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Deutsch K, Lewandowska KB, Kowalik A, Bartoszuk I, Radwan-Röhrenschef P, Sobiecka M, Dybowska M, Tomkowski WZ, Szturmowicz M. Does a Type of Inciting Antigen Correlate with the Presence of Lung Fibrosis in Patients with Hypersensitivity Pneumonitis? J Clin Med 2024; 13:5074. [PMID: 39274286 PMCID: PMC11396382 DOI: 10.3390/jcm13175074] [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: 07/14/2024] [Revised: 08/23/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Introduction: Hypersensitivity pneumonitis (HP) is an interstitial inflammatory lung disease that develops as a result of exposition to various, mostly organic antigens. In some patients, fibrotic HP is diagnosed. Factors predisposing to the development of fibrotic lung disease in HP patients are not well documented in the literature. The genetic susceptibility of the patient, type of inciting antigen, and type of exposure, as well as various demographic and clinical variables, may influence the fibrotic process. Aim: The aim of the present study was to investigate whether the type of inciting antigen increases the risk of fibrotic lung disease in HP patients. Methods: Clinical data of consecutive patients with HP diagnosed between 2019 and 2023 were retrospectively reviewed. The exposition to the inciting antigens was investigated by the standardized questionnaire. Recent HP classification into fibrotic (fHP) and non-fibrotic (non-fHP) types was applied. Results: Sixty-six patients diagnosed with HP were analyzed. All patients filled out the exposure questionnaire, and 62 (94%) reported at least one possible exposure. The most prevalent exposures reported were avian, water systems, feather duvets, and hay/straw. Exposure to avian antigens as well as to coal/biomass heating were significantly more prevalent among patients with fHP compared to those with non-fHP (70% vs. 40%, p = 0.03 and 27% vs. 5%, p = 0.04, respectively). Nevertheless, in the multivariate analysis, older age at diagnosis was the only factor influencing the development of fHP (OR 1.064, 95% CI 1.004 to 1.138, p = 0.04). Reported avian antigen exposure correlated well with positive precipitins to avian antigens, whereas no correlation was found between hay/straw exposure and positive antibodies to termophilic actinomycetes. Conclusions: Exposure to birds and coal heating was the most frequently present factor in subjects with fHP, but only older age at diagnosis remained a significant fHP predictor in the multifactor analysis.
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Affiliation(s)
- Kamila Deutsch
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Katarzyna B Lewandowska
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Agata Kowalik
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Iwona Bartoszuk
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Piotr Radwan-Röhrenschef
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Małgorzata Sobiecka
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Małgorzata Dybowska
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Witold Z Tomkowski
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Research Institute of Tuberculosis and Lung Diseases, Płocka 26, 01-138 Warsaw, Poland
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Maher TM. Interstitial Lung Disease: A Review. JAMA 2024; 331:1655-1665. [PMID: 38648021 DOI: 10.1001/jama.2024.3669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Importance Interstitial lung disease (ILD) consists of a group of pulmonary disorders characterized by inflammation and/or fibrosis of the lung parenchyma associated with progressive dyspnea that frequently results in end-stage respiratory failure. In the US, ILD affects approximately 650 000 people and causes approximately 25 000 to 30 000 deaths per year. Observations The most common forms of ILD are idiopathic pulmonary fibrosis (IPF), which accounts for approximately one-third of all cases of ILD, hypersensitivity pneumonitis, accounting for 15% of ILD cases, and connective tissue disease (CTD), accounting for 25% of ILD cases. ILD typically presents with dyspnea on exertion. Approximately 30% of patients with ILD report cough. Thoracic computed tomography is approximately 91% sensitive and 71% specific for diagnosing subtypes of ILDs such as IPF. Physiologic assessment provides important prognostic information. A 5% decline in forced vital capacity (FVC) over 12 months is associated with an approximately 2-fold increase in mortality compared with no change in FVC. Antifibrotic therapy with nintedanib or pirfenidone slows annual FVC decline by approximately 44% to 57% in individuals with IPF, scleroderma associated ILD, and in those with progressive pulmonary fibrosis of any cause. For connective tissue disease-associated ILD, immunomodulatory therapy, such as tocilizumab, rituximab, and