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Kaburaki S, Okuda R, Takemura T, Hagiwara E, Seike M, Gemma A, Ogura T. Compatible with fibrotic hypersensitivity pneumonitis on high-resolution computed tomography: from the ATS/JRS/ALAT 2020 hypersensitivity pneumonitis guidelines. J Thorac Dis 2024; 16:2353-2364. [PMID: 38738228 PMCID: PMC11087622 DOI: 10.21037/jtd-23-1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/07/2024] [Indexed: 05/14/2024]
Abstract
Background In compatible with fibrotic hypersensitivity pneumonitis (HP) of the computed tomography (CT) classification using the American Thoracic Society (ATS)/Japanese Respiratory Society (JRS)/Latin American Thoracic Association (ALAT) HP guidelines, the lung fibrosis pattern was classified as either a usual interstitial pneumonia (UIP) pattern or a diffuse ground-glass opacity (GGO) pattern with subtle fibrosis. We investigated whether patients with the same imaging classification had different disease progression. We also attempted to reclassify these patients using the CHEST HP guidelines. Methods Patients with fibrotic HP who had compatible CT pattern in the ATS/JRS/ALAT classification were investigated retrospectively. Results With 62 patients in the UIP pattern group and 25 patients in the diffuse GGO pattern group, 87 patients with fibrotic HP had compatible pattern on CT. Annual forced vital capacity changes in the UIP pattern group and diffuse GGO pattern group were -2.7% and +3.3% (P=0.004), respectively. The 5-year survival rates in the UIP pattern group and diffuse GGO pattern group were 86% and 100% (P=0.02). In UIP pattern group in the ATS/JRS/ALAT classification, 27% patients were classified as typical fibrotic HP pattern in the CHEST guidelines. In the diffuse GGO pattern group, 52% patients were classified as typical pattern of fibrotic HP. In the CHEST guidelines, more patients in the GGO pattern were classified as typical pattern compared with those in the UIP pattern (P=0.02). Conclusions The two patterns in compatible with fibrotic HP of CT classification using the ATS/JRS/ALAT HP guidelines had different disease progression. Typical patterns were more frequent in the CHEST guidelines than the ATS/JRS/ALAT guidelines.
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Affiliation(s)
- Shota Kaburaki
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Masahiro Seike
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akihiko Gemma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Jung HI, Nam DR, You SH, Jung JW, Gu KM, Jung SY. Nationwide Study of the Epidemiology, Diagnosis, and Treatment of Hypersensitivity Pneumonitis in Korea. J Korean Med Sci 2024; 39:e96. [PMID: 38501183 PMCID: PMC10948259 DOI: 10.3346/jkms.2024.39.e96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/05/2023] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is a condition with an uncertain global incidence, and information on its diagnosis and management is limited. This study aimed to address these knowledge gaps. METHODS This study utilized customized claims data from the Health Insurance Review and Assessment Service (HIRA) in South Korea from January 2010, to December 2021. Patients with HP were identified based on the diagnosis code (International Classification of Diseases, 10th Revision, J67) between 2011 and 2020. Incident HP cases were defined as new HP claims, excluding those with claims in the previous year. The study examined various factors such as age, sex, comorbidities, diagnostic methods, and treatment patterns. Additionally, multivariate logistic regression analysis was performed to identify risk factors associated with treatment initiation. RESULTS A total of 8,678 HP incident cases were confirmed, with age- and sex-adjusted annual incidence rates ranging from 1.14/100,000 in 2020 to 2.16/100,000 in 2012. The mean age of patients with incident HP was 52 years, with a higher incidence observed among males. Additionally, the most common comorbidity was asthma. Bronchoscopy was performed on 16.9% of patients, and 25.4% of patients did not receive treatment within 1 year of diagnosis. Among those who received treatment, prednisone was the most used systemic steroid, and azathioprine was the most commonly used second-line immunosuppressant. Factors associated with treatment initiation included the female sex, having asthma or gastroesophageal reflux disease (GERD), and undergoing bronchoscopy. CONCLUSION This study provides valuable insights into the incidence, diagnosis, and treatment patterns of HP in South Korea using nationwide medical claims data.
