1
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Churg A, Tazelaar H, Matej R, Vasakova MK, Stewart B, Patel D, Duarte E, Gomez Manjarres DC, Mehta HJ, Wright JL. Pathologic Criteria for the Diagnosis of Usual Interstitial Pneumonia vs Fibrotic Hypersensitivity Pneumonitis in Transbronchial Cryobiopsies. Mod Pathol 2023; 36:100221. [PMID: 37236510 DOI: 10.1016/j.modpat.2023.100221] [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: 03/19/2023] [Revised: 04/23/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023]
Abstract
Transbronchial cryobiopsy (TBCB) is increasingly used for the diagnosis of fibrosing interstitial pneumonias, but there are few detailed descriptions of the pathologic findings in such cases. It has been proposed that a combination of patchy fibrosis and fibroblast foci with an absence of alternative features is diagnostic of usual interstitial pneumonia (UIP; ie, idiopathic pulmonary fibrosis [IPF]) in TBCB. In this study, we reviewed 121 TBCB in which a diagnosis of fibrotic hypersensitivity pneumonitis (FHP; n = 83) or IPF (n = 38) was made by multidisciplinary discussion and evaluated a range of pathologic features. Patchy fibrosis was found in 65 of 83 (78%) biopsies from FHP and 32of 38 (84%) biopsies from UIP/IPF cases. Fibroblast foci were present in 47 of 83 (57%) FHP and 27 of 38 (71%) UIP/IPF cases. Fibroblast foci/patchy fibrosis combined did not favor either diagnosis. Architectural distortion was seen in 54 of 83 (65%) FHP and 32 of 38 (84%) UIP/IPF cases (odds ratio [OR] for FHP, 0.35; P = .036) and honeycombing in 18 of 83 (22%) and 17 of 38 (45%), respectively (OR, 0.37; P = .014). Airspace giant cells/granulomas were present in 13 of 83 (20%) FHP and 1 of 38 (2.6%) UIP/IPF cases (OR for FHP, 6.87; P = .068), and interstitial giant cells/granulomas in 20 of 83 (24%) FHP and 0 of 38 (0%) UIP/IPF (OR, 6.7 x 106; P = .000). We conclude that patchy fibrosis plus fibroblast foci can be found in TBCB from both FHP and UIP/IPF. The complete absence of architectural distortion/honeycombing favors a diagnosis of FHP, as does the presence of airspace or interstitial giant cells/granulomas, but these measures are insensitive, and many cases of FHP cannot be separated from UIP/IPF on TBCB.
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Affiliation(s)
- Andrew Churg
- Department of Pathology, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada.
| | - Henry Tazelaar
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | - Radoslav Matej
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine of Charles University and Thomayer University Hospital, Prague, Czech Republic; Department of Pathology, First Faculty of Medicine of Charles University and General University Hospital, Prague, Czech Republic
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine, First Faculty of Medicine of Charles University and Thomayer University Hospital, Prague, Czech Republic
| | - Brian Stewart
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Divya Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Ernesto Duarte
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Diana C Gomez Manjarres
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Hiren J Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Joanne L Wright
- Department of Pathology, University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada
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2
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Kadura S, Raghu G. Hypersensitivity pneumonitis: Principles in diagnosis and management. Respirology 2023; 28:599-602. [PMID: 37140095 DOI: 10.1111/resp.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Suha Kadura
- Center for Interstitial Lung Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ganesh Raghu
- Center for Interstitial Lung Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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3
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Yoon YM, Velez TE, Upadhyay V, Vazquez SE, Lee CT, Selvan KC, Law CS, Blaine KM, Hollinger MK, Decker DC, Clark MR, Strek ME, Guzy RD, Adegunsoye A, Noth I, Wolters PJ, Anderson M, DeRisi JL, Shum AK, Sperling AI. Antigenic responses are hallmarks of fibrotic interstitial lung diseases independent of underlying etiologies. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.08.23289640. [PMID: 37214861 PMCID: PMC10197719 DOI: 10.1101/2023.05.08.23289640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Interstitial lung diseases (ILD) are heterogeneous conditions that may lead to progressive fibrosis and death of affected individuals. Despite diversity in clinical manifestations, enlargement of lung-associated lymph nodes (LLN) in fibrotic ILD patients predicts worse survival. Herein, we revealed a common adaptive immune landscape in LLNs of all ILD patients, characterized by highly activated germinal centers and antigen-activated T cells including regulatory T cells (Tregs). In support of these findings, we identified serum reactivity to 17 candidate auto-antigens in ILD patients through a proteome-wide screening using phage immunoprecipitation sequencing. Autoantibody responses to actin binding LIM protein 1 (ABLIM1), a protein highly expressed in aberrant basaloid cells of fibrotic lungs, were correlated with LLN frequencies of T follicular helper cells and Tregs in ILD patients. Together, we demonstrate that end-stage ILD patients have converging immune mechanisms, in part driven by antigen-specific immune responses, which may contribute to disease progression.
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Affiliation(s)
- Young me Yoon
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | - Tania E. Velez
- University of Virginia, Department of Medicine, Charlottesville, VA 22908
| | - Vaibhav Upadhyay
- University of California San Francisco, Department of Medicine, San Francisco, CA 94143
| | - Sara E. Vazquez
- University of California San Francisco and Chan Zuckerberg Biohub, San Francisco, CA 94158
| | - Cathryn T. Lee
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | | | - Christopher S. Law
- University of California San Francisco, Department of Medicine, San Francisco, CA 94143
| | - Kelly M. Blaine
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | - Maile K. Hollinger
- University of Chicago, Department of Medicine, Chicago, IL 60637
- University of Virginia, Department of Medicine, Charlottesville, VA 22908
| | - Donna C. Decker
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | - Marcus R. Clark
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | - Mary E. Strek
- University of Chicago, Department of Medicine, Chicago, IL 60637
| | - Robert D. Guzy
- University of Wisconsin at Madison, Department of Medicine, Madison, WI 53792
| | | | - Imre Noth
- University of Virginia, Department of Medicine, Charlottesville, VA 22908
| | - Paul J. Wolters
- University of California San Francisco, Department of Medicine, San Francisco, CA 94143
| | - Mark Anderson
- University of California San Francisco, Department of Medicine, San Francisco, CA 94143
| | - Joseph L. DeRisi
- University of California San Francisco and Chan Zuckerberg Biohub, San Francisco, CA 94158
| | - Anthony K. Shum
- University of California San Francisco, Department of Medicine, San Francisco, CA 94143
| | - Anne I. Sperling
- University of Chicago, Department of Medicine, Chicago, IL 60637
- University of Virginia, Department of Medicine, Charlottesville, VA 22908
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4
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Pandya SM, Pandya AP, Fels Elliott DR, Hamblin MJ. Hypersensitivity Pneumonitis: Updates in Evaluation, Management, and Ongoing Dilemmas. Immunol Allergy Clin North Am 2023; 43:245-257. [PMID: 37055087 DOI: 10.1016/j.iac.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Hypersensitivity pneumonitis (HP) is a heterogenous disease entity characterized by an aberrant immune response to inhalational antigens. Disease modification hinges on early antigen remediation with a goal to attenuate immune dysregulation. Disease severity and progression are mediated by an interface between degree, type and chronicity of exposure, genetic predisposition, and biochemical properties of the inducing agent. Guidelines have provided a standardized approach; however, decision-making remains with many clinical dilemmas. The delineation of fibrotic and nonfibrotic HP is crucial to identify the differences in clinical trajectories, and further clinical trials are needed to understand optimal therapeutic strategies.
