantially in recent years. It is important to identify the risk factors of HP significantly associated with mortality to ensure close patient monitoring and assess disease progression.

RESEARCH DESIGN AND METHODS

Extensive literature search was conducted in accordance with the PRISMA checklist. Literature search of PUBMED, EMBASE and Cochrane Library database between January 2009 and April 2021 using the terms "hypersensitivity pneumonitis", "hazard ratio", and "mortality" identified 325 articles. A total of 22 independent original studies focusing on mortality of HP patients were assessed.

RESULTS

This systematic review and meta-analysis suggests that increased age, male sex, honeycombing and traction bronchiectasis patterns on high-resolution computed tomography (HRCT) images are the major mortality-related risk factors of patients with HP. In case of chronic HP, antigen exposure appeared to be an additional risk factor.

CONCLUSIONS

The clinico-radiological risk factors of mortality identified for HP will enable effective and close monitoring of patients, prognostication and guide towards appropriate management decisions. However, association between the type of antigen and mortality remains to be explored.

A Pilot Randomized Trial of Transdermal Nicotine for Pulmonary Sarcoidosis

BACKGROUND

Tobacco smoking is associated with a reduced risk of developing sarcoidosis, and we previously reported that nicotine normalizes immune responses to environmental antigens in patients with active pulmonary sarcoidosis. The effects of nicotine on the progression of pulmonary sarcoidosis are unknown.

RESEARCH QUESTION

Is nicotine treatment well tolerated, and will it improve lung function in patients with active pulmonary sarcoidosis?

STUDY DESIGN AND METHODS

With local institutional review board approval, a randomized, double-blind, controlled pilot trial was conducted of daily nicotine transdermal patch treatment (21 mg daily) or placebo patch use for 24 weeks. The Ohio State University Wexner Medical Center and Cleveland Clinic enrolled 50 consecutive adult subjects aged ≥ 18 years with active pulmonary sarcoidosis, based on symptoms (ie, dyspnea, cough) and objective radiographic evidence of infiltrates consistent with nonfibrotic lung disease. Each study group was compared at 26 weeks based on repeated measures of FVC, FEV₁, quantitative lung texture score based on CT texture analysis, Fatigue Assessment Score (FAS), St. George's Respiratory Questionnaire (SGRQ), and the Sarcoidosis Assessment Tool.

RESULTS

Nicotine treatment was associated with a clinically significant, approximately 2.1% (70 mL) improvement in FVC from baseline to 26 weeks. FVC decreased by a similar amount (2.2%) in the placebo group, with a net increase of 140 mL (95% CI, 10-260) when comparing nicotine vs placebo groups at 26 weeks. FEV₁ and FAS improved marginally in the nicotine-treated group, compared with those on placebo. No improvement was observed in lung texture score, FAS, St. George's Respiratory Questionnaire score, or the Sarcoidosis Assessment Tool. There were no reported serious adverse events or evidence of nicotine addiction.

INTERPRETATION

Nicotine treatment was well tolerated in patients with active pulmonary sarcoidosis, and the preliminary findings of this pilot study suggest that it may reduce disease progression, based on FVC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02265874; URL: www.clinicaltrials.gov.

A cohort study of cucumber greenhouse workers' exposure to microorganisms as measured using NGS and MALDI-TOF MS and biomarkers of systemic inflammation

Work in greenhouses entails exposure to airborne fungi and bacteria. The aims of this study are to obtain knowledge about whether exposure to fungal and bacterial genera and species during work in a cucumber greenhouse is affected by work tasks, and whether a cohort of greenhouse workers' serum levels of serum amyloid A (SAA) and C-reactive protein (CRP), biomarkers of systemic inflammation, are associated with this. Data on personal exposure to airborne fungal and bacterial species measured over 4 years as well as serum levels of SAA and CRP sampled over two years were analyzed. For data analysis, the main work tasks were grouped into three different groups, called 'grouped work task'. Microorganisms were identified using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF MS) and next-generation sequencing (NGS). The 'daily exposure' of greenhouse workers' were as follows: 4.8 × 10⁴ CFU bacteria/m³, 1.4 × 10⁶ CFU fungi/m³, and 392 EU/m³ of endotoxin. Workers were exposed to many different microbial species including several species within the genera Acinetobacter, Bacillus, Microbacterium, Pseudomonas, Staphylococcus, and Streptomyces. The genera Ralstonia and Cladosporium were found in most samples. The exposure levels as well as the microbial composition were associated significantly with grouped work task and season with high exposures during tasks in close contact with mature and old plants and in the autumn. CRP and SAA levels were also associated with exposure level and grouped work tasks. The Shannon-Wiener indices were not different in the 3 'grouped work tasks'. Several specific species including e.g. Halomonas elongata, Stenotrophomonas maltophilia, Podosphaera fusca, and Wallemia spp. were found frequently or in high concentrations in the exposures associated with the highest levels of CRP and SAA. The microorganisms S. maltophilia, P. fusca, and Wallemia spp. were also found on the cucumber plant leaves. In conclusion, both exposure level and the species composition seem to have an effect on the serum levels of CRP and SAA of exposed workers. The greenhouse workers were exposed to only a few species characterized as human pathogens.