mycophenolate mofetil, may slow decline or even improve FVC at 12-month follow-up. Structured exercise therapy reduces symptoms and improves 6-minute walk test distance in individuals with dyspnea. Oxygen reduces symptoms and improves quality of life in individuals with ILD who desaturate below 88% on a 6-minute walk test. Lung transplant may improve symptoms and resolve respiratory failure in patients with end-stage ILD. After lung transplant, patients with ILD have a median survival of 5.2 to 6.7 years compared with a median survival of less than 2 years in patients with advanced ILD who do not undergo lung transplant. Up to 85% of individuals with end-stage fibrotic ILD develop pulmonary hypertension. In these patients, treatment with inhaled treprostinil improves walking distance and respiratory symptoms. Conclusions and Relevance Interstitial lung disease typically presents with dyspnea on exertion and can progress to respiratory failure. First-line therapy includes nintedanib or pirfenidone for IPF and mycophenolate mofetil for ILD due to connective tissue disease. Lung transplant should be considered for patients with advanced ILD. In patients with ILD, exercise training improves 6-minute walk test distance and quality of life.
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Affiliation(s)
- Toby M Maher
- University of Southern California, Los Angeles
- National Heart and Lung Institute, Imperial College, London, UK
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Demirkol B, Satici C, Tanriverdi E, Eren R, Altundas Hatman E, Yardimci HA, Urer HN, Baydili KN, Cetinkaya E. Serum Specific Antibodies Do Not Seem to Have an Additional Role in the Diagnosis of Hypersensitivity Pneumonitis. LA MEDICINA DEL LAVORO 2023; 114:e2023042. [PMID: 37878260 PMCID: PMC10627099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/22/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND We aimed to investigate the contribution of serum IgG testing to the history of exposure in the diagnosis of fibrotic hypersensitivity pneumonitis. METHODS A single-center, retrospective, cross-sectional study including 63 patients pathologically diagnosed with fibrotic hypersensitivity pneumonitis in line with the guidelines of the American Thoracic Society. Descriptive statistics were presented and Kappa statistic was performed to evaluate the compatibility between panel and the history of exposure. RESULTS The median age was 63 (22-81) years and 34 (54%) were male. Forty-six patients (73%) had a positive history of exposure. Thirty-nine patients (61.9%) had a positive HP/Avian panel. The most common exposure agent was mold (34.9%), followed by parakeet (31.7%). The antibody detected the most was penicillium chrysogenum lgG (36.5%), followed by aspergillus fumigatus (31.8%). There was no compatibility between HP/Avian panel and history of exposure (kappa coefficient= 0.18, p= 0.14). When the exposure was only assessed based on the history, 4 (6.35%) patients were diagnosed as fibrotic hypersensitivity pneumonitis with low confidence, 6 (9.52%) with moderate confidence, 11 (17.46%) with high confidence and 42 (66.67%) with definite confidence; whereas 4 (6.35%) patients were diagnosed as fibrotic hypersensitivity pneumonitis with low confidence, 6 (9.52%) with moderate confidence, 9 (14.29%) patients with high confidence and 44 (69.84%) patients with definite confidence if exposure was evaluated with history and/or panel. CONCLUSIONS Serum specific precipitating antibody panel does not seem to provide additional value to the history of exposure in the diagnosis of fibrotic hypersensitivity pneumonitis.
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Affiliation(s)
- Baris Demirkol
- University of Health Sciences Turkey, Basaksehir Cam and Sakura City Hospital, Department of Chest Diseases, Istanbul, Turkey.
| | - Celal Satici
- University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Chest Diseases, Istanbul, Turkey.
| | - Elif Tanriverdi
- University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Chest Diseases, Istanbul, Turkey.
| | - Ramazan Eren
- University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Chest Diseases, Istanbul, Turkey.
| | - Elif Altundas Hatman
- Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Occupational Medicine, Istanbul, Turkey.
| | - Hande Aytul Yardimci
- University of Health Sciences Turkey, Basaksehir Cam and Sakura City Hospital, Department of Radiology, Istanbul, Turkey.
| | - Halide Nur Urer
- University of Health Sciences Turkey, Haseki Training and Research Hospital, Department of Pathology, Istanbul, Turkey.
| | - Kursad Nuri Baydili
- University of Health Sciences Turkey, Hamidiye Medical Faculty, Biostatistics and Medical Informatics, Istanbul, Turkey .
| | - Erdogan Cetinkaya
- University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Department of Chest Diseases, Istanbul, Turkey.