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Affiliation(s)
- Sahil M Pandya
- University of Kansas Medical Center, 4000 Cambridge Street, Mail Stop 3007, Kansas City, KS 66160, USA.
| | - Aarti P Pandya
- Children's Mercy Hospital, 3101 Broadway Boulevard, Kansas City, MO 64111, USA
| | | | - Mark J Hamblin
- University of Kansas Medical Center, 4000 Cambridge Street, Mail Stop 3007, Kansas City, KS 66160, USA
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5
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Mordant P, Dauriat G, Brugière O, Borie R, Crestani B, Reynaud-Gaubert M. [Lung transplantation for fibrotic interstitial lung diseases]. Rev Mal Respir 2023; 40 Suppl 1:e42-e51. [PMID: 36610850 DOI: 10.1016/j.rmr.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- P Mordant
- Service de chirurgie vasculaire, thoracique, et transplantation pulmonaire, hôpital Bichat, Assistance publique-Hôpitaux de Paris, université de Paris, Paris, France.
| | - G Dauriat
- Service de pneumologie, hôpital Marie-Lannelongue, groupe hospitalier Paris-Saint Joseph, Le Plessis-Robinson, France
| | - O Brugière
- Service de pneumologie, hôpital Foch, Suresnes, France
| | - R Borie
- Service de pneumologie A, hôpital Bichat, Assistance publique-Hôpitaux de Paris, université de Paris, Paris, France
| | - B Crestani
- Service de pneumologie A, hôpital Bichat, Assistance publique-Hôpitaux de Paris, université de Paris, Paris, France
| | - M Reynaud-Gaubert
- Service de pneumologie, équipe de transplantation pulmonaire, centre hospitalo-universitaire Nord, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
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6
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New Paradigms in Hypersensitivity Pneumonitis. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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7
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Anwar J, Kong WT, Balakrishnan B. Updates in Hypersensitivity Pneumonitis: A Narrative Review. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00294-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
Hypersensitivity pneumonitis (HP) is an immune-mediated disease triggered by a known or unknown antigen. While reversible in the early stages of disease, progression toward irreversible pulmonary fibrosis may occur. This narrative review summarizes recent publications highlighting a methodical approach toward the diagnosis, classification, and management of fibrotic and nonfibrotic HP.
Recent Findings
Establishing the diagnosis of HP is often challenging given its variable clinical course, extensive inciting agents, and overlapping features with other interstitial lung diseases. Recently, HP has been re-classified into nonfibrotic and fibrotic subtypes based on radiographic and histopathological features. Chronic fibrotic HP is associated with significant functional impairment and increased mortality. In addition to antigen avoidance, immunosuppression is the cornerstone of management in nonfibrotic HP. Antifibrotic agents have emerged as a therapeutic option in halting the progression of chronic fibrotic HP.
Summary
The combination of clinical, radiographical, and histopathological data will assist in increasing the diagnostic certainty of HP. The new dichotomization of HP is thought to provide better prognostication for patients. This review provides clinicians with a current and evidence-based approach toward the management of patients with HP.
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Mullin ML, Churg A, Ryerson CJ. Management of fibrotic hypersensitivity pneumonitis. Curr Opin Pulm Med 2022; 28:421-431. [PMID: 35861479 DOI: 10.1097/mcp.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Recent guidelines have updated the classification of hypersensitivity pneumonitis, stratifying by the presence or absence of fibrosis as either fibrotic or nonfibrotic hypersensitivity pneumonitis. Fibrotic hypersensitivity pneumonitis represents up to 10% of interstitial lung disease in large cohort studies, and is occasionally even more common in some regions; however, there are many unknown aspects to the diagnosis and management. The goal of this review article is to summarize the management of fibrotic hypersensitivity pneumonitis. RECENT FINDINGS Historically, the only treatment options for patients with hypersensitivity pneumonitis were antigen avoidance and corticosteroids, although other immunosuppressive therapies are increasingly endorsed by experts in the field. There is accumulating evidence that antifibrotic medications can be useful as a second-line therapy in some patients with fibrotic hypersensitivity pneumonitis who have progression despite immunosuppression. There remains no direct comparison of immunosuppressive vs. antifibrotic medication for the management of fibrotic hypersensitivity pneumonitis, but some clinical, radiological and pathological features may suggest greater likelihood of benefit from one option or the other. SUMMARY We anticipate that future treatment of fibrotic hypersensitivity pneumonitis will consider a variety of patient features to suggest the most prominent underlying biology that will then be used to guide initial pharmacotherapy; however, additional data are still needed.
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Affiliation(s)
| | - Andrew Churg
- Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia
- Centre for Heart Lung Innovation, St. Paul's Hospital
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9
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Rama Esendagli D, Ntiamoah P, Kupeli E, Bhardwaj A, Ghosh S, Mukhopadhyay S, Mehta AC. Recurrence of primary disease following lung transplantation. ERJ Open Res 2022; 8:00038-2022. [PMID: 35651363 PMCID: PMC9149385 DOI: 10.1183/23120541.00038-2022] [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: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation. This article reviews the underlying conditions leading to lung transplant with potential for recurrence and the impact of such recurrences on the overall outcome following transplanthttps://bit.ly/3v3gSvJ
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10
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Nosotti M, Leiva-Juarez M, D'Ovidio F, Van Raemdonck D, Ceulemans L, Keshavjee S, Rackauskas M, Paladini P, Luzzi L, Casado PM, Alvarez A, Inci I, Ehrsam J, Krueger T, Roth A, Rea F, Schiavon M, Rosso L. Survival After Lung Transplantation for Chronic Hypersensitivity Pneumonitis: Results From a Large International Cohort Study. Transpl Int 2022; 35:10450. [PMID: 35431638 PMCID: PMC9008138 DOI: 10.3389/ti.2022.10450] [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: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022]
Abstract
Repeated exposure to antigens via inhalation is the primary cause of hypersensitivity pneumonitis, a form of interstitial pneumonia. The chronic form of hypersensitivity pneumonitis leads to progressive loss of respiratory function; lung transplantation is the only therapeutic option for chronically ill patients. The ESTS Lung Transplantation Working Group conducted a retrospective multicentred cohort study to increase the body of knowledge available on this rare indication for lung transplantation. Data were collected for every patient who underwent lung transplant for hypersensitivity pneumonitis in participating centres between December 1996 and October 2019. Primary outcome was overall survival; secondary outcome was freedom from chronic lung allograft dysfunction. A total of 114 patients were enrolled from 9 centres. Almost 90% of patients were diagnosed with hypersensitivity pneumonitis before transplantation, yet the antigen responsible for the infection was identified in only 25% of cases. Eighty per cent of the recipients received induction therapy. Survival at 1, 3, and 5 years was 85%, 75%, and 70%, respectively. 85% of the patients who survived 90 days after transplantation were free from chronic lung allograft dysfunction after 3 years. The given study presents a large cohort of HP patients who underwent lung transplants. Overall survival rate is higher in transplanted hypersensitivity pneumonitis patients than in those suffering from any other interstitial lung diseases. Hypersensitivity pneumonitis patients are good candidates for lung transplantation.
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Affiliation(s)
- Mario Nosotti
- Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Miguel Leiva-Juarez
- Department of Surgery, Columbia University Medical Center, New York, NY, United States
| | - Frank D'Ovidio
- Department of Surgery, Columbia University Medical Center, New York, NY, United States
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurens Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | | | - Piero Paladini
- Thoracic Surgery, University Hospital of Siena (AOUS), Siena, Italy
| | - Luca Luzzi
- Thoracic Surgery, University Hospital of Siena (AOUS), Siena, Italy
| | - Paula Moreno Casado
- Division of Thoracic Surgery and Lung Transplantation, Reina Sofia University Hospital, Córdoba, Spain
| | - Antonio Alvarez
- Division of Thoracic Surgery and Lung Transplantation, Reina Sofia University Hospital, Córdoba, Spain
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jonas Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thorsten Krueger
- Department of Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrey Roth
- Department of Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
| | - Lorenzo Rosso
- Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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11
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Hamblin M, Prosch H, Vašáková M. Diagnosis, course and management of hypersensitivity pneumonitis. Eur Respir Rev 2022; 31:31/163/210169. [PMID: 35140104 DOI: 10.1183/16000617.0169-2021] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/21/2021] [Indexed: 11/05/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a complex and heterogeneous interstitial lung disease (ILD) that occurs when susceptible individuals develop an exaggerated immune response to an inhaled antigen. In this review, we discuss the latest guidelines for the diagnostic evaluation of patients with suspected HP, the importance of identifying patients with fibrotic and progressive disease, and the evidence supporting the drugs commonly used in the treatment of HP. Differential diagnosis of HP can be challenging and requires a thorough exposure history, multidisciplinary discussion of clinical and radiologic data, and, in some cases, assessment of bronchoalveolar lavage lymphocytosis and histopathologic findings. Patients with HP may be categorised as having non-fibrotic or fibrotic HP. The presence of fibrosis is associated with worse outcomes. A proportion of patients with fibrotic HP develop a progressive phenotype, characterised by worsening fibrosis, decline in lung function and early mortality. There are no established guidelines for the treatment of HP. Antigen avoidance should be implemented wherever possible. Immunosuppressants are commonly used in patients with HP but have not been shown to slow the worsening of fibrotic disease. Nintedanib, a tyrosine kinase inhibitor, has been approved by the US Food and Drug Administration for slowing the progression of chronic fibrosing ILDs with a progressive phenotype, including progressive fibrotic HP. Non-pharmacological interventions, such as oxygen therapy, pulmonary rehabilitation and supportive care, may be important components of the overall care of patients with progressive HP.
