1
|
Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e97-e156. [PMID: 33861992 DOI: 10.1016/j.chest.2021.03.066] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/07/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
Collapse
Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, UK
| | | | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
| | | |
Collapse
|
2
|
Magee AL, Montner SM, Husain A, Adegunsoye A, Vij R, Chung JH. Imaging of Hypersensitivity Pneumonitis. Radiol Clin North Am 2016; 54:1033-1046. [PMID: 27719974 DOI: 10.1016/j.rcl.2016.05.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The management of hypersensitivity pneumonitis (HP) depends on early identification of the disease process, which is complicated by its nonspecific clinical presentation in addition to variable and diverse laboratory and radiologic findings. HP is the result of exposure and sensitization to myriad aerosolized antigens. HP develops in the minority of antigenic exposures, and conversely has been documented in patients with no identifiable exposure, complicating the diagnostic algorithm significantly. Prompt diagnosis and early intervention are critical in slowing the progression of irreversible parenchymal damage, and additionally in preserving the quality of life of affected patients.
Collapse
Affiliation(s)
- Andrea L Magee
- Department of Radiology, The University of Chicago, 5841 South Maryland Avenue, MC2026, Chicago, IL 60637, USA.
| | - Steven M Montner
- Department of Radiology, The University of Chicago, 5841 South Maryland Avenue, MC2026, Chicago, IL 60637, USA
| | - Aliya Husain
- Department of Pathology, The University of Chicago, 5841 South Maryland Avenue, #6101, Chicago, IL 60637, USA
| | - Ayodeji Adegunsoye
- Department of Pathology, The University of Chicago, 5841 South Maryland Avenue, #6101, Chicago, IL 60637, USA
| | - Rekha Vij
- Department of Pulmonology & Critical Care, The University of Chicago, 5841 South Maryland Avenue, MC6076, Chicago, IL 60637, USA
| | - Jonathan H Chung
- Department of Radiology, The University of Chicago, 5841 South Maryland Avenue, MC2026, Chicago, IL 60637, USA
| |
Collapse
|
3
|
Sato K, Nagai T, Izumi T, Ohmine K, Ozaki K, Muroi K, Ozawa K. Rituximab-induced interstitial pneumonia due to CD8-positive T cell infiltration. Acta Haematol 2012; 128:107-9. [PMID: 22760000 DOI: 10.1159/000338259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 03/13/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Kazuya Sato
- Division of Hematology, Jichi Medical University, Tochigi, Japan
| | | | | | | | | | | | | |
Collapse
|
4
|
Facco M, Brun P, Baesso I, Costantini M, Rizzetto C, Berto A, Baldan N, Palù G, Semenzato G, Castagliuolo I, Zaninotto G. T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens. Am J Gastroenterol 2008; 103:1598-609. [PMID: 18557707 DOI: 10.1111/j.1572-0241.2008.01956.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The loss of myenteric neurons in the lower esophageal sphincter (LES) characterizes achalasia, an esophageal motor disorder. Because the presence of lymphocytic infiltrates suggests an immuno-mediated mechanism ongoing at the sites of disease, we investigated the T-cell receptor (TCR) repertoire and the ability to recognize human herpes virus type 1 (HSV-1) antigens of LES-infiltrating T lymphocytes in achalasia patients. METHODS Fifty-nine patients with idiopathic achalasia and 38 heart-beating cadaveric multiorgan donors (controls) were studied. By flow cytometry evaluation and CDR3 length spectratyping analysis, the lymphocytes of 18 patients and 15 controls were analyzed, whereas 41 patients and 23 controls were employed for functional assays. RESULTS Achalasia patients were characterized by a significantly higher esophagus lymphocytic infiltrate than controls (24.71%+/- 3.11 and 9.54%+/- 1.34, respectively; P < 0.05), mainly represented by CD3+CD8+ T cells. The characterization of TCR beta chain repertoire of CD3+ cells showed the expression of a limited number of TCR beta variable (BV) gene families (from two to five out of 26), with highly restricted spectratypes, suggesting a disease-associated oligoclonal selection of T cells. Furthermore, lymphocytes from achalasia LES specifically responded to exposure to HSV-1 antigens in vitro as showed by increased proliferation and Th-1 type cytokines release. CONCLUSIONS These data suggest that the oligoclonal lymphocytic infiltrate within the LES of achalasia patients may represent the trace of an immune-inflammatory reaction triggered by HSV-1 antigens and that the Th1-type cytokines released by the activated lymphocytes may contribute to establish the neuronal damage accounting for the clinical features of idiopathic achalasia.
