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Chelala L, Adegunsoye A, Strek M, Lee CT, Jablonski R, Husain AN, Udofia I, Chung JH. Hypersensitivity Pneumonitis on Thin-Section Chest CT Scans: Diagnostic Performance of the ATS/JRS/ALAT versus ACCP Imaging Guidelines. Radiol Cardiothorac Imaging 2024; 6:e230068. [PMID: 38990131 PMCID: PMC11369651 DOI: 10.1148/ryct.230068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/01/2024] [Accepted: 05/24/2024] [Indexed: 07/12/2024]
Abstract
Purpose To compare the diagnostic performance of the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) versus the American College of Chest Physicians (ACCP) imaging classifications for hypersensitivity pneumonitis (HP). Materials and Methods Patients in the institutional review board-approved Interstitial Lung Disease (ILD) registry referred for multidisciplinary discussion (MDD) at the authors' institution (January 1, 2006-April 1, 2021) were included in this retrospective study when ILD was diagnosed at MDD. MDD diagnoses included HP, connective tissue disease-ILD, and idiopathic pulmonary fibrosis. Retrospective review of thin-section CT images was performed in consensus by two cardiothoracic radiologists blinded to the diagnosis. Diagnostic patterns were determined for thin-section CT images using both classifications. Discordance rates were determined. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were assessed using MDD diagnosis as the reference standard. Results A total of 297 patients were included in the study: 200 (67%) with HP, 49 (16%) with connective tissue disease-ILD, and 48 (16%) with idiopathic pulmonary fibrosis at MDD. The discordance rate between the two classifications was 21%. Assuming low HP prevalence (10%), ATS/JRS/ALAT classification outperformed ACCP classification, with greater accuracy (92.3% vs 87.6%) and greater positive predictive value (60.7% vs 42.9%). Assuming high prevalence (50%), accuracy and negative predictive value were superior using ACCP classification (81.7% vs 79.7% and 77.7% vs 72.6%, respectively), and positive predictive value was superior using ATS/JRS/ALAT classification (93.3% vs 87.1%). Conclusion Accuracy of the ATS/JRS/ALAT and ACCP HP classifications was greater in settings with low and high HP prevalence, respectively. Diagnostic performance of both classifications was discordant in a minority of cases. Keywords: CT, Thorax, Hypersensitivity Pneumonitis, Interstitial Lung Disease Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Lydia Chelala
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Ayodeji Adegunsoye
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Mary Strek
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Cathryn T. Lee
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Renea Jablonski
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Aliya N. Husain
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Inemesit Udofia
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
| | - Jonathan H. Chung
- From the Department of Cardiopulmonary Imaging (L.C., J.H.C.),
Department of Medicine, Section of Pulmonary & Critical Care (A.A., M.S.,
C.T.L., R.J., I.U.), and Department of Pathology (A.N.H.), University of Chicago
Medicine, 5841 S Maryland Ave, Chicago, IL 60637
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Reccardini N, Chernovsky M, Salton F, Confalonieri P, Mondini L, Barbieri M, Romallo A, Maggisano M, Torregiani C, Geri P, Hughes M, Campochiaro C, Confalonieri M, Scarda A, Zuccon U, Ruaro B. Pirfenidone in Idiopathic Pulmonary Fibrosis: Real-World Observation on Efficacy and Safety, Focus on Patients Undergoing Antithrombotic and Anticoagulant. Pharmaceuticals (Basel) 2024; 17:930. [PMID: 39065780 PMCID: PMC11280355 DOI: 10.3390/ph17070930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/28/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a rare and progressive interstitial lung disease characterized by irreversible distortion of lung architecture and subsequent loss of pulmonary function. Pirfenidone is an antifibrotic agent associated with increased progression-free survival and overall survival rates, but it carries multiple side effects. The aim of the study was to examine the efficacy and safety profile of pirfenidone in a real-life context, with a focus on the concomitant use of antithrombotic and/or anticoagulant treatments. The clinical and functional data (forced vital capacity [FVC], forced expiratory volume in 1 s [FEV1], diffusing lung capacity for carbon monoxide [DLCO], and 6 min walking test distance [6MWD]) of all IPF patients treated with pirfenidone and referred to our two centers between 2019 and 2022 were retrospectively analyzed at baseline, 6 and 12 months after the start of treatment. A total of 55 IPF subjects undergoing pirfenidone treatment were included in the analysis (45.5% females, median [IQR] age at disease onset 68.0 [10.0] years, median [IQR] age at baseline 69.0 [10.8] years). Compared to baseline, at 12 months, FVC (86.0% vs. 80.0%; p = 0.023) and DLCO (44.0% vs. 40.0%; p = 0.002) were significantly reduced, while FEV1 (p = 0.304) and 6MWD (p = 0.276) remained stable; no significant change was recorded at 6 months. Most of the reported adverse events were mild or moderate. Gastrointestinal intolerance (9.1%) was the main cause of treatment discontinuation. A total of 5% of patients reported at least one minor bleeding event, although all episodes occurred in those receiving concomitant antithrombotic or anticoagulant. Overall, this real-life experience confirms the efficacy and safety profile of pirfenidone in the case of the concomitant use of antithrombotic and/or anticoagulant drugs.