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Affiliation(s)
- Mark Hamblin
- Department of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martina Vašáková
- Department of Respiratory Medicine, University Thomayer Hospital, Prague, Czech Republic
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12
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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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13
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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: 26] [Impact Index Per Article: 13.0] [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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14
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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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15
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Kapnadak SG, Raghu G. Lung transplantation for interstitial lung disease. Eur Respir Rev 2021; 30:30/161/210017. [PMID: 34348979 DOI: 10.1183/16000617.0017-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/02/2021] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA .,Dept of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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16
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Griese M, Stehling F, Schwerk N, Rosewich M, Jerkic PS, Rock H, Ruckes C, Kronfeld K, Sebah D, Wetzke M, Seidl E. Hypersensitivity pneumonitis: Lessons from a randomized controlled trial in children. Pediatr Pulmonol 2021; 56:2627-2633. [PMID: 34048641 DOI: 10.1002/ppul.25513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/22/2021] [Accepted: 05/14/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) in children is a severe interstitial lung disease and potentially, a chronic condition, if not treated appropriately. No evidence-based guidelines are available; in particular, the role of systemic glucocorticoid therapy is unclear. METHODS The aim of this randomized, double-blind, placebo-controlled, parallel-group, multi-center, phase II trial in pediatric HP was to assess the outcome of HP in children after 6 months of treatment and to compare 3 months of treatment with oral prednisolone or placebo. RESULTS After 1.5 years and the inclusion of only four children, we terminated the study prematurely. Two of the children randomized to prednisolone did not achieve the predefined response of FVC to normal. One child treated with placebo recovered to normal, similar to another child treated with prednisolone. All children treated with steroids developed drug-related side effects. DISCUSSION This uncompleted study illustrates the urgent medical need for evidence-based treatment protocols for this condition. We discuss the hurdles which were specific for completion of this trial in a rare condition. Among other options, we suggest the inclusion of children into an all-age study of HP, as in adults the same questions are unanswered.
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Affiliation(s)
- Matthias Griese
- Department of Pediatric Pneumology, Dr. von Haunersches Kinderspital, German Center for Lung Research, University of Munich, Munich, Germany
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Nicolaus Schwerk
- Clinic for Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | | | - Pera-Silvija Jerkic
- Division for Allergy, Pneumology and Cystic Fibrosis, Department for Children and Adolescence, Goethe-University, Frankfurt/Main, Germany
| | - Hans Rock
- CIO Marburg GmbH, Fronhausen-Bellnhausen, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kai Kronfeld
- Interdisciplinary Center for Clinical Trials, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniela Sebah
- Department of Pediatric Pneumology, Dr. von Haunersches Kinderspital, German Center for Lung Research, University of Munich, Munich, Germany
| | - Martin Wetzke
- Clinic for Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | - Elias Seidl
- Department of Pediatric Pneumology, Dr. von Haunersches Kinderspital, German Center for Lung Research, University of Munich, Munich, Germany
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17
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Abstract
Fibrotic hypersensitivity pneumonitis (fHP) is a chronic, often progressive fibrosing form of interstitial lung disease caused by inhaled antigenic exposures. fHP can lead to impaired respiratory function, reduced disease-related quality of life, and early mortality. Management of fHP should start with exposure remediation where possible, with systemic immunosuppression and antifibrotic therapy considered in patients with symptomatic or progressive disease. Nonpharmacologic and supportive management should be offered and, in cases of treatment-resistant, progressive illness, lung transplant should be considered.
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Affiliation(s)
- Hayley Barnes
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia.
| | - Kerri A Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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18
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Mudawi D, Heyes K, Hastings R, Rivera-Ortega P, Chaudhuri N. An update on interstitial lung disease. Br J Hosp Med (Lond) 2021; 82:1-14. [PMID: 34338019 DOI: 10.12968/hmed.2020.0556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interstitial lung diseases are a complex group of conditions that cause inflammation and scarring of the lung interstitium. This article discusses the diagnosis and management of common interstitial lung diseases including idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, connective tissue disease associated-interstitial lung disease, sarcoidosis and drug-induced interstitial lung disease. A multidisciplinary approach to diagnosis of interstitial lung disease is the gold standard; key history and examination features, blood panel, pulmonary function tests, high resolution computed tomography imaging, and when required bronchoalveolar lavage and lung biopsy results are discussed to reach a multidisciplinary consensus diagnosis. Advances, including the development of the disease-modifying anti-fibrotic medications nintedanib and pirfenidone, continue to shape the future management of interstitial lung disease. A holistic approach to the care of patients with interstitial lung disease is paramount, as they often have a high symptom burden and considerable palliative care needs.
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Affiliation(s)
- D Mudawi
- Interstitial Lung Disease Unit, Respiratory Medicine Department, Wythenshawe Hospital, Manchester, UK
| | - K Heyes
- Interstitial Lung Disease Unit, Respiratory Medicine Department, Wythenshawe Hospital, Manchester, UK
| | - R Hastings
- Barnet Hospital, Royal Free London NHS Foundation Trust, London UK
| | - P Rivera-Ortega
- Interstitial Lung Disease Unit, Respiratory Medicine Department, Wythenshawe Hospital, Manchester, UK
| | - N Chaudhuri
- Interstitial Lung Disease Unit, Respiratory Medicine Department, Wythenshawe Hospital, Manchester, UK
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19
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Abstract
PURPOSE OF REVIEW Lung transplantation (LTx) is increasingly used as ultimate treatment modality in end-stage interstitial lung diseases (ILDs). This review aims to give an overview of the latest evolutions in this field. RECENT FINDINGS In the last two years, important new findings regarding LTx outcomes in specific ILD entities have been reported. More data are available on optimization of pre-LTx management of ILD patients especially with regard to pretransplant antifibrotic treatment. SUMMARY LTx is the only treatment option with curative intent for ILDs and is increasingly used for this indication. Several studies have now reported adequate outcomes in different ILD entities, although outcome is shown to be affected by underlying telomeropathies. As new studies could not replicate inferior survival with single compared with double LTx, both options remain acceptable. ILD specialists can beneficially impact on post-LTx outcome by optimizing pre-LTx management: corticosteroids should be avoided, antifibrotics should be initiated whenever possible and BMI and nutritional status optimized, rehabilitation and depression-screening strategies should be implemented in all LTx candidates, as these interventions may all improve postlung transplant survival.
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20
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[Hypersensitivity Pneumonitis: An update]. Rev Med Interne 2021; 42:772-780. [PMID: 33941410 DOI: 10.1016/j.revmed.2021.03.333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/21/2021] [Accepted: 03/27/2021] [Indexed: 12/23/2022]
Abstract
Hypersensitivity Pneumonitis (HP) is a common immune-mediated interstitial lung disease (ILD) induced by repeated exposure to environmental antigens in susceptible individuals. The most commonly known forms are bird fancier's disease and farmer's lung. However, the antigens involved are widely diverse. Therefore, the list of causes of HP is frequently expanding. HP seems to be under-diagnosed owing to its highly heterogeneous presentation in both the non-fibrotic and fibrotic subtypes and could represent up to 15% of all ILDs encountered in clinical practice. However, the recognition of HP cases is essential to ensure appropriate therapy for the patient. Home health care workers' intervention is sometimes critical in this context. In case of confirmed exposure, the diagnosis could be considered with high confidence if the high-resolution computed tomography (HR-CT) shows a typical HP pattern associated with a lymphocytosis over 30% in the broncho-alveolar lavage (BAL). In all other situations, the patients should undergo further investigations and additional histopathological sampling should be considered and submitted to a multidisciplinary team discussion. After diagnosis, antigenic eviction is the rule whenever possible. Corticosteroid treatment is the first-line medical treatment for severe forms and aims to prevent the development of fibrosis. Anti-fibrotic therapy is now an option for patients with progressive ILD and failure of immunomodulatory/immunosuppressive therapies.