Hypersensitivity pneumonitis: a complex lung disease

Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a respiratory syndrome involving the lung parenchyma and specifically the alveoli, terminal bronchioli, and alveolar interstitium, due to a delayed allergic reaction. Such reaction is secondary to a repeated and prolonged inhalation of different types of organic dusts or other substances to which the patient is sensitized and hyper responsive, primarily consisting of organic dusts of animal or vegetable origin, more rarely from chemicals. The prevalence of HP is difficult to evaluate because of uncertainties in detection and misdiagnosis and lacking of widely accepted diagnostic criteria, and varies considerably depending on disease definition, diagnostic methods, exposure modalities, geographical conditions, agricultural and industrial practices, and host risk factors. HP can be caused by multiple agents that are present in work places and in the home, such as microbes, animal and plant proteins, organic and inorganic chemicals. The number of environment, settings and causative agents is increasing over time. From the clinical point of view HP can be divided in acute/subacute and chronic, depending on the intensity and frequency of exposure to causative antigens. The mainstay in managing HP is the avoidance of the causative antigen, though the complete removal is not always possible due to the difficulties to identify the agent or because its avoidance may lead to major changes in life style or occupational settings. HP is a complex syndrome that needs urgently for more stringent and selective diagnostic criteria and validation, including wider panels of IgG, and a closer collaboration with occupational physicians, as part of a multidisciplinary expertise.

Occupational hypersensitivity pneumonitis: an EAACI position paper

The aim of this document was to provide a critical review of the current knowledge on hypersensitivity pneumonitis caused by the occupational environment and to propose practical guidance for the diagnosis and management of this condition. Occupational hypersensitivity pneumonitis (OHP) is an immunologic lung disease resulting from lymphocytic and frequently granulomatous inflammation of the peripheral airways, alveoli, and surrounding interstitial tissue which develops as the result of a non-IgE-mediated allergic reaction to a variety of organic materials or low molecular weight agents that are present in the workplace. The offending agents can be classified into six broad categories that include bacteria, fungi, animal proteins, plant proteins, low molecular weight chemicals, and metals. The diagnosis of OHP requires a multidisciplinary approach and relies on a combination of diagnostic tests to ascertain the work relatedness of the disease. Both the clinical and the occupational history are keys to the diagnosis and often will lead to the initial suspicion. Diagnostic criteria adapted to OHP are proposed. The cornerstone of treatment is early removal from exposure to the eliciting antigen, although the disease may show an adverse outcome even after avoidance of exposure to the causal agent.

Characterization of bioaerosols from dairy barns: reconstructing the puzzle of occupational respiratory diseases by using molecular approaches

To understand the etiology of exposure-related diseases and to establish standards for reducing the risks associated with working in contaminated environments, the exact nature of the bioaerosol components must be defined. Molecular biology tools were used to evaluate airborne bacterial and, for the first time, archaeal content of dairy barns. Three air samplers were tested in each of the 13 barns sampled. Up to 10(6) archaeal and 10(8) bacterial 16S rRNA genes per m(3) of air were detected. Archaeal methanogens, mainly Methanobrevibacter species, were represented. Saccharopolyspora rectivirgula, the causative agent of farmer's lung, was quantified to up to 10(7) 16S rRNA genes per m(3) of air. In addition, a wide variety of bacterial agents were present in our air samples within the high airborne bioaerosol concentration range. Despite recommendations regarding hay preservation and baling conditions, farmers still develop an S. rectivirgula-specific humoral immune response, suggesting intense and continuous exposure. Our results demonstrate the complexity of bioaerosol components in dairy barns which could play a role in occupational respiratory diseases.