Collapse
Affiliation(s)
- Monica Facco
- Department of Clinical and Experimental Medicine, Hematology and Clinical Immunology Branch, Padua University School of Medicine, Padova, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Madison JM. Hypersensitivity pneumonitis: clinical perspectives. Arch Pathol Lab Med 2008; 132:195-8. [PMID: 18251575 DOI: 10.5858/2008-132-195-hpcp] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2007] [Indexed: 11/06/2022]
Abstract
CONTEXT The clinical course of hypersensitivity pneumonitis (HSP) is highly variable and its diagnosis clinically challenging. OBJECTIVE To provide a concise review of major clinical, radiographic, and laboratory findings that permits diagnosis of HSP from the standpoint of a clinician/pulmonologist. DATA SOURCES Review of major contemporary and historical literature in combination with the author's experience and viewpoints. CONCLUSIONS The approach to the diagnosis of HSP is multidisciplinary. For patients being evaluated for unexplained dyspnea and cough and an unknown interstitial disease process, the initial evaluation should include detailed environmental and occupational histories with ancillary testing such as serology, chest imaging, inhalation challenges, and bronchoalveolar lavage, as indicated. In uncertain cases, lung biopsy is recommended.
Collapse
Affiliation(s)
- J Mark Madison
- University of Massachusetts Medical School, Department of Medicine, 55 Lake Ave N, Worcester, MA 01655, USA.
| |
Collapse
|
6
|
Caffieri S, Di Lisa F, Bolesani F, Facco M, Semenzato G, Dall'Acqua F, Canton M. The mitochondrial effects of novel apoptogenic molecules generated by psoralen photolysis as a crucial mechanism in PUVA therapy. Blood 2007; 109:4988-94. [PMID: 17311998 DOI: 10.1182/blood-2006-08-037192] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The generation of photoproducts of psoralen (POPs) might be relevant in cell death induced by psoralen plus UVA, namely PUVA, which is a recognized effective treatment for cutaneous T-cell lymphoma, chronic graft-versus-host disease, and psoriasis. We investigated the occurrence of POP-induced cell death and the underlying mechanisms. POPs were produced by irradiating a psoralen solution with UVA. Jurkat cells treated in the dark with these mixtures died mainly through an apoptotic mechanism. POPs were separated by high-performance liquid chromatography (HPLC), and cells were added with each of these fractions. A total of 2 dimers of psoralen and 6-formyl-7-hydroxycoumarin (FHC) were identified in the apoptogenic fractions. Apoptosis was preceded by mitochondrial dysfunction caused by the opening of the mitochondrial permeability transition pore (PTP). In fact, both mitochondrial depolarization and cell death were prevented by the PTP inhibitor cyclosporin A (CsA). PTP opening was also documented in isolated mitochondria added with POP, suggesting that apoptosis is caused by a direct effect of POP on mitochondria. In fact, FHC alone induced PTP opening and CsA-inhibitable cell death of Jurkat cells, whereas nontransformed T lymphocytes were resistant. Along with identifying novel apoptogenic molecules, the present results indicate that POP generation directs transformed cells to apoptosis.
Collapse
Affiliation(s)
- Sergio Caffieri
- Department of Pharmaceutical Sciences, University of Padua, I-35121 Padua, Italy
| | | | | | | | | | | | | |
Collapse
|
7
|
Facco M, Zilli C, Siviero M, Ermolao A, Travain G, Baesso I, Bonamico S, Cabrelle A, Zaccaria M, Agostini C. Modulation of immune response by the acute and chronic exposure to high altitude. Med Sci Sports Exerc 2005; 37:768-74. [PMID: 15870630 DOI: 10.1249/01.mss.0000162688.54089.ce] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The chronic exposure at high altitude (HA) represents an ideal model for evaluating the in vivo effects of hypobaric hypoxia. Taking advantage of the EV-K2-CNR Pyramid, this study was designed to evaluate whether acute and chronic hypoxia differently modulates the in vivo immune responses. METHODS The study includes 13 healthy female moderately active volunteers participating to the Italian HA project EV-K2-CNR. Peripheral blood lymphocytes, collected at sea level and at HA in the Pyramid Laboratory of CNR, Nepal (5050 m), were immunologically characterized by flow cytometry and a series of molecular and functional analyses. RESULTS Flow cytometric analyses showed that: a) CD3+ T lymphocytes significantly decreased during both acute and chronic exposure to HA, b) T-cell fall was totally due to CD4+ T-cell reduction, c) B lymphocytes were not influenced by the exposure to HA, and d) natural killer (NK) cells significantly increased during acute and chronic exposure. The evaluation of the Th1/Th2 pattern demonstrated a significant decrease of the expression of the Th1 cytokine interferon-gamma (IFN-gamma) by circulating T cells during acute and chronic exposure to HA. The expression by T cells of CXCR3, a chemokine receptor typically expressed by Th1/Tc1 cells, paralleled the decrease of IFN-gamma. On the contrary, the expression of IL-4 was not conditioned by the exposure to HA. Finally, functional studies showed a significant reduction of the proliferative activity in response to mitogen (PHA) both in acute and chronic HA exposure. Despite the increased number of NK cells, NK cytotoxic activity was not influenced by the HA exposure. CONCLUSIONS Our results indicate that the in vivo exposure to HA leads to an impairment of the homeostatic regulation of Th1/Th2 immune balance that potentially could favor long-term immunological alterations and increase the risk of infections.