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21
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Abstract
CONTEXT.— Because granulomas are represented in almost every disease category, the number of clinically and pathologically important granulomatous pulmonary diseases is large. Their diagnosis by pathologists is particularly challenging because of their nonspecificity. A specific diagnosis can be achieved only when a granuloma-inciting agent(s) (eg, acid-fast bacilli, fungi, foreign bodies, etc) are identified microscopically or by culture; this does not occur in most cases. Furthermore, a specific diagnosis cannot be reached in a high percentage of cases. Although sarcoidosis and infectious diseases account for approximately half of pulmonary granulomatous diseases worldwide, there is significant geographic variation in their prevalence. OBJECTIVES.— To present updated information to serve as a guide to pathologic diagnosis of pulmonary granulomatous diseases, to address some commonly held misconceptions and to stress the importance of multidisciplinary coordination. Presentation of basic aspects of granulomas is followed by discussion of specific disease entities, such as tuberculous and nontuberculous Mycobacterial infections, fungal, bacterial, and parasitic infections, sarcoidosis, necrotizing sarcoid granulomatosis, berylliosis, hypersensitivity pneumonitis, hot tub lung, rheumatoid nodule, bronchocentric granulomatosis, aspirated, inhaled, and embolized foreign bodies, drug-induced granulomas, chronic granulomatous disease, common variable immunodeficiency, and granulomatous lesions associated with various types of cancer. DATA SOURCES.— Review of pertinent medical literature using the PubMed search engine and the author's practical experience. CONCLUSIONS.— Although the diagnosis of granulomatous lung diseases continues to present significant challenges to pathologists, the information presented in this review can be helpful in overcoming them. The importance of multidisciplinary coordination in cases where morphologic diagnosis is not possible cannot be overstated.
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Affiliation(s)
- Yale Rosen
- From the Department of Pathology, SUNY Downstate Health Sciences University, Brooklyn, New York
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22
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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23
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Nambiar AM, Walker CM, Sparks JA. Monitoring and management of fibrosing interstitial lung diseases: a narrative review for practicing clinicians. Ther Adv Respir Dis 2021; 15:17534666211039771. [PMID: 34477452 PMCID: PMC8422822 DOI: 10.1177/17534666211039771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Close monitoring of patients with fibrosing interstitial lung diseases (ILDs) is important to enable prompt identification and management of progressive disease. Monitoring should involve regular assessment of physiology (including pulmonary function tests), symptoms, and, when appropriate, high-resolution computed tomography. The management of patients with fibrosing ILDs requires a multidisciplinary approach and should be individualized based on factors such as disease severity, evidence of progression, risk factors for progression, comorbidities, and the preferences of the patient. In this narrative review, we discuss how patients with fibrosing ILDs can be effectively monitored and managed in clinical practice.
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Affiliation(s)
- Anoop M. Nambiar
- Division of Pulmonary and Critical Care
Medicine, Department of Medicine, University of Texas Health San Antonio,
7703 Floyd Curl Drive, MC 7885, San Antonio, TX 78229, USA
| | - Christopher M. Walker
- Cardiothoracic Imaging Division, Department of
Radiology, The University of Kansas Medical Center, Kansas City, KS,
USA
| | - Jeffrey A. Sparks
- Division of Rheumatology, Inflammation, and
Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
USA
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24
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Johannson KA, Barnes H, Bellanger AP, Dalphin JC, Fernández Pérez ER, Flaherty KR, Huang YCT, Jones KD, Kawano-Dourado L, Kennedy K, Millerick-May M, Miyazaki Y, Morisset J, Morell F, Raghu GR, Robbins C, Sack CS, Salisbury ML, Selman M, Vasakova M, Walsh SLF, Rose CS. Exposure Assessment Tools for Hypersensitivity Pneumonitis. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17:1501-1509. [PMID: 33258669 PMCID: PMC7706597 DOI: 10.1513/annalsats.202008-942st] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This report is based on proceedings from the Exposure Assessment Tools for Hypersensitivity Pneumonitis (HP) Workshop, sponsored by the American Thoracic Society, that took place on May 18, 2019, in Dallas, Texas. The workshop was initiated by members from the Environmental, Occupational, and Population Health and Clinical Problems Assemblies of the American Thoracic Society. Participants included international experts from pulmonary medicine, occupational medicine, radiology, pathology, and exposure science. The meeting objectives were to 1) define currently available tools for exposure assessment in evaluation of HP, 2) describe the evidence base supporting the role for these exposure assessment tools in HP evaluation, 3) identify limitations and barriers to each tool's implementation in clinical practice, 4) determine which exposure assessment tools demonstrate the best performance characteristics and applicability, and 5) identify research needs for improving exposure assessment tools for HP. Specific discussion topics included history-taking and exposure questionnaires, antigen avoidance, environmental assessment, specific inhalational challenge, serum-specific IgG testing, skin testing, lymphocyte proliferation testing, and a multidisciplinary team approach. Priorities for research in this area were identified.
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25
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Furusawa H, Cardwell JH, Okamoto T, Walts AD, Konigsberg IR, Kurche JS, Bang TJ, Schwarz MI, Brown KK, Kropski JA, Rojas M, Cool CD, Lee JS, Wolters PJ, Yang IV, Schwartz DA. Chronic Hypersensitivity Pneumonitis, an Interstitial Lung Disease with Distinct Molecular Signatures. Am J Respir Crit Care Med 2020; 202:1430-1444. [PMID: 32602730 PMCID: PMC7667907 DOI: 10.1164/rccm.202001-0134oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/25/2020] [Indexed: 12/11/2022] Open
Abstract
Rationale: Chronic hypersensitivity pneumonitis (CHP) is caused by an immune response to antigen inhalation and is characterized by variable histopathological and clinical features. A subset of subjects with CHP have usual interstitial pneumonia and appear to be clinically similar to subjects with idiopathic pulmonary fibrosis (IPF).Objectives: To determine the common and unique molecular features of CHP and IPF.Methods: Transcriptome analysis of lung samples from CHP (n = 82), IPF (n = 103), and unaffected controls (n = 103) was conducted. Differential gene expression was determined adjusting for sex, race, age, and smoking history and using false discovery rate to control for multiple comparisons.Measurements and Main Results: When compared with controls, we identified 413 upregulated and 317 downregulated genes in CHP and 861 upregulated and 322 downregulated genes in IPF. Concordantly upregulated or downregulated genes in CHP and IPF were related to collagen catabolic processes and epithelial development, whereas genes specific to CHP (differentially expressed in CHP when compared with control and not differentially expressed in IPF) were related to chemokine-mediated signaling and immune responsiveness. Using weighted gene coexpression network analysis, we found that among subjects with CHP, genes involved in adaptive immunity or epithelial cell development were associated with improved or reduced lung function, respectively, and that MUC5B expression was associated with epithelial cell development. MUC5B expression was also associated with lung fibrosis and honeycombing.Conclusions: Gene expression analysis of CHP and IPF identified signatures common to CHP and IPF, as well as genes uniquely expressed in CHP. Select modules of gene expression are characterized by distinct clinical and pathological features of CHP.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kevin K. Brown
- Department of Medicine
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Mauricio Rojas
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlyne D. Cool
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | | | - Paul J. Wolters
- Department of Internal Medicine, University of California, San Francisco, San Francisco, California
| | | | - David A. Schwartz
- Department of Medicine
- Department of Immunology and Microbiology, University of Colorado, Aurora, Colorado
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26
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Assessment and Management of Occupational Hypersensitivity Pneumonitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3295-3309. [PMID: 33161960 DOI: 10.1016/j.jaip.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
The diagnosis and treatment of occupational hypersensitivity pneumonitis (OHP) remain complex and challenging in the absence of diagnostic gold standards or clinical guidelines. This review provides an update of the recent literature regarding the different presentations of OHP and the diagnostic yield and value of the diagnostic tests currently available, which include occupational and medical history, laboratory tests (serum-specific immunoglobulins, environmental sampling), imaging, bronchoalveolar lavage, transbronchial biopsy, transbronchial cryobiopsy, surgical lung biopsy, and specific inhalation challenges. These tools provide a precise differential diagnosis within the framework of interstitial lung diseases. However, among the chronic fibrotic forms, distinguishing OHP from sarcoidosis, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis remains a diagnostic challenge. Avoidance of exposure is pivotal for OHP management, whereas corticosteroids are fundamental in the pharmacological approach to this disease. In addition, studies describing the long-term benefits of immunosuppressive and antifibrotic agents have increased the use of these treatments in OHP.