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Affiliation(s)
- Hae In Jung
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dal Ri Nam
- College of Pharmacy, Chung-Ang University, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Korea
| | - Seung-Hun You
- College of Pharmacy, Chung-Ang University, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Korea
| | - Jae-Woo Jung
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kang-Mo Gu
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea.
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Korea.
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Cano-Jiménez E, Villar Gómez A, Velez Segovia E, Aburto Barrenechea M, Sellarés Torres J, Francesqui J, Portillo Carroz K, Solis Solis AJ, Acosta Fernández O, Llanos González AB, Bordas-Martinez J, Cabrera Cesar E, Balcells Vilarnau E, Castillo Villegas D, Reyes Pardessus A, González Fernández C, García Moyano M, Urrutia Gajate A, Blanco Hortas A, Molina-Molina M. Prognostic factors of progressive fibrotic hypersensitivity pneumonitis: a large, retrospective, multicentre, observational cohort study. ERJ Open Res 2024; 10:00405-2023. [PMID: 38410707 PMCID: PMC10895428 DOI: 10.1183/23120541.00405-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/14/2024] [Indexed: 02/28/2024] Open
Abstract
Background Fibrotic hypersensitivity pneumonitis (fHP) is an immune-mediated interstitial lung disease caused by sensitisation to chronic allergen inhalation. This study aimed to determine prognostic indicators of progression and mortality in fHP. Methods This was a retrospective, multicentre, observational, cross-sectional cohort study of consecutive patients diagnosed with fHP from 1 January 2012 to 31 December 2021. Multivariate Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals for predictors of progression and survival. Results A total of 403 patients were diagnosed with fHP: median (interquartile range) age 66.5 (14.0) years, 51.9% females and 55.1% never-smokers. The cause of fHP was mainly fungal (39.7%) or avian (41.4%). Lung biopsy was performed in 269 cases (66.7%). In the whole cohort the variables that were related to mortality or lung transplant were older age (HR 1.08; p<0.001), percentage predicted forced vital capacity (HR 0.96; p=0.001), lymphocytosis in bronchoalveolar lavage (BAL) (HR 0.93; p=0.001), presence of acute exacerbation during follow-up (HR 3.04; p=0.001) and GAP (gender, age and lung physiology) index (HR 1.96; p<0.01). In the group of biopsied patients, the presence of fibroblastic foci at biopsy (HR 8.39; p<0.001) stands out in multivariate Cox regression analyses as a highly significant predictor for increased mortality or lung transplant. GAP index (HR 1.26; p=0.009), lymphocytosis in BAL (HR 0.97; p=0.018) and age (HR 1.03; p=0.018) are also predictors of progression. Conclusions The study identified several prognostic factors for progression and/or survival in fHP. The presence of fibroblastic foci at biopsy was a consistent predictor for increased mortality and the presence of lymphocytosis in BAL was inversely related to mortality.
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Affiliation(s)
| | - Ana Villar Gómez
- Hospital Vall d'Hebrón, Barcelona, Spain
- CIBER de Respiratorio (CIBERES), Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | - Diego Castillo Villegas
- CIBER de Respiratorio (CIBERES), Madrid, Spain
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | | | - Andrés Blanco Hortas
- Fundación Instituto de Investigación Sanitaria de Santiago de Compostela, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - María Molina-Molina
- CIBER de Respiratorio (CIBERES), Madrid, Spain
- Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
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Yi ES, Wawryko P, Ryu JH. Diagnosis of interstitial lung diseases: from Averill A. Liebow to artificial intelligence. J Pathol Transl Med 2024; 58:1-11. [PMID: 38229429 DOI: 10.4132/jptm.2023.11.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 01/18/2024] Open
Abstract
Histopathologic criteria of usual interstitial pneumonia (UIP)/idiopathic pulmonary fibrosis (IPF) were defined over the years and endorsed by leading organizations decades after Dr. Averill A. Liebow first coined the term UIP in the 1960s as a distinct pathologic pattern of fibrotic interstitial lung disease. Novel technology and recent research on interstitial lung diseases with genetic component shed light on molecular pathogenesis of UIP/IPF. Two antifibrotic agents introduced in the mid-2010s opened a new era of therapeutic approaches to UIP/IPF, albeit contentious issues regarding their efficacy, side effects, and costs. Recently, the concept of progressive pulmonary fibrosis was introduced to acknowledge additional types of progressive fibrosing interstitial lung diseases with the clinical and pathologic phenotypes comparable to those of UIP/IPF. Likewise, some authors have proposed a paradigm shift by considering UIP as a stand-alone diagnostic entity to encompass other fibrosing interstitial lung diseases that manifest a relentless progression as in IPF. These trends signal a pendulum moving toward the tendency of lumping diagnoses, which poses a risk of obscuring potentially important information crucial to both clinical and research purposes. Recent advances in whole slide imaging for digital pathology and artificial intelligence technology could offer an unprecedented opportunity to enhance histopathologic evaluation of interstitial lung diseases. However, current clinical practice trends of moving away from surgical lung biopsies in interstitial lung disease patients may become a limiting factor in this endeavor as it would be difficult to build a large histopathologic database with correlative clinical data required for artificial intelligence models.