Hypersensitivity pneumonitis: a historical, clinical, and radiologic review

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.

Biological activities of respirable dust from Eastern Canadian peat moss factories

Bacteria, moulds, endotoxin and quartz from respirable dust of agricultural and industrial buildings are typically incriminated for the respiratory health decline of exposed workers despite that dust being an undefined mixture and quantification methods of aerosolized bacteria, moulds or endotoxin not being standardized yet. We developed an in vitro alveolar epithelial cell system in which biological activities of peat moss factories' dust might be correlated to bacteria, mould, endotoxin and quartz concentrations of the analyzed samples. Following exposure, interleukin-8 protein secretion, necrosis and apoptosis of the exposed A549 cells were monitored respectively with ELISA on cell supernatants, trypan blue exclusion and DNA fragmentation detection by flow cytometry. Respirable dust was collected with liquid impingers and respirable quartz with 10mm Dorr-Oliver cyclones. We quantified mesophilic bacteria, mesophilic moulds and endotoxins from liquid impinger samples. No correlation was observed between biological activities of dust and bacteria, mould, endotoxin or quartz concentrations under our experimental conditions. Our speculation is that simple measurements, such as dust concentrations, may not be adequate indicators of the human respiratory health hazard for a given environment.

Occupational hypersensitivity pneumonitis due to molds in an onion and potato sorter

A 42-year-old female non-smoking onion and potato sorter developed work-related shortness of breath, cough, fatigue and flu-like symptoms. The diagnosis of hypersensitivity pneumonitis was based on patchy infiltrates in both lungs on high resolution computed tomography and lymphocytosis of 71% in a bronchoalveolar lavage sample with a CD4/CD8 ratio of 0.4. Exposure cessation and initial corticosteroid therapy resulted in complete recovery. IgG antibodies to Penicillium species and Fusarium solani cultivated from samples from the patient's workplace were detected in the patient's serum and cross-reactivity was demonstrated within Penicillium species, but also between Penicillium species and Aspergillus fumigatus. We conclude that occupational hypersensitivity pneumonitis due to molds may develop in onion and potato sorters.

Identification of mycobacteria in peat moss processing plants: application of molecular biology approaches

Peat moss processing plant workers are exposed to high concentrations of bioaerosols. Although mycobacteria have been cultured from peat moss, no study has examined the workers' exposure to mycobacterial bioaerosols. We evaluated the presence of mycobacteria in air samples from peat moss processing plants using molecular biology approaches (cloning-sequencing and polymerase chain reaction (PCR)) and the workers exposure using immunoglobulin G (IgG) complexes to mycobacteria. In addition, species detected in air samples and in peat moss were compared. Two peat moss processing plants were chosen among 14 previously studied. A total of 49 clones were sequenced. Real-time PCR was also performed on the same air samples to evaluate the airborne concentration of mycobacteria and estimate exposure levels. Several Mycobacterium species were present in the air samples (M. malmoense, M. smegmatis, M. graceum, M. bohemicum, and M. interjectum). Mycobacterium avium was recovered by culture in peat moss but not in the air using the molecular approach. Total airborne Mycobacterium concentration was estimated at 8.2 x 10(8)/m3. Workers had IgG against the mycobacterial mix and M. avium, suggesting significant exposure. The findings from air samples, supported by IgG measurements, demonstrate that peat moss processing plant workers are exposed to mycobacteria in addition to other biological agents.

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 immunoglobulin E-mediated asthma due to Penicillium camemberti in a dry-sausage packer

A 62-year-old female sausage packer reported progressive work-related asthma, rhinitis and contact urticaria after contact to dry sausages refined by moulds. Whereas skin prick tests with commercial mould extracts were negative, the patient showed weak skin sensitization to a cultivated mould sample from a dry sausage. Specific immunoglobulin E antibodies to various moulds were demonstrated by ImmunoCAP and antibodies to the cultivated mould sample were demonstrated by enzyme allergosorbent test. The mould was identified by pheno- and genotyping as Penicillium camemberti. Five atopic controls did not show sensitization with the same tests. Crossreactivity of P. camemberti and Penicillium notatum was shown by enzyme allergosorbent inhibition tests. Although no challenge tests were considered due to the patient's airway obstruction, a diagnosis of allergic occupational asthma was made. We conclude that immunoglobulin E-mediated allergic occupational asthma due to moulds may occur in dry sausage packers.