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27
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Ferreira M, Borie R, Crestani B, Rigaud P, Wemeau L, Israel-Biet D, Leroy S, Quétant S, Plantier L, Dalphin JC, Cottin V, Marchand-Adam S. Efficacy and safety of rituximab in patients with chronic hypersensitivity pneumonitis (cHP): A retrospective, multicentric, observational study. Respir Med 2020; 172:106146. [DOI: 10.1016/j.rmed.2020.106146] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/26/2020] [Accepted: 08/30/2020] [Indexed: 01/05/2023]
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28
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Costabel U, Miyazaki Y, Pardo A, Koschel D, Bonella F, Spagnolo P, Guzman J, Ryerson CJ, Selman M. Hypersensitivity pneumonitis. Nat Rev Dis Primers 2020; 6:65. [PMID: 32764620 DOI: 10.1038/s41572-020-0191-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 02/06/2023]
Abstract
Hypersensitivity pneumonitis (HP) is a complex syndrome caused by the inhalation of a variety of antigens in susceptible and sensitized individuals. These antigens are found in the environment, mostly derived from bird proteins and fungi. The prevalence and incidence of HP vary widely depending on the intensity of exposure, the geographical area and the local climate. Immunopathologically, HP is characterized by an exaggerated humoral and cellular immune response affecting the small airways and lung parenchyma. A complex interplay of genetic, host and environmental factors underlies the development and progression of HP. HP can be classified into acute, chronic non-fibrotic and chronic fibrotic forms. Acute HP results from intermittent, high-level exposure to the inducing antigen, usually within a few hours of exposure, whereas chronic HP mostly originates from long-term, low-level exposure (usually to birds or moulds in the home), is not easy to define in terms of time, and may occur within weeks, months or even years of exposure. Some patients with fibrotic HP may evolve to a progressive phenotype, even with complete exposure avoidance. Diagnosis is based on an accurate exposure history, clinical presentation, characteristic high-resolution CT findings, specific IgG antibodies to the offending antigen, bronchoalveolar lavage and pathological features. Complete antigen avoidance is the mainstay of treatment. The pharmacotherapy of chronic HP consists of immunosuppressive drugs such as corticosteroids, with antifibrotic therapy being a potential therapy for patients with progressive disease.
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Affiliation(s)
- Ulrich Costabel
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany.
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Dirk Koschel
- Department of Internal Medicine and Pneumology, Fachkrankenhaus Coswig, Centre for Pulmonary Diseases and Thoracic Surgery, Coswig, Germany.,Division of Pneumology, Medical Department I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Josune Guzman
- General and Experimental Pathology, Ruhr-University, Bochum, Germany
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
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Raghu G, Remy-Jardin M, Ryerson CJ, Myers JL, Kreuter M, Vasakova M, Bargagli E, Chung JH, Collins BF, Bendstrup E, Chami HA, Chua AT, Corte TJ, Dalphin JC, Danoff SK, Diaz-Mendoza J, Duggal A, Egashira R, Ewing T, Gulati M, Inoue Y, Jenkins AR, Johannson KA, Johkoh T, Tamae-Kakazu M, Kitaichi M, Knight SL, Koschel D, Lederer DJ, Mageto Y, Maier LA, Matiz C, Morell F, Nicholson AG, Patolia S, Pereira CA, Renzoni EA, Salisbury ML, Selman M, Walsh SLF, Wuyts WA, Wilson KC. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:e36-e69. [PMID: 32706311 PMCID: PMC7397797 DOI: 10.1164/rccm.202005-2032st] [Citation(s) in RCA: 459] [Impact Index Per Article: 114.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.
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30
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Hanzawa S, Tateishi T, Ishizuka M, Inoue Y, Honda T, Kawahara T, Tomita M, Miyazaki Y. Changes in serum KL-6 levels during short-term strict antigen avoidance are associated with the prognosis of patients with fibrotic hypersensitivity pneumonitis caused by avian antigens. Respir Investig 2020; 58:457-464. [PMID: 32698996 DOI: 10.1016/j.resinv.2020.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/13/2020] [Accepted: 05/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bird-related hypersensitivity pneumonitis (BRHP) is the most common type of fibrotic hypersensitivity pneumonitis (HP). Antigen avoidance (AA) is a key step in the diagnosis and management of HP, but not all fibrotic HP patients improve through AA. Because of the poor prognosis of fibrotic HP, predictive biomarkers to identify patients showing rapid progression during AA are urgently needed. METHODS From a retrospective review of the medical records of 1941 patients with interstitial lung disease, 75 cases of fibrotic BRHP confirmed by a provocation test or surgical lung biopsy were identified. To identify potential prognostic markers obtained at or around diagnosis, physiological and serological variables at diagnosis and the relative changes in those variables during strict AA were evaluated. Cox proportional hazards models with log-rank testing were used to compare the associations between these variables and survival. RESULTS Univariate analyses showed that gender, smoking status, and the relative change in the serum levels of Krebs von den Lungen-6 (KL-6) were associated with prognosis (P = 0.02, 0.04, and 0.02, respectively), but the presence of honeycombing and the forced vital capacity were not associated with survival. The relative change in KL-6 levels (greater than vs. less than a 10% decrease) was significantly associated with survival in a stratified analysis (73.9 vs. 34.9 months; P = 0.04). CONCLUSIONS The relative change in KL-6 levels is associated with the prognosis of patients with fibrotic BRHP independent of previously identified prognostic biomarkers. This finding could help pulmonologists identify fibrotic BRHP patients that are likely to show rapid progression.
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Affiliation(s)
- Satoshi Hanzawa
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Tomoya Tateishi
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Masahiro Ishizuka
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Yukihisa Inoue
- Department of Respiratory Medicine, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka, Kanagawa, 254-8502, Japan.
| | - Takayuki Honda
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Tatsuo Kawahara
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Makoto Tomita
- School of Data Science, Yokohama City University, 1-50-1, Mutsuura Higashi, Kanazawa-ku, Yokohama, Kanagawa, 236-8501, Japan.
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Stącel T, Nęcki M, Antończyk R, Latos M, Urlik M, Kościołek J, Kordylewska-Kubus A, Litewka J, Przybyłowski P, Zawadzki F, Wajda-Pokrontka M, Pyrć K, Zembala M, Ochman M. Effectiveness of Lung Transplantation in Patients With Interstitial Lung Diseases. Transplant Proc 2020; 52:2143-2148. [PMID: 32571712 DOI: 10.1016/j.transproceed.2020.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Interstitial lung diseases (ILDs) are a heterogeneous group of more than 200 diseases manifested by progressive exercise dyspnea, radiological lung changes, and ventilation restrictive disorders. ILDs are the second most common indication for lung transplantation (LTx). Our study group consisted of 139 patients who qualified for LTx at the Silesian Center for Heart Diseases between 2004 and 2018. Of the 139, 92 patients died while on the waiting list, and 47 patients underwent LTx. Medical records including laboratory test results, spirometry, and the 6-minute walk test (6MWT) were analyzed to determine eligibility for LTx. We also assessed quality of life post-LTx. RESULTS Patients who qualified for LTx showed decreased values of parameters measured by spirometry (43.69 ± 19.05% of forced expiratory volume in the first second [FEV1] and 43.07 ± 20.55% of forced vital capacity [FVC] and severe desaturation during the 6MWT (SpO2 = 88.78% before 6-minute walk test and 73.23% after the test). After LTx, longer distances were achieved in the 6MWT (235.47 ± 159.57 m during qualification vs 533.2 ± 34.15 m 12 months after LTx) and increased values of spirometry. On average, patients had stopped working 6 years prior to LTx. CONCLUSION There is no effective medical treatment for patients with end-stage ILDs. Therefore, lung transplantation is a lifesaving procedure for patients that also extends patients' lives and improves their quality of life.
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Affiliation(s)
- Tomasz Stącel
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Mirosław Nęcki
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Remigiusz Antończyk
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Magdalena Latos
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Maciej Urlik
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Joanna Kościołek
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Angelika Kordylewska-Kubus
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Joanna Litewka
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland; Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Fryderyk Zawadzki
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marta Wajda-Pokrontka
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Pyrć
- Małopolska Centre of Biotechnology, Jagiellonian University, Krakow, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.