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Affiliation(s)
- Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Paul Wawryko
- Division of Anatomic Pathology, Mayo Clinic Arizona, Arizona, FL, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Medicine, Mayo Clinic Rochester, Rochester, MN, USA
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Tomioka H, Miyazaki Y, Inoue Y, Egashira R, Kawamura T, Sano H, Johkoh T, Takemura T, Hisada T, Fukuoka J. Japanese clinical practice guide 2022 for hypersensitivity pneumonitis. Respir Investig 2024; 62:16-43. [PMID: 37931427 DOI: 10.1016/j.resinv.2023.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 11/08/2023]
Abstract
Considering recently published two guidelines for the diagnosis of hypersensitivity pneumonitis (HP), the Japanese Respiratory Society (JRS) has now published its own Japanese clinical practice guide for HP. Major types of HP in Japan include summer-type, home-related, bird-related, farmer's lung, painter's lung, humidifier lung, and mushroom grower's lung. Identifying causative antigens is critical for increasing diagnostic confidence, as well as improving prognosis through appropriate antigen avoidance. This guide proposes a comprehensive antigen questionnaire including the outbreak sources reported in Japan. Drawing on the 2021 CHEST guideline, this guide highlights the antigen identification confidence level and adaptations for environmental surveys. The detection of specific antibodies against causative antigens is an important diagnostic predictor of HP. In Japan, the assessments of bird-specific IgG (pigeons, budgerigars) and the Trichosporon asahii antibody are covered by medical insurance. Although this guide adopts the 2020 ATS/JRS/ALAT guideline diagnostic criteria based on the combination of imaging findings, exposure assessment, bronchoalveolar lavage lymphocytosis, and histopathological findings, it added some annotations to facilitate the interpretation of the content and correlate the medical situation in Japan. It recommends checking biomarkers; seasonal changes in the KL-6 concentration (increase in winter for bird-related HP/humidifier lung and in summer for summer-type HP) and high KL-6 concentrations providing a basis for the suspicion of HP. Antigen avoidance is critical for disease management of HP. This guide also addresses the pharmacological management of HP, highlighting the treatment strategy for fibrotic HP including combination therapies with anti-inflammatory/immunosuppressive and antifibrotic drugs.
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Affiliation(s)
- Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Japan.