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Affiliation(s)
- Nicolò Reccardini
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Maria Chernovsky
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Francesco Salton
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Paola Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Lucrezia Mondini
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Mariangela Barbieri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Antonio Romallo
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Marta Maggisano
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Chiara Torregiani
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Pietro Geri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Michael Hughes
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Healt, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Marco Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Angelo Scarda
- Pulmonology Unit, General Hospital “Santa Maria degli Angeli”, 33170 Pordenone, Italy
| | - Umberto Zuccon
- Pulmonology Unit, General Hospital “Santa Maria degli Angeli”, 33170 Pordenone, Italy
| | - Barbara Ruaro
- Department of Pulmonology, University Hospital of Cattinara, 34149 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
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Petnak T, Cheungpasitporn W, Thongprayoon C, Sodsri T, Tangpanithandee S, Moua T. Phenotypic subtypes of fibrotic hypersensitivity pneumonitis identified by machine learning consensus clustering analysis. Respir Res 2024; 25:41. [PMID: 38238763 PMCID: PMC10797808 DOI: 10.1186/s12931-024-02664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Patients with fibrotic hypersensitivity pneumonitis (f-HP) have varied clinical and radiologic presentations whose associated phenotypic outcomes have not been previously described. We conducted a study to evaluate mortality and lung transplant (LT) outcomes among clinical clusters of f-HP as characterized by an unsupervised machine learning approach. METHODS Consensus cluster analysis was performed on a retrospective cohort of f-HP patients diagnosed according to recent international guideline. Demographics, antigen exposure, radiologic, histopathologic, and pulmonary function findings along with comorbidities were included in the cluster analysis. Cox proportional-hazards regression was used to assess mortality or LT risk as a combined outcome for each cluster. RESULTS Three distinct clusters were identified among 336 f-HP patients. Cluster 1 (n = 158, 47%) was characterized by mild restriction on pulmonary function testing (PFT). Cluster 2 (n = 46, 14%) was characterized by younger age, lower BMI, and a higher proportion of identifiable causative antigens with baseline obstructive physiology. Cluster 3 (n = 132, 39%) was characterized by moderate to severe restriction. When compared to cluster 1, mortality or LT risk was lower in cluster 2 (hazard ratio (HR) of 0.42; 95% CI, 0.21-0.82; P = 0.01) and higher in cluster 3 (HR of 1.76; 95% CI, 1.24-2.48; P = 0.001). CONCLUSIONS Three distinct phenotypes of f-HP with unique mortality or transplant outcomes were found using unsupervised cluster analysis, highlighting improved mortality in fibrotic patients with obstructive physiology and identifiable antigens.
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Affiliation(s)
- Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Nakhon Pathom, Thailand
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, United States
| | | | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Tulaton Sodsri
- Faculty of Medicine Ramathibodi Hospital, Chakri Naruebodindra Medical Institute, Mahidol University, Samut Prakan, Thailand
| | | | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, United States.
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Delgado-García D, Miranda-Astorga P, Delgado-Cano A, Gómez-Salgado J, Ruiz-Frutos C. Workers with Suspected Diagnosis of Silicosis: A Case Study of Sarcoidosis Versus Siderosis. Healthcare (Basel) 2023; 11:1782. [PMID: 37372900 DOI: 10.3390/healthcare11121782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Silicosis is one of the most important occupational respiratory diseases worldwide, hence the importance of making a correct diagnosis. Diagnosis is commonly based on radiological findings according to the ILO International Classification of Radiographs of Pneumoconioses and occupational exposure. High-resolution computed tomography is indicated for differential diagnosis. This article presents two cases with an initial diagnosis of silicosis that ended up being diagnosed as sarcoidosis and siderosis, respectively. The first case was a 42-year-old male who worked as a crushing operator in an underground copper and molybdenum mine for 22 years. He had a history of exposure to silicon dioxide and was asymptomatic. X-rays did not distinguish silicosis or siderosis, but histological findings (open lung biopsy) allowed for a diagnosis of sarcoidosis. The second case was a 50-year-old male who had worked as a welder in a molybdenum filter plant, an open pit mine since 2013; he spent the previous 20 years as a welder in an underground copper mine, with exposure to silicon dioxide and was symptomatic. The first radiograph showed opacities that were compatible with pulmonary silicosis. A subsequent high-resolution computed tomography and lung biopsy showed a pattern of pulmonary siderosis. Due to the similarities in the radiographs of these three diseases, greater emphasis must be placed on the differential diagnosis, for which a complete occupational and clinical history is important in order to provide clues for the performance of complementary tests to avoid misdiagnosing.
