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Jensen HE, Becker CB. Pathological Diagnosis of Pulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:41-49. [PMID: 38266999 DOI: 10.1055/s-0043-1776757] [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: 01/26/2024]
Abstract
Pulmonary aspergillosis constitutes an increasingly prevalent and potentially fatal complex of mycotic diseases, caused by different species of Aspergillus. The broad spectrum of pathological manifestations associated with pulmonary aspergillosis necessitates a differentiation of commensalism from saprophytic colonization, hypersensitivity reactions, and true invasive infections, which highlights the importance of histopathology as a gold standard in a diagnostic setting. For the past decades, changes in terminology and contradicting contributions from different diagnostic disciplines have made the classification of pulmonary aspergillosis rather confusing. This review offers a categorization of aspergillosis lesions based on what can be histopathologically identified and distinguished, differentiating between acute invasive infection and forms of subacute, chronic, and allergic diseases and coinfections, and summarizes important manifestations of lesions associated with the different forms of pulmonary aspergillosis.
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Affiliation(s)
- Henrik E Jensen
- Section for Pathobiological Sciences, Division of Pathology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie B Becker
- Section for Pathobiological Sciences, Division of Pathology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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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: 25] [Impact Index Per Article: 12.5] [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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Botelho AB, Ferreira RG, Coletta ENAM, Cerezoli MT, Martins RB, Gomes PS, Gimenez A, Ota LH, Soares MR, Pereira CAC. Transbronchial biopsy in chronic hypersensitivity pneumonitis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2021; 38:e2021018. [PMID: 34316258 PMCID: PMC8288203 DOI: 10.36141/svdld.v38i2.8998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/13/2021] [Indexed: 11/02/2022]
Abstract
Introduction The diagnosis of chronic hypersensitivity pneumonitis (CHP) is based on relevant exposure, tomographic findings and, in some cases, pathological data. The role of bronchoscopy is uncertain, especially in the fibrotic form of CHP. Aim To analyze the yield of transbronchial biopsy (TBBx) in patients with CHP according to tomographic findings and to evaluate the importance of bronchoalveolar lavage (BAL) in the diagnostic approach. Methods This retrospective study analyzed patients with CHP who underwent TBBx in São Paulo, Brazil. The TBBx findings were classified as characteristic (granulomas and/or multinucleated giant cells, associated or not with peribronchiolar infiltration of lymphocytes and plasma cells and bronchiolocentric distribution) and supportive (data indicative of small airway injury: peribronchiolar metaplasia, organizing pneumonia, and intra-alveolar foamy macrophages). Results One hundred nine patients were included. The presence of characteristic findings of HP was seen in 16 patients (14.7%), and supportive findings were seen in 32 patients (29.4%), with a total yield of 44%. Pathological characteristic findings were more common in cases without fibrosis on high-resolution computed tomography (HRCT) (27.3% vs. 9.2%, p= 0.014), whereas the presence of supportive findings was more common in fibrotic HP (38.1% vs. 9.1%, p= 0.002). Fifty-two patients had differential cytology in BAL fluid. Lymphocytosis (> 20%) was present in 51.9% of the patients. There was no difference in the median lymphocyte count according to nonfibrotic and fibrotic tomographic findings on HRCT. Conclusion TBBx and BAL fluid cytology have a role in CHP diagnosis.
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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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Samsonova MV, Chernyaev AL. [Histological differential diagnosis of granulomatous lung diseases (part I)]. Arkh Patol 2019; 81:65-70. [PMID: 30830108 DOI: 10.17116/patol20198101165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Granulomatous diseases are a heterogeneous group of the diseases of different etiology, which are manifested by a variety of clinical syndromes and variants of tissue changes, by non-uniform sensitivity to therapy, and by the predominance of the common dominant histologic sign - the presence of granulomas that determine the clinical and morphological essence of each disease. Granuloma is a chronic inflammatory response, which involves macrophages and other inflammatory cells. After exposure to an antigen, T-lymphocytes, macrophages, epithelioid cells, and multinucleated giant cells are activated, resulting in the formation of granulomas. Granuloma also includes the extracellular matrix produced by fibroblasts, which can demarcate and isolate the antigen. According to etiology, granulomatous diseases are classified as infectious and non-infectious. However, recent investigations demonstrate that pathogenic microorganisms can cause granulomas in diseases previously considered non-infectious. In some cases, it is very difficult to classify a granulomatous process as infectious and non-infectious. The aim of this paper is to draw the attention of readers to the diversity of granulomatous diseases, to describe the key points of pathological and anatomical manifestations of various non-infectious diseases, as well as to determine an approach to the differential diagnosis of granulomatoses.