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Tetsuji Kawamura
- National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hiroyuki Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, Maebashi, Japan
| | - Junya Fukuoka
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Chen X, Yang X, Ren Y, Xie B, Xie S, Zhao L, Wang S, Geng J, Jiang D, Luo S, He J, Shu S, Hu Y, Zhu L, Li Z, Zhang X, Liu M, Dai H. Clinical characteristics of hypersensitivity pneumonitis: non-fibrotic and fibrotic subtypes. Chin Med J (Engl) 2023; 136:2839-2846. [PMID: 37464421 PMCID: PMC10686610 DOI: 10.1097/cm9.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The presence of fibrosis is a criterion for subtype classification in the newly updated hypersensitivity pneumonitis (HP) guidelines. The present study aimed to summarize differences in clinical characteristics and prognosis of non-fibrotic hypersensitivity pneumonitis (NFHP) and fibrotic hypersensitivity pneumonitis (FHP) and explore factors associated with the presence of fibrosis. METHODS In this prospective cohort study, patients diagnosed with HP through a multidisciplinary discussion were enrolled. Collected data included demographic and clinical characteristics, laboratory findings, and radiologic and histopathological features. Logistic regression analyses were performed to explore factors related to the presence of fibrosis. RESULTS A total of 202 patients with HP were enrolled, including 87 (43.1%) NFHP patients and 115 (56.9%) FHP patients. Patients with FHP were older and more frequently presented with dyspnea, crackles, and digital clubbing than patients with NFHP. Serum levels of carcinoembryonic antigen, carbohydrate antigen 125, carbohydrate antigen 153, gastrin-releasing peptide precursor, squamous cell carcinoma antigen, and antigen cytokeratin 21-1, and count of bronchoalveolar lavage (BAL) eosinophils were higher in the FHP group than in the NFHP group. BAL lymphocytosis was present in both groups, but less pronounced in the FHP group. Multivariable regression analyses revealed that older age, <20% of lymphocyte in BAL, and ≥1.75% of eosinophil in BAL were risk factors for the development of FHP. Twelve patients developed adverse outcomes, with a median survival time of 12.5 months, all of whom had FHP. CONCLUSIONS Older age, <20% of lymphocyte in BAL, and ≥1.75% of eosinophil in BAL were risk factors associated with the development of FHP. Prognosis of patients with NFHP was better than that of patients with FHP. These results may provide insights into the mechanisms of fibrosis in HP.
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Affiliation(s)
- Xueying Chen
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Xiaoyan Yang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Yanhong Ren
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Bingbing Xie
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ling Zhao
- Department of Pathology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shiyao Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Jing Geng
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Dingyuan Jiang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Sa Luo
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Jiarui He
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Shi Shu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Yinan Hu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Lili Zhu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Zhen Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
| | - Xinran Zhang
- Institute of Clinical Medical Sciences, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Huaping Dai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100029, China
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Okuda R, Takemura T, Misumi T, Nagasawa R, Iwasawa T, Baba T, Hagiwara E, Ogura T. Acute Exacerbation and Proposed Criteria for Progressive Pulmonary Fibrosis in Patients with Fibrotic Hypersensitivity Pneumonitis and Idiopathic Pulmonary Fibrosis. Respiration 2023; 102:803-812. [PMID: 37619546 DOI: 10.1159/000533312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Acute exacerbation (AE) occasionally develops in the course of fibrotic hypersensitivity pneumonitis (HP). OBJECTIVE The aim of the study was to compare AE of fibrotic HP with that of idiopathic pulmonary fibrosis (IPF). METHODS Consecutive patients with pathologically confirmed fibrotic HP and IPF diagnosed based on a multidisciplinary discussion were included in the analysis. AE in patients with fibrotic HP and IPF was evaluated retrospectively. RESULTS This study included 309 and 160 patients with fibrotic HP and IPF, respectively. Their 50% survival times were 96.1 and 78.0 months, respectively (hazard ratio [HR]: 0.54 [95% confidence interval, CI: 0.36-0.77], log-rank test; p < 0.001). Notably, the cumulative AE rates of fibrotic HP were 3% at 1 year and 10% at 3 years. Moreover, the corresponding rates of IPF were 8% at 1 year and 20% at 3 years (HR: 0.66 [95% CI: 0.45-0.93], log-rank test; p = 0.034). The 90-day survival rates from the AE onset of fibrotic HP and IPF were 75% and 64%, respectively (HR: 0.51 [95% CI: 0.31-0.83], log-rank test; p = 0.006). The respiratory function test on the physiological criteria of progressive pulmonary fibrosis (PPF) was a predictor of AE in fibrotic HP. However, the high-resolution CT (HRCT) changes in the criteria of PPF were not. Nevertheless, both the physiological and radiological criteria of PPF were a predictor of AE of IPF. CONCLUSION AE of fibrotic HP has a lesser prognostic effect than that of IPF. HRCT criteria for PPF were not a risk factor for AE in patients with fibrotic HP.