Bioaerosols in peat moss processing plants

Peat moss is organic matter colonized by large numbers of microorganisms. Storage prior to its processing may result in massive microbial growth. These biological contaminants can become airborne during processing. Our goals were (a) to evaluate concentrations of bioaerosols (inhalable dust, molds, bacteria) in peat moss processing plants that used dust removing systems, and (b) to evaluate the presence of these microorganisms in peat moss. Fourteen plants from Eastern Canada were visited; 3 plants operated all year (all-year mixing plants), and 11 plants functioned only during summer months (seasonal). Air samples were taken throughout the day at different work sites using IOM cassettes for inhalable dust and All-Glass Impinger-30 samplers and Andersen six-stage impactors for microorganisms. Samples of nonprocessed and bagged peat moss (solid material) were also taken and analyzed. A total of 25 work sites for air sampling and 33 solid material samples were analyzed. Air samples contained up to 441.7 mg/m3 of inhalable dust and up to 1.0 x 10(8) CFU/m3 mesophilic molds and 3.3 x 10(5) CFU/m3 bacteria. Seasonal plants were more contaminated with molds and dust than all-year mixing plants. Sieving sites were the most highly contaminated work sites. Airborne dust concentration was significantly correlated with molds and bacteria. Up to 3.8 x 10(7) CFU/g (dry weight) and 4.8 x 10(7) CFU/g (dry weight) molds and bacteria, respectively, were found in the solid material samples. Airborne contaminants did not correlate with solid material content. Despite the use of dust removing systems, peat moss processing plants contain very large amounts of microbially contaminated bioaerosols that do not correlate with the quality of the processed peat. Efficiency of dust removing systems could influence the contamination levels.

Sensitization to airborne molds and its health effects in peat moss processing plant workers

The goal of this study was to evaluate the incidence of sensitization to the major molds found in peat dust in workers exposed to stored peat moss and the health impact of this sensitization. Air samples from each plant were obtained to measure the levels of airborne molds, bacteria, and dust. There were 189 workers from 14 peat moss processing plants (3 all-year mixing plants and 11 seasonal plants) recruited for the study. The subjects completed a symptoms questionnaire, underwent spirometric measurements and skin-prick tests, and gave venous blood samples. Blood samples from 43 nonexposed control subjects were also taken. A similar percentage of smokers from both plant types was observed. Twenty-eight percent of the workers tested had a positive serum reaction to at least one of the tested molds. The percentage of positive workers varied from plant to plant, going from none in 4 plants to 14 out of 21 for 1 plant. This variability was not correlated with the airborne levels of molds. FEV tended to be lower in the workers with positive antibodies compared with seronegative workers. IgG positive frequency was higher for those workers employed in the all-year plants, and workers from those plants had lower FEV/FVC than seasonal plant workers. Seasonal plants were more contaminated with molds than all-year mixing plants, suggesting that the duration of exposure may trigger more sensitization than the level of exposure. We conclude that there is a high incidence of mold sensitization in peat moss factory workers and that this sensitization may have a negative respiratory health impact.

Hypersensitivity pneumonitis in a hardwood processing plant related to heavy mold exposure

Two workers employed in a hardwood floor plant presented symptoms suggestive of hypersensitivity pneumonitis (HP). At that plant, kiln-dried wood often shows moldy growth and is subsequently brought inside for processing. This study evaluated the environment in attempt to identify the causative antigen and verify whether other workers of this and similar plants had or were at risk of developing HP. Dust from dust-removing systems and molds on the surface of wood planks were collected and air samples taken from a sister plant. Blood samples, spirometry, and symptoms' questionnaires were obtained from 11 co-workers. Dense Paecilomyces growth was observed on the surface of the dried processed wood in the index plant. This fungal genus was not detected in the sister plant. An additional worker had symptoms suggestive of HP, and his bronchoalveolar lavage revealed a lymphocytic alveolitis. The 3 confirmed cases of HP and the other 10 workers had positive specific IgG antibodies to Paecilomyces. We report 3 cases of HP out of 13 workers and a 100% sensitization to molds in workers of a hardwood processing plant. This rate is much higher than what is commonly seen in other environments associated with HP. The drying process is suspected of being responsible for the massive Paecilomyces contamination likely responsible for the HP.

Cough: occupational and environmental considerations: ACCP evidence-based clinical practice guidelines

OBJECTIVES

This section of the guideline aims to review the role of occupational and environmental factors in causing and contributing to cough. It also aims to indicate when such causes should be considered in a clinical setting, and a general approach to assessment and management.

