[Hypersensitivity pneumonitis: Diagnostic criteria, treatment, prognosis and prevention]

Factors Predictive for Immunomodulatory Therapy Response and Survival in Patients with Hypersensitivity Pneumonitis-Retrospective Cohort Analysis

Hypersensitivity pneumonitis (HP) is one of the interstitial lung diseases with clearly established diagnostic criteria. Nevertheless, pharmacologic treatment recommendations are still lacking. Most specialists use steroids as first-line drugs, sometimes combined with an immunosuppressive agent. Aim: The aim of the present retrospective study was to establish predictive factors for treatment success and survival advantage in HP patients. Methods: We analyzed the short-term treatment outcome and overall survival in consecutive HP patients treated with prednisone alone or combined with azathioprine. Results: The study group consisted of 93 HP patients, 54 (58%) with fibrotic HP and 39 (42%) with non-fibrotic HP. Mean (± SD) VCmax % pred. and TL,co % pred. before treatment initiation were 81.5 (±20.8)% and 48.3 (±15.7)%, respectively. Mean relative VCmax and TL,co change after 3−6 months of therapy were 9.5 (±18.8)% and 21.4 (±35.2)%, respectively. The short-term treatment outcomes were improvement in 49 (53%) patients, stabilization in 16 (17%) patients, and progression in 28 (30%) patients. Among those with fibrotic HP, improvement was noted in 19 (35%) cases. Significant positive treatment outcome predictors were fever after antigen exposure, lymphocyte count in broncho-alveolar lavage fluid (BALF) exceeding 54%, RV/TLC > 120% pred., and ill-defined centrilobular nodules in high-resolution computed tomography (HRCT). An increased eosinophil count in BALF and fibrosis in HRCT were significant negative treatment outcome predictors. The presence of fibrosis in HRCT remained significant in a multivariate analysis. A positive response to treatment, as well as preserved baseline VCmax (% pred.) and TLC (% pred.), predicted longer survival, while fibrosis in HRCT was related to a worse prognosis. Conclusion: Immunomodulatory treatment may be effective in a significant proportion of patients with HP, including those with fibrotic changes in HRCT. Therefore, future trials are urgently needed to establish the role of immunosuppressive treatment in fibrotic HP.

Occupational hypersensitivity pneumonitis caused by fossil-containing rocks

AIMS

We present a hypersensitivity immune response to inhalation of antigens from fossil soils frequently used in tile manufacture. We found that the soil polished by a worker affected by pneumonitis was a paleosol containing bivalves from the cretaceous period called Hippurites.

METHODS

We made a diagnostic study for pneumonitis (analysis, microbiology, radiology, high-resolution CT, bronchoalveolar lavage, pulmonary biopsy. A biochemical study of the polishing materials used (magnesium hexafluorosilicate crystallizer), steel spoilage, washing liquid and Bilbao red limestone) after scraping of the same. Allergy study included skin tests with extracts from fossil soils, determination of IgG and IgE to mollusks, IgE-immunodetection with soil extracts with the patient's serum and non-atopic controls. Histology was made using scanning electron microscopy of the lung biopsy and the fossil soil to determine the presence of remains of mollusks, fungi, pollen or other fossil elements.

RESULTS

SDS-PAGE IgE Immunoblotting assay detecting IgE binding in soil extract between 66 and 35 kDa. Likewise, IgE-Immunblotting assay with extracts from bivalve mollusks (razor shell, mussel and scallop) and gastropod (sea snail), detecting IgE binding between 100 kDa - 30 kDa, as well as in some bands with molecular mass between 20 and 14 kDa, proving sensitization to mollusks.

CONCLUSIONS

Bivalve proteins preserved in fossil soils may produce an immune hypersensitivity response. This may impact on the precautions exposed workers, in this case fossil soil cutters and polishers, should take.

Sooty bark disease of maples: the risk for hypersensitivity pneumonitis by fungal spores not only for woodman

In the middle of the twentieth century, the from North America sooty bark disease (SBD) of maples was first discovered in England and has spread in the last decades in Central Europe, in particular. The trigger of SBD is the mould fungus Cryptostroma (C.) corticale. The most common infested maple is the sycamore, Acer pseudoplatanus, a common tree in woods and parks. The disease is characterised by peeling of the outer layer of the bark and brownish-black spores under the peeled off bark. These spores can cause maple bark disease (MBD) in humans, a hypersensitivity pneumonitis (HP) with similar symptoms like COPD, allergic asthma, influenza or flu-like infections and interstitial pneumonia. Persons who have intensive respectively occupational contact with infested trees or wood, e.g., woodman, foresters, sawyers or paper mill workers, are at risk in particular. Since C. corticale favours hot summers and host trees weakened by drought, SBD will increasingly spread in the future due to ongoing climate change. Consequently, the risk of developing MBD will increase, too. As with all HPs, e.g., farmer's lung and pigeon breeder's disease, the diagnosis of MBD is intricate because it has no clear distinguishing characteristics compared to other interstitial lung diseases. Therefore, the establishment of consistent diagnosis guidelines is required. For correct diagnosis and successful therapy, multidisciplinary expertise including pulmonologists, radiologists, pathologists and occupational physicians is recommended. If MBD is diagnosed in time, the removal of the triggering fungus or the infested maple wood leads to complete recovery in most cases. Chronic HP can lead to lung fibrosis and a total loss of lung function culminating in death. HP and, thus, MBD, is a disease with a very high occupational amount. To avoid contact with spores of C. corticale, persons working on infested wood or trees have to wear personal protective equipment. To protect the public, areas with infested maples have to be cordoned off, and the trees should be removed. This is also for impeding further spreading of the spores.