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Affiliation(s)
- Ryo Okuda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Toshihiro Misumi
- Department of Data Science, National Cancer Center Hospital East, Chiba, Japan
| | - Ryo Nagasawa
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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Pereira CAC, Cordero S, Resende AC. Progressive fibrotic interstitial lung disease. J Bras Pneumol 2023; 49:e20230098. [PMID: 37610955 PMCID: PMC10578905 DOI: 10.36416/1806-3756/e20230098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/24/2023] [Indexed: 08/25/2023] Open
Abstract
Many interstitial lung diseases (ILDs) share mechanisms that result in a progressive fibrosing phenotype. In Brazil, the most common progressive fibrosing interstitial lung diseases (PF-ILDs) are chronic hypersensitivity pneumonitis, idiopathic pulmonary fibrosis, unclassified ILD, and connective tissue diseases. PF-ILD is seen in approximately 30% of patients with ILD. Because PF-ILD is characterized by disease progression after initiation of appropriate treatment, a diagnosis of the disease resulting in fibrosis is critical. Different criteria have been proposed to define progressive disease, including worsening respiratory symptoms, lung function decline, and radiological evidence of disease progression. Although the time elapsed between diagnosis and progression varies, progression can occur at any time after diagnosis. Several factors indicate an increased risk of progression and death. In the last few years, antifibrotic drugs used in patients with idiopathic pulmonary fibrosis have been tested in patients with PF-ILD. The effects of nintedanib and placebo have been compared in patients with PF-ILD, a mean difference of 107.0 mL/year being observed, favoring nintedanib. The U.S. Food and Drug Administration and the Brazilian Health Regulatory Agency have approved the use of nintedanib in such patients on the basis of this finding. Pirfenidone has been evaluated in patients with unclassified ILD and in patients with other ILDs, the results being similar to those for nintedanib. More studies are needed in order to identify markers of increased risk of progression in patients with ILD and determine the likelihood of response to treatment with standard or new drugs.
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Affiliation(s)
- Carlos A C Pereira
- . Programa de Assistência e Pesquisa em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Soraya Cordero
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Ana Carolina Resende
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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9
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Salonen J, Jansa S, Vähänikkilä H, Kaarteenaho R. Re-hospitalisation predicts poor prognosis after acute exacerbation of interstitial lung disease. BMC Pulm Med 2023; 23:236. [PMID: 37393286 DOI: 10.1186/s12890-023-02534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/24/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Several markers have been identified to increase the risk for acute exacerbation of interstitial lung disease (AE-ILD) or mortality related to AE-ILD. However, less is known about the risk predictors of ILD patients who have survived AE. The aim of the study was to characterise AE-ILD survivors and investigate prognostic factors in this subpopulation. METHODS All AE-ILD patients (n = 95) who had been discharged alive from two hospitals located in Northern Finland were selected from a population of 128 AE-ILD patients. Clinical data related to the hospital treatment and six-month follow-up visit were collected retrospectively from medical records. RESULTS Fifty-three patients with idiopathic pulmonary fibrosis (IPF) and 42 patients with other ILD were identified. Two thirds of the patients had been treated without invasive or non-invasive ventilation support. The clinical features of six-month survivors (n = 65) and non-survivors (n = 30) did not differ in terms of medical treatment or oxygen requirements. Of the patients, 82.5% used corticosteroids at the six-month follow-up visit. Fifty-two patients experienced at least one non-elective respiratory re-hospitalisation before the six-month follow-up visit. In a univariate model, IPF diagnosis, high age and a non-elective respiratory re-hospitalisation increased the risk of death, although re-hospitalisation was the only independent risk factor in a multivariate model. In six-month survivors, there was no statistically significant decrease in pulmonary function test results (PFT) examined at the follow-up visit compared with earlier PFT examined near the time of AE-ILD. CONCLUSIONS The AE-ILD survivors were a heterogeneous group of patients both clinically and in terms of their outcome. A non-elective respiratory re-hospitalisation was identified as a marker of poor prognosis among AE-ILD survivors.
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Affiliation(s)
- Johanna Salonen
- Research Unit of Biomedicine and Internal Medicine, University of Oulu, Oulun Yliopisto, P.O. Box 8000, 90014, Oulu, Finland.