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Varone F, Iovene B, Sgalla G, Calvello M, Calabrese A, Larici AR, Richeldi L. Fibrotic Hypersensitivity Pneumonitis: Diagnosis and Management. Lung 2020; 198:429-440. [PMID: 32415523 DOI: 10.1007/s00408-020-00360-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/05/2020] [Indexed: 11/26/2022]
Abstract
Fibrotic hypersensitivity pneumonitis is a complex interstitial lung disease that is not entirely understood. In its chronic and fibrotic form, hypersensitivity pneumonitis is one of the main mimickers of idiopathic pulmonary fibrosis (IPF). Distinguishing between these two conditions is challenging but is of particular clinical relevance. Two approved therapies are available for IPF, and a considerable number of clinical trials are now exploring newer pharmacological options. This impressive research effort is a consequence of new pathogenetic understanding, updated diagnostic criteria and a long history of pharmacological trials. Conversely, current knowledge gaps on pathogenesis of chronic hypersensitivity pneumonitis, coupled with lack of validated diagnostic criteria, make the management of this disease an unsolved clinical challenge. This also reflects the paucity of therapeutic clinical trials in this field. In this review, we describe the current evidence and the possible future options to approach this complex disease.
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Affiliation(s)
- Francesco Varone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Iovene
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Sgalla
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Angelo Calabrese
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anna Rita Larici
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Richeldi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Adderley N, Humphreys CJ, Barnes H, Ley B, Premji ZA, Johannson KA. Bronchoalveolar lavage fluid lymphocytosis in chronic hypersensitivity pneumonitis: a systematic review and meta-analysis. Eur Respir J 2020; 56:13993003.00206-2020. [DOI: 10.1183/13993003.00206-2020] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/28/2020] [Indexed: 11/05/2022]
Abstract
BackgroundThe role of bronchoalveolar lavage fluid (BALF) lymphocyte percentage in diagnosing chronic hypersensitivity pneumonitis (CHP) is unclear. We conducted a systematic review and meta-analysis of bronchoalveolar lavage (BAL) lymphocyte percentage in the diagnosis of CHP.MethodsWe searched Medline, Embase and the Cochrane Library from inception to August 2019. Individual patient data were obtained to test performance characteristics of BAL lymphocyte percentage at different thresholds. Random-effects models were used for pooled estimates, with comparisons made between CHP and non-CHP interstitial lung diseases (ILDs).ResultsFifty-three studies were included in the systematic review and 42 in the meta-analysis. The pooled estimate for BAL lymphocyte percentage was 42.8% (95% CI 37.7–47.8, I2=95.3%) in CHP, 10.0% (95% CI 6.9–13.1, I2=91.2%) in idiopathic pulmonary fibrosis (IPF), 23.1% (95% CI 3.0–43.2, I2=85.2%) in non-IPF idiopathic interstitial pneumonia (IIP), 23.4% (95% CI 11.0–35.9, I2=45.7%) in connective-tissue disease associated ILD (CTD-ILD) and 31.2% (95% CI 17.6–44.8, I2=95.2%) in sarcoidosis. Results differed between CHP and IPF (p<0.0001), non-IPF IIP (p=0.0309) or CTD-ILD (p=0.0824), but not between CHP and sarcoidosis (p=0.0966). Using individual patient data from eight studies, a lymphocyte percentage threshold of >20% provided a sensitivity of 68.1% and a specificity of 64.8% for CHP. Higher thresholds provided lower sensitivity with higher specificity. Older age and ever having smoked were associated with lower lymphocyte percentage in CHP.ConclusionsBAL lymphocyte percentage is higher in CHP compared to IPF and other IIPs, with higher thresholds providing improved specificity at the cost of sensitivity. However, the parent studies are at risk of incorporation bias and prospective studies should evaluate the additive discriminate value of BAL lymphocyte percentage to accurately diagnose CHP.
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Clinical characteristics and outcomes of hypersensitivity pneumonitis: a population-based study in China. Chin Med J (Engl) 2019; 132:1283-1292. [PMID: 31021982 PMCID: PMC6629344 DOI: 10.1097/cm9.0000000000000256] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Backgrounds: Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease (ILD) that develops in response to the inhalation of various antigens. The clinical pathologies are very complex and undetermined. The clinical features and outcomes of HP have not been fully elucidated. The aim of this study was to analyze the incidence, clinical features, and outcomes of HP patients and construct a simple clinical model for diagnosing chronic HP (CHP). Methods: The cohort study included 101 patients with HP admitted to the Nanjing Drum Tower Hospital from January 2009 to December 2017. The patients were categorized into acute HP (AHP, n = 72) and CHP (n = 29) groups according to the updated international criteria. The clinical, imaging, treatment, and follow-up data were retrospectively reviewed. All patients were followed up until December 31, 2017. Statistical analysis was performed, and a clinical scoring system for CHP was constructed by SPSS 20.0 software. Results: The incidence of HP was 2.4% in ILD inpatients in our center. Patients in the CHP group were older (t = −2.212, P = 0.029), had more smokers (χ2 = 8.428, P = 0.004), and longer duration of symptoms (t = −4.852, P < 0.001) than those in the AHP group. Weight loss, crackles, digital clubbing, and cyanosis were more common in the CHP group than those in the AHP group (χ2 = 5.862, P < 0.001; χ2 = 8.997, P = 0.003; χ2 = 11.939, P = 0.001; and χ2 = 4.025, P = 0.045, respectively). On chest high-resolution computed tomography (HRCT), reticular patterns, traction bronchiectasis, and accompanying honeycombing were more common in CHP cases than those in AHP cases (χ2 = 101.000, P < 0.001; χ2 = 32.048, P < 0.001; and χ2 = 36.568, P < 0.001, respectively). The clinical scoring system for CHP was established based on the clinical variables (age [A], duration of symptoms [D], smoking history [S], unidentified exposure [U], and chest HRCT [C]; ADSUC) (area under the curve 0.935, 95% confidence interval: 0.883–0.987, P < 0.001). Eleven patients (15.3%) in the AHP group developed CHP, and unidentified exposure was an independent risk factor for the progression of disease (P = 0.038). The survival of patients with CHP, smoking history, unidentified antigens and fibrosis on Chest HRCT were significantly worse (P = 0.011, P = 0.001, P = 0.005, and P = 0.011, respectively) by Kaplan-Meier analysis. Cox multivariate regression analysis revealed that unidentified exposure and total lung volume (TLC pred%) were independent prognostic predictors for HP patients (P = 0.017 and P = 0.017, respectively). Conclusions: The clinical features and outcomes of the CHP patients differ from those of the AHP patients. ADSUC is a simple and feasible clinical model for CHP. Unidentified exposure is an independent risk factor for the progression of AHP to CHP. Unidentified exposure and a low baseline TLC pred% are independent predictors for survival in HP patients.
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Tam WS, Islam T, Nambiar AM. Hypersensitivity Pneumonitis (Including Environmental Assessment): Diagnosis and Management. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-00239-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Morisset J, Lee JS. New trajectories in the treatment of interstitial lung disease: treat the disease or treat the underlying pattern? Curr Opin Pulm Med 2019; 25:442-449. [PMID: 31365378 PMCID: PMC11008767 DOI: 10.1097/mcp.0000000000000600] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW A subset of patients with interstitial lung diseases (ILDs), such as rheumatoid arthritis (RA)-associated ILD and chronic hypersensitivity pneumonitis, will experience a disease course similar to patients with idiopathic pulmonary fibrosis (IPF). They also often have a usual interstitial pneumonia (UIP) pattern of fibrosis. Although the standard of care for patients with RA-ILD and chronic hypersensitivity pneumonitis is immunosuppression, the optimal treatment for patients with progressive disease and a UIP pattern remains unknown. RECENT FINDINGS Recent research has highlighted shared risk factors, disease behavior and pathobiology between RA-ILD, chronic hypersensitivity pneumonitis and IPF. The presence of a UIP pattern, in both RA-ILD and chronic hypersensitivity pneumonitis, is associated with a worse prognosis. Moreover, genetic risk factors, previously well characterized in IPF, are increasingly being linked to RA-ILD and chronic hypersensitivity pneumonitis. The MUC5B promoter variant rs5705950, telomerase complex mutations and short telomere lengths are also linked to an increased susceptibility to pulmonary fibrosis in RA and chronic hypersensitivity pneumonitis. SUMMARY IPF shares several clinical, genetic and biological features with other ILDs exhibiting the UIP pattern. The optimal pharmacologic management of these patients remains uncertain. Several ongoing trials are evaluating the efficacy of antifibrotic medications in these other diagnoses and may change how we approach ILD treatment.