Correlation of bronchoalveolar lavage lymphocyte count with the extent of lung fibrosis and with plethysmographic lung volumes in patients with newly recognized hypersensitivity pneumonitis

Introduction

Hypersensitivity pneumonitis (HP) is an increasingly recognized interstitial lung disease, presenting with elevated total cell counts and high percentage of lymphocytes in bronchoalveolar lavage fluid (BALF). Despite many publications, there is no consensus in the literature concerning BALF cellular composition in patients with prolonged course of HP.

Aim

The aim of the present retrospective study was to investigate the influence of disease duration, smoking habits, and the extent of lung fibrosis on BALF cells’ population in patients with newly recognized HP.

Material and methods

In total, 94 patients (49 females, 45 males), mean age 52 (±12) years, with HP recognized according to recently proposed criteria, were enrolled into the present study. Chest CT scans were retrospectively reviewed by two independent radiologists. BALF evaluation was performed as a part of routine diagnostics according to recent recommendations.

Results

Percentage of lymphocytes in BALF was significantly lower in patients with lung fibrosis (stage 1 and 2) comparing to those without lung fibrosis (stage 0). Significant correlation was also found between the percentage of BALF lymphocytes and plethysmographic lung volumes, but not with lung transfer capacity for carbon monoxide (TLCO% pred). Smoking did not influence BALF results in our study group.

Conclusions

BALF lymphocytosis correlated with the presence and the extent of lung fibrosis on chest CT as well as with plethysmographic lung volumes but did not with TLCO and smoking habits in newly recognized HP pneumonitis.

Rare imaging findings of hypersensitivity pneumonitis: A case report

BACKGROUND

Hypersensitivity pneumonitis (HP) is an immune-mediated syndrome caused by allergen inhalation. High-resolution computed tomography (HRCT) of HP may show diffuse ground-glass opacity, centrilobular ground-glass nodules, areas of air-trapping, thin-walled cysts, or fibrotic changes.

CASE SUMMARY

A 47-year-old male patient went to the hospital complaining of cough and gradual aggravation of shortness of breath. HRCT of the lung showed that multiple nodules and ground-glass high-density shadows were present in both lungs. In addition, circular high-density shadows of various sizes were widely distributed in both lungs with relatively normal lung markings inside them. But other tests did not have a positive finding that can clarify the cause. Therefore, the patient underwent a lung biopsy. The pathological results showed that the lesions tended to be HP. After 4 mo of follow-up, the lesions in the patient's lungs were absorbed spontaneously, and the symptoms of cough and shortness of breath have disappeared. The review results suggested that the patient’s disease was self-healing, which was consistent with the characteristics of HP.

CONCLUSION

For some patients with HP, abnormal HRCT findings, such as the lesions in the lungs, can be absorbed on their own, which is an important clue in the diagnosis of the disease. Early diagnosis by lung biopsy is necessary when antigen exposure is unknown.

The value of serum precipitins against specific antigens in patients diagnosed with hypersensitivity pneumonitis - retrospective study

INTRODUCTION

Hypersensitivity pneumonitis (HP) is the third most common interstitial lung disease, and is often under-recognized, especially in patients who are not aware of their occupational or environmental contact with organic antigens. The aim of the present study was to assess the results of serum specific IgG antibodies (ssIgG) in HP patients and their correlation with clinical data.

MATERIAL AND METHODS

128 HP patients, median age 53 years, participated in the study. The control group consisted of 102 patients with interstitial lung diseases (ILDs) other than HP. Assessment of pretreatment ssIgG to thermophilic actinomycetes and protein antigens from bird droppings (pigeons, hens, ducks, parrots, turkeys) was performed by double diffusion in agar gel according to Ouchterlony method.

RESULTS

Positive precipitins were obtained in 57% of all HP patients and in 61% of those exposed to above mentioned antigens. Positive results in the control group were obtained in 7% of patients. Sensitivity of ssIgG in HP group was 0.57 and specificity 0.93. Precipitins to at least one bird antigen was confirmed in 64% of HP patients exposed to birds. Precipitins to thermophilic bacteria were found in 29% of HP patients exposed to hay or hay products.

CONCLUSIONS

The results of the study indicate that ssIgG against birds' allergens were the valuable diagnostic tool in HP patients. Low-rate of confirmation of ssIgG to thermophilic bacteria in patients exposed to hay or hay products indicate that other microorganisms, most likely molds, could be responsible for the disease development.