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Affiliation(s)
- M V Samsonova
- Pulmonology Research Institute, Federal Biomedical Agency of Russia, Moscow, Russia; A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - A L Chernyaev
- Pulmonology Research Institute, Federal Biomedical Agency of Russia, Moscow, Russia; A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia; Research Institute of Human Morphology, Moscow, Russia; N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia, Moscow, Russia
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Knežević S, Đurović L, Srećković B, Vulović J. Hypersensitivity pneumonitis with frequent hemoptysis. PRAXIS MEDICA 2019. [DOI: 10.5937/pramed1904025k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Volkers SM, Sander LE. Local Encounters: Extrafollicular T-Cell/B-Cell Interactions in Airway Inflammation. Am J Respir Cell Mol Biol 2018; 59:403-404. [PMID: 30036084 DOI: 10.1165/rcmb.2018-0153ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sarah M Volkers
- 1 Department of Infectious Diseases and Pulmonary Medicine Charité-Universitätsmedizin Berlin Berlin, Germany and
| | - Leif E Sander
- 1 Department of Infectious Diseases and Pulmonary Medicine Charité-Universitätsmedizin Berlin Berlin, Germany and.,2 German Center for Lung Research Berlin, Germany
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Dias OM, Baldi BG, Pennati F, Aliverti A, Chate RC, Sawamura MVY, Carvalho CRRD, Albuquerque ALPD. Computed tomography in hypersensitivity pneumonitis: main findings, differential diagnosis and pitfalls. Expert Rev Respir Med 2017; 12:5-13. [PMID: 29048936 DOI: 10.1080/17476348.2018.1395282] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is a disease with variable clinical presentation in which inflammation in the lung parenchyma is caused by the inhalation of specific organic antigens or low molecular weight substances in genetically susceptible individuals. Alterations of the acute, subacute and chronic forms may eventually overlap, and the diagnosis based on temporality and presence of fibrosis (acute/inflammatory HP vs. chronic HP) seems to be more feasible and useful in clinical practice. Differential diagnosis of chronic HP with other interstitial fibrotic diseases is challenging due to the overlap of the clinical history, and the functional and imaging findings of these pathologies in the terminal stages. Areas covered: This article reviews the essential features of HP with emphasis on imaging features. Moreover, the main methodological limitations of high-resolution computed tomography (HRCT) interpretation are discussed, as well as new perspectives with volumetric quantitative CT analysis as a useful tool for retrieving detailed and accurate information from the lung parenchyma. Expert commentary: Mosaic attenuation is a prominent feature of this disease, but air trapping in chronic HP seems overestimated. Quantitative analysis has the potential to estimate the involvement of the pulmonary parenchyma more accurately and could correlate better with pulmonary function results.
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Affiliation(s)
- Olívia Meira Dias
- a Pulmonary Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
| | - Bruno Guedes Baldi
- a Pulmonary Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
| | - Francesca Pennati
- b Dipartimento di Elettronica, Informazione e Bioingegneria , Politecnico di Milano , Milan , Italy
| | - Andrea Aliverti
- b Dipartimento di Elettronica, Informazione e Bioingegneria , Politecnico di Milano , Milan , Italy
| | - Rodrigo Caruso Chate
- c Radiology Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
| | - Márcio Valente Yamada Sawamura
- c Radiology Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- a Pulmonary Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
| | - André Luis Pereira de Albuquerque
- a Pulmonary Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , Sao Paulo , Brazil
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Houser KV, Broadbent AJ, Gretebeck L, Vogel L, Lamirande EW, Sutton T, Bock KW, Minai M, Orandle M, Moore IN, Subbarao K. Enhanced inflammation in New Zealand white rabbits when MERS-CoV reinfection occurs in the absence of neutralizing antibody. PLoS Pathog 2017; 13:e1006565. [PMID: 28817732 PMCID: PMC5574614 DOI: 10.1371/journal.ppat.1006565] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 08/29/2017] [Accepted: 08/01/2017] [Indexed: 12/26/2022] Open
Abstract