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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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Sobiecka M, Szturmowicz M, Lewandowska K, Kowalik A, Łyżwa E, Zimna K, Barańska I, Jakubowska L, Kuś J, Langfort R, Tomkowski W. Chronic hypersensitivity pneumonitis is associated with an increased risk of venous thromboembolism: a retrospective cohort study. BMC Pulm Med 2021; 21:416. [PMID: 34920701 PMCID: PMC8684138 DOI: 10.1186/s12890-021-01794-y] [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: 10/08/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis share commonalities in pathogenesis shifting haemostasis balance towards the procoagulant and antifibrinolytic activity. Several studies have suggested an increased risk of venous thromboembolism in IPF. The association between venous thromboembolism and chronic hypersensitivity pneumonitis has not been studied yet.
Methods
A retrospective cohort study of IPF and chronic hypersensitivity pneumonitis patients diagnosed in single tertiary referral center between 2005 and 2018 was conducted. The incidence of symptomatic venous thromboembolism was evaluated. Risk factors for venous thromboembolism and survival among those with and without venous thromboembolism were assessed.
Results
A total of 411 (259 IPF and 152 chronic hypersensitivity) patients were included (mean age 66.7 ± 8.4 vs 51.0 ± 13.3 years, respectively). There were 12 (4.6%) incident cases of venous thromboembolism in IPF and 5 (3.3%) in chronic hypersensitivity pneumonitis cohort. The relative risk (RR) of venous thromboembolism in chronic hypersensitivity pneumonitis was not significantly different to that found in patients with IPF (7.1 vs 11.8/1000 person-years, RR 1.661 95% CI 0.545–6.019, respectively).
The treatment with systemic steroids (OR 5.38; 95% CI 1.65–18.8, p = 0.006) and GAP stage 3 (OR 7.85; 95% CI 1.49–34.9; p = 0.037) were significant risk factors for venous thromboembolism in IPF. Arterial hypertension and pulmonary hypertension significantly increased risk of venous thromboembolism in chronic hypersensitivity pneumonitis. There were no significant differences in survival between patients with and without venous thromboembolism.
Conclusions
The patients with chronic hypersensitivity pneumonitis have a marked increase in the risk of venous thromboembolism, similar to the patients with IPF. Venous thromboembolism does not affect the survival of patients with IPF and chronic hypersensitivity pneumonitis.