- Center of Internal and Respiratory Medicine and Medical Research Center (MRC) Oulu, Oulu University Hospital, Oulu, Finland.
| | - Sanna Jansa
- Research Unit of Biomedicine and Internal Medicine, University of Oulu, Oulun Yliopisto, P.O. Box 8000, 90014, Oulu, Finland
| | - Hannu Vähänikkilä
- Northern Finland Birth Cohorts, Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Riitta Kaarteenaho
- Research Unit of Biomedicine and Internal Medicine, University of Oulu, Oulun Yliopisto, P.O. Box 8000, 90014, Oulu, Finland
- Center of Internal and Respiratory Medicine and Medical Research Center (MRC) Oulu, Oulu University Hospital, Oulu, Finland
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10
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Usual interstitial pneumonia as a stand-alone diagnostic entity: the case for a paradigm shift? THE LANCET. RESPIRATORY MEDICINE 2023; 11:188-196. [PMID: 36640788 DOI: 10.1016/s2213-2600(22)00475-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 01/13/2023]
Abstract
Usual interstitial pneumonia (UIP) is characterised by a distinctive morphological and radiological appearance that was considered the pathognomonic hallmark of idiopathic pulmonary fibrosis (IPF). However, this peculiar lung remodelling pattern is also seen in other fibrotic interstitial lung diseases, including hypersensitivity pneumonitis, and connective tissue diseases. In this Personal View, we advocate the designation of a UIP pattern as a single, discrete diagnostic entity, amalgamating its primary form and secondary processes in disorders such as hypersensitivity pneumonitis (hypersensitivity pneumonitis with UIP), rheumatoid arthritis (rheumatoid arthritis with UIP), and others. The current separation between primary and secondary UIP is in keeping with the view that every individual interstitial lung disease must be viewed as a separate entity but does not reflect striking similarities between primary and secondary UIP in the morphological or radiological appearance, clinical behaviour, pathogenic pathways, and the efficacy of anti-fibrotic therapy. We believe that the unification of UIP as a single diagnostic entity has undeniable advantages.
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11
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Coelho DB, Santos V, Alexandre AT, Bastos HNE, Mota PC, Morais A, Melo N. Risk Factors for Acute Exacerbations of Fibrotic Hypersensitivity Pneumonitis-Is Exposure a Trigger That We're Missing? Arch Bronconeumol 2023; 59:59-60. [PMID: 35945072 DOI: 10.1016/j.arbres.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Affiliation(s)
- David Barros Coelho
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Vanessa Santos
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Helder Novais E Bastos
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde I3S, University of Porto, Porto, Portugal
| | - Patrícia Caetano Mota
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde I3S, University of Porto, Porto, Portugal
| | - António Morais
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde I3S, University of Porto, Porto, Portugal
| | - Natália Melo
- Pulmonology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
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12
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Oh JH, Kang J, Song JW. Fibrosis score predicts mortality in patients with fibrotic hypersensitivity pneumonitis. Front Med (Lausanne) 2023; 10:1131070. [PMID: 37025957 PMCID: PMC10070979 DOI: 10.3389/fmed.2023.1131070] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023] Open
Abstract
Background Variable clinical courses make it challenging to predict mortality resulting from fibrotic hypersensitivity pneumonitis (HP). This study evaluated the usefulness of radiologic parameters for predicting mortality in patients with fibrotic HP. Methods Clinical data and high-resolution computed tomography (HRCT) images, which were scored for reticulation, honeycombing, ground glass opacity (GGO), consolidation, and mosaic attenuation (MA) by visual assessment, were retrospectively analyzed in a total of 101 patients with fibrotic HP (all biopsy-proven cases). Fibrosis score was defined as the sum of reticulation and honeycombing scores. Results The mean age of the 101 patients was 58.9 years, and 60.4% were females. During the follow-up (median: 55.5 months; interquartile range: 37.7-89.0 months), the 1-, 3-and 5-year mortality rates were 3.9, 16.8, and 32.7%, respectively. The non-survivors were older and had significantly lower lung function and minimum oxygen saturation during the 6-min walk test than the survivors. The non-survivors had higher scores of reticulation, honeycombing, GGO, fibrosis, and MA on HRCT than survivors. In the multivariable Cox analysis, reticulation, GGO, and fibrosis scores were independent prognostic factors for mortality in patients with fibrotic HP, as well as age. Fibrosis score showed great performance for predicting the 5-year mortality (AUC = 0.752, p < 0.001) and higher mortality was recorded for patients with high fibrosis score (≥12.0%) (the mean survival time: 58.3 vs. 146.7 months, p < 0.01) than those without. Conclusion Our results suggest that radiologic fibrosis score may be a useful predictor of mortality in patients with fibrotic HP.