Collapse
Affiliation(s)
- Monica Facco
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, Padova, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ, Kreiss K, Kunkel S, Lynch D, Quirce S, Rose C, Schleimer RP, Schuyler MR, Selman M, Trout D, Yoshizawa Y. Needs and Opportunities for Research in Hypersensitivity Pneumonitis. Am J Respir Crit Care Med 2005; 171:792-8. [PMID: 15657460 DOI: 10.1164/rccm.200409-1205ws] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) develops after inhalation of many different environmental antigens, causing variable clinical symptoms that often make diagnosis uncertain. The prevalence of HP is higher than recognized, especially its chronic form. Mechanisms of disease are still incompletely known. Strategies to improve detection and diagnosis are needed, and treatment options, principally avoidance, are limited. A workshop recommended: a population-based study to more accurately document the incidence and prevalence of HP; better classification of disease stages, including natural history; evaluation of diagnostic tests and biomarkers used to detect disease; better correlation of computerized tomography lung imaging and pathologic changes; more study of inflammatory and immune mechanisms; and improvement of animal models that are more relevant for human disease.
Collapse
Affiliation(s)
- Jordan N Fink
- DLD/NHLBI, Two Rockledge Center, 6701 Rockledge Drive, Bethesda, MD 20892-7952, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Agostini C, Calabrese F, Poletti V, Marcer G, Facco M, Miorin M, Cabrelle A, Baesso I, Zambello R, Trentin L, Semenzato G. CXCR3/CXCL10 interactions in the development of hypersensitivity pneumonitis. Respir Res 2005; 6:20. [PMID: 15725351 PMCID: PMC554979 DOI: 10.1186/1465-9921-6-20] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Accepted: 02/22/2005] [Indexed: 11/10/2022] Open
Abstract
Background Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by repeated inhalations of finely dispersed organic particles or low molecular weight chemicals. The disease is characterized by an alveolitis sustained by CD8(+) cytotoxic T lymphocytes, granuloma formation, and, whenever antigenic exposition continues, fibrosis. Although it is known that T-cell migration into the lungs is crucial in HP reaction, mechanisms implicated in this process remain undefined. Methods Using flow cytometry, immunohistochemistry, confocal microscopy analysis and chemotaxis assays we evaluated whether CXCL10 and its receptor CXCR3 regulate the trafficking of CD8(+) T cells in HP lung. Results Our data demonstrated that lymphocytes infiltrating lung biopsies are CD8 T cells which strongly stain for CXCR3. However, T cells accumulating in the BAL of HP were CXCR3(+)/IFNγ(+) Tc1 cells exhibiting a strong in vitro migratory capability in response to CXCL10. Alveolar macrophages expressed and secreted, in response to IFN-γ, definite levels of CXCL10 capable of inducing chemotaxis of the CXCR3(+) T-cell line. Interestingly, striking levels of CXCR3 ligands could be demonstrated in the fluid component of the BAL in individuals with HP. Conclusion These data indicate that IFN-γ mediates the recruitment of lymphocytes into the lung via production of the chemokine CXCL10, resulting in Tc1-cell alveolitis and granuloma formation.
Collapse
Affiliation(s)
- Carlo Agostini
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Fiorella Calabrese
- Padua University School of Medicine, Department of Pathology, via Gabelli 61, 35121 Padua. Italy
| | - Venerino Poletti
- G.B: Morgani Hospital, Division of Pneumology, via Forlanini 34, 47100 Forlì, Italy
| | - Guido Marcer
- Padua University School of Medicine, Department of Environmental Medicine and Public Healthy, via Giustiniani 2, 35128 Padua. Italy
| | - Monica Facco
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Marta Miorin
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Anna Cabrelle
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Ilenia Baesso
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Renato Zambello
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Livio Trentin
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| | - Gianpietro Semenzato
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Clinical Immunology Branch, via Giustiniani 2, 35128 Padua. Italy
| |
Collapse
|
10
|
Abstract
Hypersensitivity pneumonitis (HP) represents a group of immunologically mediated lung disorders provoked by recurrent exposure to various environmental agents. HP is multifaceted and may mimic almost any interstitial lung disease, some infectious diseases,and even bronchiolar disorders. In the absence of a diagnostic gold standard,diagnosis of HP requires a combination of clinical, environmental, radiologic, physiologic,and pathologic findings that represent a diagnostic challenge for clinicians and-in the chronic form-even for experienced pathologists. Therapeutic approach includes avoiding further exposure and, depending on the clinical form, the administration of a course of prednisone. New anti-inflammatory, immunoregulatory, and antifibrotic drugs are urgently needed for this and other interstitial lung diseases.
Collapse
Affiliation(s)
- Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502, CP 14080, México DF, México.
| |
Collapse
|