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Dybowska M, Barańska I, Franczuk M, Skoczylas A, Szturmowicz M. Echocardiographic signs of pulmonary hypertension in patients with newly recognized hypersensitivity pneumonitis, prevalence and clinical predictors. J Thorac Dis 2021; 13:3988-3997. [PMID: 34422329 PMCID: PMC8339783 DOI: 10.21037/jtd-21-130] [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: 01/21/2021] [Accepted: 05/20/2021] [Indexed: 11/06/2022]
Abstract
Background Hypersensitivity pneumonitis (HP) is the third, according to frequency, interstitial lung disease, with the estimated incidence rate of 1–2/100,000. In HP patients, the extensive inflammatory lesions encompassing both small airways and lung parenchyma, as well as subsequent development of lung fibrosis, may result in respiratory insufficiency and secondary pulmonary hypertension (PH). The aim of the present retrospective study was to assess the prevalence of echocardiographic signs of PH and its’ clinical predictors, in newly recognized HP patients. Methods Consecutive HP patients, recognized in single pulmonary unit between 2005 and 2017, in whom echocardiography was performed at diagnosis, entered the present study. HP diagnosis was verified in every patient according to current diagnostic recommendations. The results of high resolution computed tomography of the chest (HRCT) were re-evaluated by two independent radiologists, blinded to clinical data. Echocardiographic signs of PH were defined as pulmonary artery systolic pressure (PASP) exceeding 36 mmHg. Regression analysis was applied to calculate PH risk, and receiver operator characteristic curves (ROC) were plotted to investigate diagnostic utility of various parameters in PH prediction. Results PASP exceeding 36 mmHg was noted in 26 out of 70 patients (37%)—with equal frequency among patients with fibrotic and non-fibrotic HP. Significant predictors of PH on echocardiography were: partial oxygen tension in arterialized capillary blood (PaO2) <69 mmHg, lung transfer capacity for carbon monoxide (TLCO) <42% of predicted, six minutes walking test (6MWT) distance <455 meters, and 6MWT desaturation rate >8%. In case of TLCO <42% of predicted, probability of PH on echocardiography was increased by five-fold, in case of 6MWT desaturation rate >8%—by four fold. Conclusions The best predictors of PASP >36 mmHg on echocardiography in HP patients at diagnosis were: TLCO <42% and 6MWT desaturation rate >8%. Neither the presence of lung fibrosis on HRCT, nor the duration of the disease or patients age, were helpful in PH prediction.
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Affiliation(s)
- Małgorzata Dybowska
- Ist Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Inga Barańska
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Monika Franczuk
- Department of Physiopathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Agnieszka Skoczylas
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Monika Szturmowicz
- Ist Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
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Sterclova M, Kremlackova V, Mottlova V, Bruzova M, Sojka P, Vasakova M. Quantitative assessment of specific serum IgGs may verify source of environmental exposure in extrinsic allergic alveolitis (EAA). COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1894688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Martina Sterclova
- Department of Respiratory Medicine of 1st Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Veronika Kremlackova
- Department of Respiratory Medicine of 1st Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Veronika Mottlova
- Department of Biochemistry, Thomayer Hospital, Prague, Czech Republic
| | - Magdalena Bruzova
- Department of Pathology and Molecular Medicine of 3rd Medical Faculty, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Pavel Sojka
- Department of Immunology, Thomayer Hospital, Prague, Czech Republic
| | - Martina Vasakova
- Department of Respiratory Medicine, Thomayer Hospital, Prague, Czech Republic
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Correlation of bronchoalveolar lavage lymphocyte count with the extent of lung fibrosis and with plethysmographic lung volumes in patients with newly recognized hypersensitivity pneumonitis. Cent Eur J Immunol 2021; 45:276-282. [PMID: 33437179 PMCID: PMC7790004 DOI: 10.5114/ceji.2020.101246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Hypersensitivity pneumonitis (HP) is an increasingly recognized interstitial lung disease, presenting with elevated total cell counts and high percentage of lymphocytes in bronchoalveolar lavage fluid (BALF). Despite many publications, there is no consensus in the literature concerning BALF cellular composition in patients with prolonged course of HP. Aim The aim of the present retrospective study was to investigate the influence of disease duration, smoking habits, and the extent of lung fibrosis on BALF cells’ population in patients with newly recognized HP. Material and methods In total, 94 patients (49 females, 45 males), mean age 52 (±12) years, with HP recognized according to recently proposed criteria, were enrolled into the present study. Chest CT scans were retrospectively reviewed by two independent radiologists. BALF evaluation was performed as a part of routine diagnostics according to recent recommendations. Results Percentage of lymphocytes in BALF was significantly lower in patients with lung fibrosis (stage 1 and 2) comparing to those without lung fibrosis (stage 0). Significant correlation was also found between the percentage of BALF lymphocytes and plethysmographic lung volumes, but not with lung transfer capacity for carbon monoxide (TLCO% pred). Smoking did not influence BALF results in our study group. Conclusions BALF lymphocytosis correlated with the presence and the extent of lung fibrosis on chest CT as well as with plethysmographic lung volumes but did not with TLCO and smoking habits in newly recognized HP pneumonitis.
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