METHODS

A review was performed of published data between 1985 and 2004 using PubMed. The search terms used included "air pollution," "sick building syndrome," "occupational asthma," "occupational lung disease," "hypersensitivity pneumonitis" (HP), "cigarette smoke," and "asthma." Selected articles were chosen when meeting the objectives, but the extent of articles available and the limited space for this section does not permit a fully comprehensive review of all of these areas, for which the reader is referred to other sections of this clinical practice guideline, the published literature, textbooks of occupational lung disease, or more specific review articles.

RESULTS/CONCLUSIONS

Almost any patient presenting with cough may have an occupational or environmental cause of or contribution to their cough. The importance of this is that recognition and intervention may result in full or partial improvement of the cough, may limit the need for medication/symptomatic treatment, and may improve the long-term prognosis. Nonoccupational environmental contributing factors for upper and lower airway causes of cough include indoor irritant and allergenic agents such as cigarette smoke, cooking fumes, animals, dust mites, fungi, and cockroaches. Causes of HP indoors include birds and fungal antigens. Outdoor pollutants and allergens also contribute to upper and lower airway causes of cough. Occupational exposures can cause hypersensitivity responses leading to rhinitis and upper airway cough syndrome, previously referred to as postnasal drip syndrome, as well as asthma, HP, chronic beryllium disease, and hard metal disease, as well as irritant or toxic responses. The diagnosis is only reached by initially considering possible occupational and environmental factors, and by obtaining an appropriate medical history to determine relevant exposures, followed by objective investigations. This may require referral to a center of expertise.

Intestinal invasion and disseminated disease associated with Penicillium chrysogenum

Background

Penicillium sp., other than P. marneffei, is an unusual cause of invasive disease. These organisms are often identified in immunosuppressed patients, either due to human immunodeficiency virus or from immunosuppressant medications post-transplantation. They are a rarely identified cause of infection in immunocompetent hosts.

Case presentation

A 51 year old African-American female presented with an acute abdomen and underwent an exploratory laparotomy which revealed an incarcerated peristomal hernia. Her postoperative course was complicated by severe sepsis syndrome with respiratory failure, hypotension, leukocytosis, and DIC. On postoperative day 9 she was found to have an anastamotic breakdown. Pathology from the second surgery showed transmural ischemic necrosis with angioinvasion of a fungal organism. Fungal blood cultures were positive for Penicillium chrysogenum and the patient completed a 6 week course of amphotericin B lipid complex, followed by an extended course oral intraconazole. She was discharged to a nursing home without evidence of recurrent infection.

Discussion

Penicillium chrysogenum is a rare cause of infection in immunocompetent patients. Diagnosis can be difficult, but Penicillium sp. grows rapidly on routine fungal cultures. Prognosis remains very poor, but aggressive treatment is essential, including surgical debridement and the removal of foci of infection along with the use of amphotericin B. The clinical utility of newer antifungal agents remains to be determined.

Aspects cliniques et immunopathologiques des pneumopathies d’hypersensibilité

INTRODUCTION

Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnoea and cough resulting from the inhalation of an antigen to which the patient has been previously sensitized.

STATE OF ART

Acute and subacute HP represent the most active forms of the disease which may become chronic while remaining progressive. HP may also evolve to end-stage lung disease. Clinical symptoms and signs tend to be non-specific and the diagnosis of HP often relies on the clinical context. The immune response is initiated when the alveolar macrophage phagocytoses the antigen, provoking the expansion of lymphocytes T and B that reach the pulmonary parenchyma through the systemic circulation. This reaction is amplified by the expression of a number of inflammatory mediators.

PERSPECTIVE AND CONCLUSION

This article summarizes our current understanding of the diagnostic approach and immunological mechanisms related to HP.