The Middle East respiratory syndrome coronavirus (MERS-CoV) is a zoonotic betacoronavirus that was first detected in humans in 2012 as a cause of severe acute respiratory disease. As of July 28, 2017, there have been 2,040 confirmed cases with 712 reported deaths. While many infections have been fatal, there have also been a large number of mild or asymptomatic cases discovered through monitoring and contact tracing. New Zealand white rabbits are a possible model for asymptomatic infection with MERS-CoV. In order to discover more about non-lethal infections and to learn whether a single infection with MERS-CoV would protect against reinfection, we inoculated rabbits with MERS-CoV and monitored the antibody and inflammatory response. Following intranasal infection, rabbits developed a transient dose-dependent pulmonary infection with moderately high levels of viral RNA, viral antigen, and perivascular inflammation in multiple lung lobes that was not associated with clinical signs. The rabbits developed antibodies against viral proteins that lacked neutralizing activity and the animals were not protected from reinfection. In fact, reinfection resulted in enhanced pulmonary inflammation, without an associated increase in viral RNA titers. Interestingly, passive transfer of serum from previously infected rabbits to naïve rabbits was associated with enhanced inflammation upon infection. We further found this inflammation was accompanied by increased recruitment of complement proteins compared to primary infection. However, reinfection elicited neutralizing antibodies that protected rabbits from subsequent viral challenge. Our data from the rabbit model suggests that people exposed to MERS-CoV who fail to develop a neutralizing antibody response, or persons whose neutralizing antibody titers have waned, may be at risk for severe lung disease on re-exposure to MERS-CoV. New Zealand white rabbits display an increase in lung inflammation following reinfection with MERS-CoV that is associated with non-neutralizing antibodies and complement proteins. The development of neutralizing antibodies resulted in protection from infection. These findings may have implications for individuals that fail to develop a neutralizing antibody response, or for those whose response wanes over time, upon re-exposure to MERS-CoV.
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Affiliation(s)
- Katherine V. Houser
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Andrew J. Broadbent
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Lisa Gretebeck
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Leatrice Vogel
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Elaine W. Lamirande
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Troy Sutton
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Kevin W. Bock
- Comparative Medicine Branch, Infectious Disease Pathogenesis Section, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Mahnaz Minai
- Comparative Medicine Branch, Infectious Disease Pathogenesis Section, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Marlene Orandle
- Comparative Medicine Branch, Infectious Disease Pathogenesis Section, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Ian N. Moore
- Comparative Medicine Branch, Infectious Disease Pathogenesis Section, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
| | - Kanta Subbarao
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States of America
- * E-mail: ,
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Kouranos V, Jacob J, Nicholson A, Renzoni E. Fibrotic Hypersensitivity Pneumonitis: Key Issues in Diagnosis and Management. J Clin Med 2017; 6:jcm6060062. [PMID: 28617305 PMCID: PMC5483872 DOI: 10.3390/jcm6060062] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 11/23/2022] Open
Abstract
The diagnosis of hypersensitivity pneumonitis (HP) relies on the clinical evaluation of a number of features, including a history of significant exposure to potentially causative antigens, physical examination, chest CT scan appearances, bronchoalveolar lavage lymphocytosis, and, in selected cases, histology. The presence of fibrosis is associated with higher morbidity and mortality. Differentiating fibrotic HP from the idiopathic interstitial pneumonias can be a challenge. Furthermore, even in the context of a clear diagnosis of fibrotic HP, the disease behaviour can parallel that of idiopathic pulmonary fibrosis in a subgroup, with inexorable progression despite treatment. We review the current knowledge on the diagnosis, management, and prognosis of HP with particular focus on the fibrotic phenotype.
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Affiliation(s)
- Vasileios Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College, Sydney Street, SW3 6NP London, UK.
| | - Joseph Jacob
- Department of Radiology, Royal Brompton Hospital, London, UK.
| | - Andrew Nicholson
- Department of Histopathology, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial College, London, UK.
| | - Elizabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College, Sydney Street, SW3 6NP London, UK.