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Affiliation(s)
- Diemen Delgado-García
- Department of Research and Postgraduate, Universidad de Aconcagua, Los Andes 2102660, Chile
- School of Medicine, Neurology and Psychiatry, Universidad de Texas Rio Grande Valley, Edinburg, TX 78539, USA
| | - Patricio Miranda-Astorga
- Departament of Occupational Health, Instituto de Salud Pública de Chile, Santiago 7780050, Chile
| | - Ashley Delgado-Cano
- School of Medicine, Universidad Andrés Bello-Viña del Mar, Valparaíso 2520000, Chile
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 092301, Ecuador
| | - Carlos Ruiz-Frutos
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 092301, Ecuador
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Dabiri M, Jehangir M, Khoshpouri P, Chalian H. Hypersensitivity Pneumonitis: A Pictorial Review Based on the New ATS/JRS/ALAT Clinical Practice Guideline for Radiologists and Pulmonologists. Diagnostics (Basel) 2022; 12:diagnostics12112874. [PMID: 36428934 PMCID: PMC9689332 DOI: 10.3390/diagnostics12112874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a complicated and heterogeneous interstitial lung disease (ILD) caused by an excessive immune response to an inhaled antigen in susceptible individuals. Accurate diagnosis of HP is difficult and necessitates a detailed exposure history, as well as a multidisciplinary discussion of clinical, histopathologic, and radiologic data. We provide a pictorial review based on the latest American Thoracic Society (ATS)/Japanese Respiratory Society (JRS)/Asociación Latinoamericana del Tórax (ALAT) guidelines for diagnosing HP through demonstrating new radiologic terms, features, and a new classification of HP which will benefit radiologists and pulmonologists.
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Affiliation(s)
- Mona Dabiri
- Department of Radiology, Children’s Medical Center, Tehran University of Medical Science, Tehran 14176-14411, Iran
| | - Maham Jehangir
- Cardiothoracic Imaging, Department of Radiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Pegah Khoshpouri
- Department of Radiology, University of Washington, Seattle, WA 98105, USA
| | - Hamid Chalian
- Cardiothoracic Imaging, Department of Radiology, University of Washington, Seattle, WA 98105, USA
- Correspondence: ; Tel.: +1-206-598-7453
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Ito Y, Miwa S, Hayakawa H, Oshima T, Eihuku T, Iwaizumi E, Ohba H, Fujita K, Kanai M, Shirai M. Antigen avoidance and environmental inhalation challenge for successful diagnosis of fibrotic hypersensitivity pneumonitis mimicking idiopathic pulmonary fibrosis. Respir Med Case Rep 2022; 39:101737. [PMID: 36133420 PMCID: PMC9483807 DOI: 10.1016/j.rmcr.2022.101737] [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: 02/12/2022] [Revised: 08/21/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022] Open
Abstract
A 77-year-old man was initially diagnosed with idiopathic pulmonary fibrosis (IPF) and treated with anti-fibrotic nintedanib. Despite undergoing anti-fibrotic treatment for one year, his condition remained unstable. The patient was admitted to our hospital for exertional dyspnea. We performed an exposure assessment, including 2-week antigen avoidance and an environmental inhalation challenge, and successfully re-diagnosed him with fibrotic hypersensitivity pneumonitis (HP), known as chronic farmer's lung. Adding oral glucocorticoids to the nintedanib treatment improved his condition. Although antigen avoidance and environmental inhalation challenge tests are not standardized, they may be useful for diagnosing fibrotic HP when properly applied. Clinical features of fibrotic HP and IPF are often indistinguishable. Antigen avoidance is crucial in the diagnosis and management of fibrotic HP. Environmental inhalation challenge is useful when applied properly. The seasonal change of clinical parameters helps suspecting fibrotic HP.
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Affiliation(s)
- Yasuhiro Ito
- Corresponding author. 4201-2, Hamamatsu, 434-8511, Japan.
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