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Affiliation(s)
- Ju Hyun Oh
- Department of Pulmonary and Critical Care Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Jieun Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- *Correspondence: Jin Woo Song,
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13
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Okuda R, Takemura T, Iwasawa T, Kaburaki S, Baba T, Hagiwara E, Ogura T. Impact of antigen avoidance test for fibrotic hypersensitivity pneumonitis in stable phase. Allergy Asthma Clin Immunol 2022; 18:104. [PMID: 36494847 PMCID: PMC9733398 DOI: 10.1186/s13223-022-00748-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The antigen avoidance has been used in the diagnosis and treatment of hypersensitivity pneumonitis (HP); however, its usefulness in stable fibrotic HP is controversial. OBJECTIVE To investigate the usefulness of the antigen avoidance test in patients with fibrotic HP in stable phase. METHODS The antigen avoidance test was conducted during a 2-week hospitalization comparing clinical parameters at admission and before discharge. A retrospective review of patients who underwent surgical lung biopsy or transbronchial lung cryobiopsy, who were diagnosed with fibrotic HP by multi-disciplinary discussion, and whose disease progression was stable for more than two months before the antigen avoidance test was done. RESULTS Between 2016 and 2021, 40 patients met the criteria, and 17 (43%) patients had a positive antigen avoidance test. The patients with positive in the antigen avoidance test had significantly greater annual forced vital capacity (FVC) decline than those with negative before the test (- 6.5% vs. - 0.3%, p = 0.045). The patients with positive antigen avoidance test had less annual FVC decline than those with negative in the year following the test (0.8% vs. - 5.0%, p = 0.048). The differences in annual improvement were found for serum Krebs von den Lungen-6 between the positive and negative patients in the year following the test (- 27% vs. - 5%, p = 0.049). In multivariate Cox hazard regression analysis, a negative result of the antigen avoidance test was a risk factor for death or acute exacerbation of fibrotic HP (HR = 0.26 [95% CI: 0.07-0.90], p = 0.034). CONCLUSIONS In fibrotic HP patients in stable phase, the antigen avoidance test under a 2-week hospitalization was valuable in predicting prognosis.
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Affiliation(s)
- Ryo Okuda
- grid.419708.30000 0004 1775 0430Departments of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, Japan
| | - Tamiko Takemura
- grid.419708.30000 0004 1775 0430Departments of Pathology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, 236-0051 Japan
| | - Tae Iwasawa
- grid.419708.30000 0004 1775 0430Departments of Radiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, 236-0051 Japan
| | - Shota Kaburaki
- grid.419708.30000 0004 1775 0430Departments of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, Japan
| | - Tomohisa Baba
- grid.419708.30000 0004 1775 0430Departments of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, Japan
| | - Eri Hagiwara
- grid.419708.30000 0004 1775 0430Departments of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, Japan
| | - Takashi Ogura
- grid.419708.30000 0004 1775 0430Departments of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-Higashi, Kanazawa-Ku, Yokohama, Japan
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14
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Moua T, Petnak T, Charokopos A, Baqir M, Ryu JH. Challenges in the Diagnosis and Management of Fibrotic Hypersensitivity Pneumonitis: A Practical Review of Current Approaches. J Clin Med 2022; 11:jcm11061473. [PMID: 35329800 PMCID: PMC8955902 DOI: 10.3390/jcm11061473] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 02/04/2023] Open
Abstract
Recent advances in fibrotic hypersensitivity pneumonitis include improved diagnostic guidance, systematic assessments of immunosuppressive therapy, and the recent availability of antifibrotic therapy (nintedanib) for those with progressive disease. A standardized approach to diagnosis may lead to better inclusion criteria for future therapeutic protocols and delineation of disease or treatment response predictors for real-world management. This review will highlight current diagnostic and treatment challenges and remaining knowledge gaps or areas of uncertainty, with a practical overview of supporting evidence and its clinical implications. Exposure history, serologic testing for antigen sensitivity, bronchoalveolar lavage lymphocytosis, histopathology, and radiologic findings will be covered in the diagnosis section, with immunosuppression, antifibrotic therapy, lung transplantation, and disease prognosis in the treatment and management section.