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Hypersensitivity pneumonitis: a complex lung disease. Clin Mol Allergy 2017; 15:6. [PMID: 28286422 PMCID: PMC5339989 DOI: 10.1186/s12948-017-0062-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/25/2017] [Indexed: 11/10/2022] Open
Abstract
Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a respiratory syndrome involving the lung parenchyma and specifically the alveoli, terminal bronchioli, and alveolar interstitium, due to a delayed allergic reaction. Such reaction is secondary to a repeated and prolonged inhalation of different types of organic dusts or other substances to which the patient is sensitized and hyper responsive, primarily consisting of organic dusts of animal or vegetable origin, more rarely from chemicals. The prevalence of HP is difficult to evaluate because of uncertainties in detection and misdiagnosis and lacking of widely accepted diagnostic criteria, and varies considerably depending on disease definition, diagnostic methods, exposure modalities, geographical conditions, agricultural and industrial practices, and host risk factors. HP can be caused by multiple agents that are present in work places and in the home, such as microbes, animal and plant proteins, organic and inorganic chemicals. The number of environment, settings and causative agents is increasing over time. From the clinical point of view HP can be divided in acute/subacute and chronic, depending on the intensity and frequency of exposure to causative antigens. The mainstay in managing HP is the avoidance of the causative antigen, though the complete removal is not always possible due to the difficulties to identify the agent or because its avoidance may lead to major changes in life style or occupational settings. HP is a complex syndrome that needs urgently for more stringent and selective diagnostic criteria and validation, including wider panels of IgG, and a closer collaboration with occupational physicians, as part of a multidisciplinary expertise.
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Torres PPTES, Moreira MAR, Silva DGST, da Gama RRM, Sugita DM, Moreira MADC. High-resolution computed tomography and histopathological findings in hypersensitivity pneumonitis: a pictorial essay. Radiol Bras 2016; 49:112-6. [PMID: 27141134 PMCID: PMC4851482 DOI: 10.1590/0100-3984.2014.0062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Hypersensitivity pneumonitis is a diffuse interstitial and granulomatous lung disease caused by the inhalation of any one of a number of antigens. The objective of this study was to illustrate the spectrum of abnormalities in high-resolution computed tomography and histopathological findings related to hypersensitivity pneumonitis. We retrospectively evaluated patients who had been diagnosed with hypersensitivity pneumonitis (on the basis of clinical-radiological or clinical-radiological-pathological correlations) and had undergone lung biopsy. Hypersensitivity pneumonitis is clinically divided into acute, subacute, and chronic forms; high-resolution computed tomography findings correlate with the time of exposure; and the two occasionally overlap. In the subacute form, centrilobular micronodules, ground-glass opacities, and air trapping are characteristic high-resolution computed tomography findings, whereas histopathology shows lymphocytic inflammatory infiltrates, bronchiolitis, variable degrees of organizing pneumonia, and giant cells. In the chronic form, high-resolution computed tomography shows traction bronchiectasis, honeycombing, and lung fibrosis, the last also being seen in the biopsy sample. A definitive diagnosis of hypersensitivity pneumonitis can be made only through a multidisciplinary approach, by correlating clinical findings, exposure history, high-resolution computed tomography findings, and lung biopsy findings.
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Affiliation(s)
- Pedro Paulo Teixeira E Silva Torres
- MD, Radiologist, Volunteer at the Hospital das Clínicas da Universidade Federal de Goiás (UFG), Radiologist at Clínica Multimagem, Goiânia, GO, Brazil
| | - Marise Amaral Rebouças Moreira
- PhD, Associate Professor in the Department of Pathology, Faculdade de Medicina da Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | | | | | - Denis Masashi Sugita
- MD, Pathologist, Assistant Professor at the Anápolis Unievangélica, Anápolis, GO, Brazil
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Cho JL, McDermott S, Tsibris AM, Mark EJ. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 37-2015. A 76-Year-Old Man with Fevers, Leukopenia, and Pulmonary Infiltrates. N Engl J Med 2015; 373:2162-72. [PMID: 26605931 DOI: 10.1056/nejmcpc1504839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
High-resolution chest computed tomography (CT) is one of the most useful techniques available for imaging bronchiolitis because it shows highly specific direct and indirect imaging signs. The distribution and combination of these various signs can further classify bronchiolitis as either cellular/inflammatory or fibrotic/constrictive. Emphysema is characterized by destruction of the airspaces, and a brief discussion of imaging findings of this class of disease is also included. Typical CT findings include destruction of airspace, attenuated vasculatures, and hyperlucent as well as hyperinflated lungs.
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Affiliation(s)
- Rachael M Edwards
- Department of Radiology, University of Washington Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| | - Gregory Kicska
- Department of Radiology, University of Washington Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Rodney Schmidt
- Department of Pathology, University of Washington Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Sudhakar N J Pipavath
- Department of Radiology, University of Washington Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
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15
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Seaman DM, Meyer CA, Kanne JP. Occupational and environmental lung disease. Clin Chest Med 2015; 36:249-68, viii-ix. [PMID: 26024603 DOI: 10.1016/j.ccm.2015.02.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Occupational and environmental lung disease remains a major cause of respiratory impairment worldwide. Despite regulations, increasing rates of coal worker's pneumoconiosis and progressive massive fibrosis are being reported in the United States. Dust exposures are occurring in new industries, for instance, silica in hydraulic fracking. Nonoccupational environmental lung disease contributes to major respiratory disease, asthma, and COPD. Knowledge of the imaging patterns of occupational and environmental lung disease is critical in diagnosing patients with occult exposures and managing patients with suspected or known exposures.