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Affiliation(s)
- Julie Morisset
- Département de Médecine, Centre Hospitalier de l’Université de Montréal, Québec, Canada
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Colorado, USA
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Falque L, Gheerbrant H, Saint-Raymond C, Quétant S, Camara B, Briault A, Porcu P, Pirvu A, Durand M, Pison C, Claustre J. [Selection of lung transplant candidates in France in 2019]. Rev Mal Respir 2019; 36:508-518. [PMID: 31006579 DOI: 10.1016/j.rmr.2018.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/30/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time. BACKGROUND The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment. OUTLOOK AND CONCLUSION These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.
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Affiliation(s)
- L Falque
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France
| | - H Gheerbrant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France
| | - C Saint-Raymond
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - S Quétant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - B Camara
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - A Briault
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - P Porcu
- Service de chirurgie cardiaque, pôle thorax et vaisseaux, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - A Pirvu
- Service de chirurgie thoracique et vasculaire, pôle thorax et vaisseaux, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - M Durand
- Service de réanimation cardio-vasculaire et thoracique, pôle anesthésie-réanimation, CHU de Grenoble-Alpes, 38000 Grenoble, France
| | - C Pison
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France; Inserm1055, laboratoire de bioénergétique fondamentale et appliquée, 38000 Grenoble, France
| | - J Claustre
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38000 Grenoble, France; Université Grenoble-Alpes, 38000 Grenoble, France.
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Chronisch-fibrosierende Lungenerkrankungen. Internist (Berl) 2019; 60:345-361. [DOI: 10.1007/s00108-019-0571-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW A number of recent studies have explored the possibility to apply personalized medicine to interstitial lung diseases (ILDs), particularly idiopathic pulmonary fibrosis (IPF), the most common and deadly of the idiopathic interstitial pneumonias. In our review, we summarize and discuss the most recent literature on personalized medicine in IPF as well as hypersensitivity pneumonitis and sarcoidosis, with emphasis on patient subgroups for which a personalized approach to disease prognostication and management may become a reality in the near future. RECENT FINDINGS Most of the studies that have explored the applicability of personalized medicine to ILDs have been conducted in patients with IPF. Such studies have suggested the existence of several distinct disease subgroups defined by similar genetic profiles, molecular pathways, exposures and individual lifestyles. Personalized medicine in hypersensitivity pneumonitis is in its infancy. The development and applicability of personalized medicine to sarcoidosis, on the other hand, remains problematic for several reasons, including the lack of a diagnostic gold standard, the highly variable and unpredictable disease course, particularly across patients of different ethnicities, the poor correlation between disease activity and disease severity and the lack of a validated management algorithm. SUMMARY A number of distinct patient subgroups have been identified in ILDs. Although available data need to be validated longitudinally, the possibility to study homogeneous groups of patients may allow prediction of disease behavior and response to treatment with dramatic clinical implications.
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Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity Pneumonitis: Perspectives in Diagnosis and Management. Am J Respir Crit Care Med 2017; 196:680-689. [PMID: 28598197 DOI: 10.1164/rccm.201611-2201pp] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Martina Vasakova
- 1 Department of Respiratory Medicine, First Faculty of Medicine of Charles University, Thomayer Hospital Prague, Prague, Czech Republic
| | - Ferran Morell
- 2 Vall d'Hebron Institut de Recerca, Servei de Pneumología, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autonóma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Respiratoria, Barcelona, Catalonia, Spain
| | - Simon Walsh
- 3 King's College National Health Service Hospital Foundation Trust, Denmark Hill, London, United Kingdom
| | | | - Ganesh Raghu
- 5 Center for Interstitial Lung Diseases, University of Washington Medical Center, Seattle, Washington
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Salisbury ML, Myers JL, Belloli EA, Kazerooni EA, Martinez FJ, Flaherty KR. Diagnosis and Treatment of Fibrotic Hypersensitivity Pneumonia. Where We Stand and Where We Need to Go. Am J Respir Crit Care Med 2017; 196:690-699. [PMID: 28002680 DOI: 10.1164/rccm.201608-1675pp] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | | | - Ella A Kazerooni
- 3 Department of Radiology, University of Michigan, Ann Arbor, Michigan; and
| | - Fernando J Martinez
- 4 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cornell Medical College, New York, New York
| | - Kevin R Flaherty
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine
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Ley B, Newton CA, Arnould I, Elicker BM, Henry TS, Vittinghoff E, Golden JA, Jones KD, Batra K, Torrealba J, Garcia CK, Wolters PJ. The MUC5B promoter polymorphism and telomere length in patients with chronic hypersensitivity pneumonitis: an observational cohort-control study. THE LANCET RESPIRATORY MEDICINE 2017. [PMID: 28648751 PMCID: PMC5555581 DOI: 10.1016/s2213-2600(17)30216-3] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with hypersensitivity pneumonitis are at risk of developing pulmonary fibrosis, which is associated with reduced survival. In families with multiple affected members, individuals might be diagnosed as having idiopathic pulmonary fibrosis (IPF) or chronic (fibrotic) hypersensitivity pneumonitis, which suggests these disorders share risk factors. We aimed to test whether the genomic risk factors associated with the development and progression of IPF are also associated with the development of fibrosis and reduced survival in people with chronic hypersensitivity pneumonitis. METHODS We did an observational study of two independent cohorts of patients with chronic hypersensitivity pneumonitis, one from the University of California San Francisco, CA, USA (UCSF), and one from the University of Texas Southwestern, TX, USA (UTSW). We measured two common single-nucleotide polymorphisms associated with IPF (MUC5B rs35705950 and TOLLIP rs5743890) and telomere length in peripheral blood leucocytes, and assessed their associations with chronic hypersensitivity pneumonitis risk, survival, and clinical, radiographic, and pathological features. We compared findings with those in patients with IPF from the UCSF and UTSW cohorts, and healthy controls from the European population of the 1000 Genomes Project Phase 3, version 1. FINDINGS The cohorts included 145 patients from UCSF and 72 from UTSW. The minor allele frequency (MAF) was greater for MUC5B rs35705950 in patients with chronic hypersensitivity pneumonitis than in healthy controls (24·4% in UCSF and 32·3% in UTSW vs 10·7%, both p<0·0001), but not for TOLLIP rs5743890. The MAFs were similar to those for IPF (UCSF 33·3%, p=0·09; UTSW 32·0%, p=0·95). In the combined UCSF and UTSW chronic hypersensitivity pneumonitis cohort, we saw associations between extent of radiographic fibrosis and MUC5B rs35705950 minor alleles (adjusted odds ratio [OR] 1·91, 95% CI 1·02-3·59, p=0·045) and short telomere length (adjusted OR per unit change in mean natural logarithm-transformed ratio of telomere repeat copy number to single gene copy number 0·23, 0·09-0·59, p=0·002). Telomere length less than the tenth percentile for age was also significantly associated with reduced survival (log-rank p=0·006). INTERPRETATION The associations between MUC5B rs35705950 and short telomere length with extent of fibrosis, histopathological features of usual interstitial pneumonia, and reduced survival in patients with chronic hypersensitivity pneumonitis suggest shared pathobiology with IPF, and might help to stratify risk. FUNDING National Institutes of Health and Nina Ireland Program for Lung Health.
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Affiliation(s)
- Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Chad A Newton
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Isabel Arnould
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christine Kim Garcia
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Churg A, Bilawich A, Wright JL. Pathology of Chronic Hypersensitivity Pneumonitis What Is It? What Are the Diagnostic Criteria? Why Do We Care? Arch Pathol Lab Med 2017; 142:109-119. [DOI: 10.5858/arpa.2017-0173-ra] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Chronic hypersensitivity pneumonitis (CHP) has emerged from obscurity during the past 15 years and is now recognized as a very common form of fibrosing interstitial pneumonia but one that is frequently misdiagnosed both clinically and on surgical lung biopsy as usual interstitial pneumonia/idiopathic pulmonary fibrosis (UIP/IPF) or fibrotic nonspecific interstitial pneumonia.