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15
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Barnes H, Troy L, Lee CT, Sperling A, Strek M, Glaspole I. Hypersensitivity pneumonitis: Current concepts in pathogenesis, diagnosis, and treatment. Allergy 2022; 77:442-453. [PMID: 34293188 DOI: 10.1111/all.15017] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/21/2021] [Indexed: 12/29/2022]
Abstract
Hypersensitivity pneumonitis is an immune-mediated interstitial lung disease caused by an aberrant response to an inhaled exposure, which results in mostly T cell-mediated inflammation, granuloma formation, and fibrosis in some cases. HP is diagnosed by exposure identification, HRCT findings of ground-glass opacities, centrilobular nodules, and mosaic attenuation, with traction bronchiectasis and honeycombing in fibrotic cases. Additional testing including serum IgG testing for the presence of antigen exposure, bronchoalveolar lavage lymphocytosis, and lung biopsy demonstrating granulomas, inflammation, and fibrosis, increases the diagnostic confidence. Treatment for HP includes avoidance of the implicated exposure, immunosuppression, and anti-fibrotic therapy in select cases. This narrative review presents the recent literature in the understanding of the immunopathological mechanisms, diagnosis, and treatment of HP.
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Affiliation(s)
- Hayley Barnes
- Central Clinical School, Monash University, Melbourne, VIC, Australia.,Alfred Hospital, Melbourne, VIC, Australia
| | - Lauren Troy
- Royal Prince Alfred Hospital, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - Cathryn T Lee
- Section of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, IL, USA
| | - Anne Sperling
- Section of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, IL, USA
| | - Mary Strek
- Section of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, IL, USA
| | - Ian Glaspole
- Central Clinical School, Monash University, Melbourne, VIC, Australia.,Alfred Hospital, Melbourne, VIC, Australia
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16
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Alberti ML, Rincon-Alvarez E, Buendia-Roldan I, Selman M. Hypersensitivity Pneumonitis: Diagnostic and Therapeutic Challenges. Front Med (Lausanne) 2021; 8:718299. [PMID: 34631740 PMCID: PMC8495410 DOI: 10.3389/fmed.2021.718299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is one of the most common interstitial lung diseases (ILD), that presents unique challenges for a confident diagnosis and limited therapeutic options. The disease is triggered by exposure to a wide variety of inciting antigens in susceptible individuals which results in T-cell hyperactivation and bronchioloalveolar inflammation. However, the genetic risk and the pathogenic mechanisms remain incompletely elucidated. Revised diagnostic criteria have recently been proposed, recommending to classify the disease in fibrotic and non-fibrotic HP which has strong therapeutic and outcome consequences. Confident diagnosis depends on the presence of clinical features of ILD, identification of the antigen(s), typical images on high-resolution computed tomography (HRCT), characteristic histopathological features, and lymphocytosis in the bronchoalveolar lavage. However, identifying the source of antigen is usually challenging, and HRCT and histopathology are often heterogeneous and not typical, supporting the notion that diagnosis should include a multidisciplinary assessment. Antigen removal and treating the inflammatory process is crucial in the progression of the disease since chronic persistent inflammation seems to be one of the mechanisms leading to lung fibrotic remodeling. Fibrotic HP has a few therapeutic options but evidence of efficacy is still scanty. Deciphering the molecular pathobiology of HP will contribute to open new therapeutic avenues and will provide vital insights in the search for novel diagnostic and prognostic biomarkers.
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Affiliation(s)
| | | | - Ivette Buendia-Roldan
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
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