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Affiliation(s)
- Danielle M Seaman
- Duke University Medical Center, 1612 Bivins Street, Durham, NC 27707, USA.
| | - Cristopher A Meyer
- University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, MC 3252, Madison, WI 53792, USA
| | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, MC 3252, Madison, WI 53792, USA
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16
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Diffuse granulomatous lung disease: combined pathological-HRCT approach. Radiol Med 2014; 119:54-63. [DOI: 10.1007/s11547-013-0381-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 08/14/2013] [Indexed: 01/15/2023]
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Human monocyte-derived dendritic cells exposed to microorganisms involved in hypersensitivity pneumonitis induce a Th1-polarized immune response. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 20:1133-42. [PMID: 23720369 DOI: 10.1128/cvi.00043-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypersensitivity pneumonitis (HP) is an immunoallergic disease characterized by a prominent interstitial infiltrate composed predominantly of lymphocytes secreting inflammatory cytokines. Dendritic cells (DCs) are known to play a pivotal role in the lymphocytic response. However, their cross talk with microorganisms that cause HP has yet to be elucidated. This study aimed to investigate the initial interactions between human monocyte-derived DCs (MoDCs) and four microorganisms that are different in nature (Saccharopolyspora rectivirgula [actinomycetes], Mycobacterium immunogenum [mycobacteria], and Wallemia sebi and Eurotium amstelodami [filamentous fungi]) and are involved in HP. Our objectives were to determine the cross talk between MoDCs and HP-causative agents and to determine whether the resulting immune response varied according to the microbial extract tested. The phenotypic activation of MoDCs was measured by the increased expression of costimulatory molecules and levels of cytokines in supernatants. The functional activation of MoDCs was measured by the ability of MoDCs to induce lymphocytic proliferation and differentiation in a mixed lymphocytic reaction (MLR). E. amstelodami-exposed (EA) MoDCs expressed higher percentages of costimulatory molecules than did W. sebi-exposed (WS), S. rectivirgula-exposed (SR), or M. immunogenum-exposed (MI) MoDCs (P < 0.05, Wilcoxon signed-rank test). EA-MoDCs, WS-MoDCs, SR-MoDCs, and MI-MoDCs induced CD4(+) T cell proliferation and a Th1-polarized immune response. The present study provides evidence that, although differences were initially observed between MoDCs exposed to filamentous fungi and MoDCs exposed to bacteria, a Th1 response was ultimately promoted by DCs regardless of the microbial extract tested.
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18
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Giant cell interstitial pneumonia: an unusual finding in a case of preoperative death. Am J Forensic Med Pathol 2013; 34:110-4. [PMID: 23629398 DOI: 10.1097/paf.0b013e318288c6f5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Giant cell interstitial pneumonia (GIP) is an exceedingly rare, debatable, perplexing, occupational lung disease, which most commonly affects individuals exposed to hard metal dust. We report a case of GIP in a 60-year-old man, scheduled for coronary artery bypass graft surgery and died during induction of general anesthesia despite all efforts to resuscitate him. Patient's relatives lodged complaint with the police alleging the negligence by the attending physicians. Despite inaccessible data pertaining to the occupation, clinical history, and radiographic findings, the diagnosis was GIP due to the presence of intra-alveolar, bizarre, "cannibalistic" multinucleated giant cells-the histologic sine qua non of GIP. To the best of our knowledge, this is the first case report of GIP in the world literature that was diagnosed on histopathologic examination of lung tissue obtained at medicolegal autopsy.