Inhibitory Effect of Nicotine on Experimental Hypersensitivity PneumonitisIn VivoandIn Vitro

The incidence of hypersensitivity pneumonitis (HP) is lower in smokers than in nonsmokers. Because nicotine is immunosuppressive, we hypothesized that it could have a protective effect on HP induction in vivo. HP was induced in mice that were treated with nicotine either intraperitoneally (IP) (0.5 to 2.0 mg/kg/day) or intranasally (IN) (0.025 to 2.0 mg/kg/day). Both IP- and IN-treated animals had fewer bronchoalveolar lavage total cells and lymphocytes and a decreased lung tissue inflammation. IFN-gamma but not interleukin-10 mRNA expression was reduced in lung tissue of 2.0-mg/kg IN-treated animals. To test the effect of nicotine on alveolar macrophages, AMJ2-C11 cells were treated with nicotine and stimulated with lipopolysaccharide or Saccharopolyspora rectivirgula, a causative agent of HP. Nicotine reduced tumor necrosis factor release and tumor necrosis factor, interleukin-10, and IFN-gamma mRNA expression after stimulation and decreased CD80 expression by 55% in lipopolysaccharide-stimulated cells and by 41% in S. rectivirgula-stimulated cells. We conclude that nicotine could be, at least in part, responsible for the protection observed in smokers against HP. The inhibitory effect of nicotine on alveolar macrophages could be one of the mechanisms involved.

Invasive infection due to penicillium species other than P. marneffei

Infection caused by Penicillium spp. due to species other than P. marneffei is rare. We present three such cases of invasive disease. The first had chronic granulomatous disorder (CGD) with pulmonary infection caused by Penicillium spp. and he responded to amphotericin B therapy. Cases two and three were not known to be immunocompromised and both failed to respond to therapy. Case two had cerebral disease from an unknown source caused by P. chrysogenum. Case three probably acquired infection caused by P. decumbens peri-operatively and presented with paravertebral infection. The pertinent literature on invasive infections of Penicillium spp. other than P. marneffei is reviewed. From 1951 onwards, 31 reported cases of invasive disease included 12 cases of pulmonary infection (six in non-immunocompromised patients), four cases of prosthetic valve endocarditis, six cases of CAPD peritonitis, five cases of endophthalmitis, individual cases of fungemia and oesophagitis (both in AIDS), upper urinary tract infection and intracranial infection. Trauma, surgery or prosthetic material is commonly implicated in the non-pulmonary cases. Superficial infection (keratitis and otomycosis) is commonly caused by Penicillium spp. Allergic pulmonary disease, often occupational (such as various cheeseworkers' diseases), is also common. Optimal therapy for invasive infection is not established, but surgery may be advisable if possible. Amphotericin B may be the most effective antifungal drug.

Pulmonary function tests in interstitial lung disease: what role do they have?

Pulmonary function tests have been widely accepted and utilized in the management of interstitial lung diseases. Although the tests performed have changed little over the past several decades, extensive literature has been published highlighting their clinical role in the diagnosis, staging, prognostication, and follow-up of patients with a wide variety of interstitial lung diseases.

Major histocompatibility complex and tumor necrosis factor-alpha polymorphisms in pigeon breeder's disease

Pigeon breeders disease (PBD) is caused by the exposure of a susceptible host to avian antigens. However, genetic factors determining individual predisposition are unknown. In this work, polymorphisms of the major histocompatibility complex (MHC) class II alleles and tumor necrosis factor alpha (TNF-alpha) promoter were evaluated in 44 patients with PBD, 99 healthy unrelated controls (HC), and 50 exposed but asymptomatic subjects (EAS). MHC typing was performed by PCR-specific sequence oligonucleotide analysis, and TNF-alpha polymorphism at -238 and -308 positions by amplification refractory mutation system-PCR. PBD patients showed a significant increase of the alleles HLA-DRB1*1305 (p < 0.001, OR = 15.4, 95% CI = 3.18-102.6 [HC], and OR = 17.05, 95% CI = 2.25-357.8 [EAS]) and HLA-DQB1*0501 (p < 0.05, OR = 2.93, 95% CI = 1.21-7.15 [HC], and OR = 2.96, 95% CI = 1.0-9.14 [EAS]). A decrease of HLA-DRB1*0802 was also noticed in patients when compared with both control groups (p < 0.05). Haplotype analysis revealed an increase of DRB1*1305-DQB1*0301 and a decrease of DRB1*0802-DQB1*0402. PBD patients had an increased frequency of TNF-2(-)(308) compared with both control groups (p < 0.05). Patients exhibiting the TNF-2(-)(308) allele were younger (33.9 +/- 14.6 versus 44.2 +/- 10.4 yr; p < 0.05), and displayed more lymphocytes in their bronchoalveolar lavages (88.0 +/- 12.1 versus 68.9 +/- 17.2; p < 0.05). These results suggest that genetic factors located within the MHC region contribute to the development of PBD.