Objective.—
To review the pathologic features of CHP.
Data Sources.—
Clinical, pathology, and radiology literature were used.
Conclusions.—
Upper lobe–predominant fibrosis and/or air-trapping on computed tomography scan are features of CHP but not UIP/IPF; however, radiologic separation is possible in only about 50% of cases. Morphologically, CHP sometimes mimics UIP/IPF, but CHP often shows isolated foci of peribronchiolar (centrilobular) fibrosis, frequently associated with fibroblast foci, and in CHP, fibrosis may bridge from the centrilobular region to another bronchiole, an interlobular septum, or the pleura (“bridging fibrosis”). This set of findings is uncommon in UIP/IPF. In addition, CHP may produce a picture of fibrotic nonspecific interstitial pneumonia. Although giant cells/granulomas are usually present in subacute hypersensitivity pneumonitis, they are much less frequently found in CHP, and their absence does not contradict the diagnosis. This diagnostic separation is clinically important because CHP is treated differently than UIP/IPF is (immunosuppressive agents versus antifibrotic agents); further, there are some data to suggest that removing the patient from antigen exposure improves outcome, and there is evidence that patients with CHP have a much better survival prognosis after lung transplantation than do patients with UIP/IPF. In most cases, accurate diagnosis of CHP requires consultation among clinicians, radiologists, and pathologists.
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Affiliation(s)
- Andrew Churg
- From the Departments of Pathology (Dr Churg) and Radiology (Dr Bilawich), Vancouver General Hospital and University of British Columbia, Vancouver, Canada; and the Department of Pathology (Dr Wright), St Paul's Hospital and University of British Columbia, Vancouver
| | - AnaMaria Bilawich
- From the Departments of Pathology (Dr Churg) and Radiology (Dr Bilawich), Vancouver General Hospital and University of British Columbia, Vancouver, Canada; and the Department of Pathology (Dr Wright), St Paul's Hospital and University of British Columbia, Vancouver
| | - Joanne L. Wright
- From the Departments of Pathology (Dr Churg) and Radiology (Dr Bilawich), Vancouver General Hospital and University of British Columbia, Vancouver, Canada; and the Department of Pathology (Dr Wright), St Paul's Hospital and University of British Columbia, Vancouver
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Abstract
Allergic asthma refers to a chronic reversible bronchoconstriction influenced by an allergic trigger, leading to symptoms of cough, wheezing, shortness of breath, and chest tightness. Allergic bronchopulmonary aspergillosis is a complex hypersensitivity reaction, often in patients with asthma or cystic fibrosis, occurring when bronchi become colonized by Aspergillus species. The clinical picture is dominated by asthma complicated by recurrent episodes of bronchial obstruction, fever, malaise, mucus production, and peripheral blood eosinophilia. Hypersensitivity pneumonitis is a syndrome associated with lung inflammation from the inhalation of airborne antigens, such as molds and dust.
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Affiliation(s)
- Jason Raymond Woloski
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA.
| | - Skye Heston
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA
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Pereira CA, Gimenez A, Kuranishi L, Storrer K. Chronic hypersensitivity pneumonitis. J Asthma Allergy 2016; 9:171-181. [PMID: 27703382 PMCID: PMC5036552 DOI: 10.2147/jaa.s81540] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Hypersensitivity pneumonitis (HSP) is a common interstitial lung disease resulting from inhalation of a large variety of antigens by susceptible individuals. The disease is best classified as acute and chronic. Chronic HSP can be fibrosing or not. Fibrotic HSP has a large differential diagnosis and has a worse prognosis. The most common etiologies for HSP are reviewed. Diagnostic criteria are proposed for both chronic forms based on exposure, lung auscultation, lung function tests, HRCT findings, bronchoalveolar lavage, and biopsies. Treatment options are limited, but lung transplantation results in greater survival in comparison to idiopathic pulmonary fibrosis. Randomized trials with new antifibrotic agents are necessary.
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Affiliation(s)
| | - Andréa Gimenez
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
| | - Lilian Kuranishi
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
| | - Karin Storrer
- Pulmonology Postgraduate, Federal University of São Paulo, São Paulo, Brazil
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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.
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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
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Adegunsoye A, Strek ME. Therapeutic Approach to Adult Fibrotic Lung Diseases. Chest 2016; 150:1371-1386. [PMID: 27521738 PMCID: PMC5989635 DOI: 10.1016/j.chest.2016.07.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 12/19/2022] Open
Abstract
Among the interstitial lung diseases (ILDs), idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis, and fibrotic connective tissue disease-related ILD are associated with a worse prognosis, with death occurring as a result of both respiratory failure and serious associated comorbidities. The recent development and approval of the antifibrotic agents nintedanib and pirfenidone, both of which reduced the rate of decline in lung function in patients with IPF in clinical trials, offer hope that it may be possible to alter the increased mortality associated with IPF. Although chronic hypersensitivity pneumonitis and connective tissue disease related-ILD may be associated with an inflammatory component, the evidence for the use of immunosuppressive agents in their treatment is largely limited to retrospective studies. The lack of benefit of immunosuppressive therapy in advanced fibrosis argues for rigorous clinical trials using antifibrotic therapies in these types of ILD as well. Patients with fibrotic ILD may benefit from identification and management of associated comorbid conditions such as pulmonary hypertension, gastroesophageal reflux, and OSA, which may improve the quality of life and, in some cases, survival in affected individuals. Because early assessment may optimize posttransplantation outcomes, lung transplant evaluation should occur early in patients with IPF and those with other forms of fibrotic ILD.
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Affiliation(s)
- Ayodeji Adegunsoye
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL.
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
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Cano-Jiménez E, Acuña A, Botana MI, Hermida T, González MG, Leiro V, Martín I, Paredes S, Sanjuán P. Revisión de la enfermedad del pulmón de granjero. Arch Bronconeumol 2016; 52:321-8. [DOI: 10.1016/j.arbres.2015.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
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49
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50
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Quirce S, Vandenplas O, Campo P, Cruz MJ, de Blay F, Koschel D, Moscato G, Pala G, Raulf M, Sastre J, Siracusa A, Tarlo SM, Walusiak-Skorupa J, Cormier Y. Occupational hypersensitivity pneumonitis: an EAACI position paper. Allergy 2016; 71:765-79. [PMID: 26913451 DOI: 10.1111/all.12866] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- S. Quirce
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPAZ) and CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - O. Vandenplas
- Department of Chest Medicine; Centre Hospitalier Universitaire de Mont-Godinne; Université Catholique de Louvain; Yvoir Belgium
| | - P. Campo
- Unidad de Gestión Clínica Allergy-IBIMA; Hospital Regional Universitario; Málaga Spain
| | - M. J. Cruz
- Pulmonology Service; Hospital Universitari Vall d'Hebron; Universitat Autonoma de Barcelona; Barcelona Spain
- CIBER de Enfermedades Respiratorias (CIBERES); Barcelona Spain
| | - F. de Blay
- Division of Asthma and Allergy; Department of Chest Diseases; University Hospital; Fédération de Médecine Translationnelle de Strasbourg; Strasbourg University; Strasbourg France
| | - D. Koschel
- Fachkrankenhaus Coswig GmbH Zentrum für Pneumologie, Allergologie, Beatmungsmedizin, Thorax- und Gefäßchirurgie; Coswig Germany
| | - G. Moscato
- Department of Public Health, Experimental and Forensic Medicine; University of Pavia; Pavia Italy
| | - G. Pala
- Occupational Physician's Division; Local Health Authority of Sassari; Sassari Italy
| | - M. Raulf
- IPA Institute for Prevention and Occupational Medicine of the German Social Accident Insurance; Institute of the Ruhr-Universität Bochum; Bochum Germany
| | - J. Sastre
- Department of Allergy; Fundación Jiménez Díaz, and CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - A. Siracusa
- Formerly Department of Clinical and Experimental Medicine; University of Perugia; Perugia Italy
| | - S. M. Tarlo
- Department of Medicine and Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
- Respiratory Division Toronto Western Hospital; Gage Occupational and Environmental Health Unit; St Michael's Hospital; Toronto ON Canada
| | - J. Walusiak-Skorupa
- Department of Occupational Diseases and Toxicology; Nofer Institute of Occupational Medicine; Lodz Poland
| | - Y. Cormier
- Centre de Pneumologie; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec City QC Canada
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