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Sakurai A, Shimizu S, Morioka S, Fujita T, Ema R, Miki Y, Tomita K, Nakamura T, Toyoda F, Otsuki Y, Kobayashi H, Nakamura H. Multiple granulomatous lung lesions in a patient with Epstein-Barr-virus-induced mononucleosis and new-onset systemic lupus erythematosus: a case report. J Med Case Rep 2012; 6:191. [PMID: 22776319 PMCID: PMC3423016 DOI: 10.1186/1752-1947-6-191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 07/09/2012] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Granulomatous lesions are commonly encountered abnormalities in pulmonary pathology, and often pose a diagnostic challenge. We report an unusual case of granulomatous lung disease with uncommon characteristics, which developed following Epstein-Barr-virus-induced mononucleosis and new-onset systemic lupus erythematosus. We aim to highlight a diagnostic approach for the condition and to raise awareness of the possibility of it being related to the immunological reaction caused by Epstein-Barr virus infection. CASE PRESENTATION A 36-year-old Japanese man, who had been diagnosed with Epstein-Barr-virus-induced infectious mononucleosis, new-onset systemic lupus erythematosus, and secondary Sjögren's syndrome three weeks previously, presented to our facility with fever and diffuse pulmonary infiltrates. A computed tomography scan of the chest revealed multiple small nodules in both lungs. Fiberoptic bronchoscopy with bronchoalveolar lavage revealed lymphocytosis with predominance of T lymphocytes. A histological examination of a lung biopsy taken during video-assisted thoracic surgery showed randomly distributed tiny granulomatous lesions with infiltration of eosinophils. The differential diagnoses included hypersensitivity pneumonitis, sarcoidosis, and pulmonary involvement of Crohn's disease, systemic lupus erythematosus, and Sjögren's syndrome, but the clinical and pathological findings were not consistent with any of these. Our patient's condition did not improve; therefore, prednisolone therapy was started because of the possibility of specific immunological reactions associated with Epstein-Barr virus infection. After steroid treatment, our patient showed radiological and clinical improvement. CONCLUSIONS To the best of our knowledge, this is the first case of a patient developing randomly distributed multiple granulomatous lung lesions with eosinophilic infiltrates after Epstein-Barr virus infection and systemic lupus erythematosus. On the basis of our data, we hypothesize that Epstein-Barr virus infection altered the immune response of our predisposed patient and contributed to the pathogenesis of the lung lesions. Our patient's clinical response to steroid treatment was excellent.
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Affiliation(s)
- Aki Sakurai
- Department of Pulmonary Medicine, Seirei Hamamatsu Hospital, 2-12-12 Sumiyoshi, Hamamatsu, Shizuoka, Japan.
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Chronic hypersensitivity pneumonitis: high resolution computed tomography patterns and pulmonary function indices as prognostic determinants. Eur Radiol 2012; 22:1672-9. [DOI: 10.1007/s00330-012-2427-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 01/18/2012] [Accepted: 02/03/2012] [Indexed: 12/20/2022]
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VERMA H, NICHOLSON AG, KERR KM, DEMPSEY OJ, GIBBS AR, CAMPBELL I, BLACK F, RASSL D, RICE AJ, RENZONI EA, WELLS AU, HANSELL DM. Alveolar proteinosis with hypersensitivity pneumonitis: A new clinical phenotype. Respirology 2010; 15:1197-202. [DOI: 10.1111/j.1440-1843.2010.01848.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hwang SJ, Kim HS, Chung DH. Fas/Fas Ligand–mediated Apoptosis Promotes Hypersensitivity Pneumonitis in Mice by Enhancing Maturation of Dendritic Cells. Am J Respir Crit Care Med 2010; 181:1250-61. [DOI: 10.1164/rccm.200909-1337oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mukhopadhyay S, Gal AA. Granulomatous lung disease: an approach to the differential diagnosis. Arch Pathol Lab Med 2010; 134:667-90. [PMID: 20441499 DOI: 10.5858/134.5.667] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Granulomas are among the most commonly encountered abnormalities in pulmonary pathology and often pose a diagnostic challenge. Although most pathologists are aware of the need to exclude an infection in this setting, there is less familiarity with the specific histologic features that aid in the differential diagnosis. OBJECTIVE To review the differential diagnosis, suggest a practical diagnostic approach, and emphasize major diagnostically useful histologic features. This review is aimed at surgical pathologists who encounter granulomas in lung specimens. DATA SOURCES Pertinent recent and classic peer-reviewed literature retrieved from PubMed (US National Library of Medicine) and primary material from the institutions of both authors. CONCLUSIONS Most granulomas in the lung are caused by mycobacterial or fungal infection. The diagnosis requires familiarity with the tissue reaction as well as with the morphologic features of the organisms, including appropriate interpretation of special stains. The major noninfectious causes of granulomatous lung disease are sarcoidosis, Wegener granulomatosis, hypersensitivity pneumonitis, hot tub lung, aspiration pneumonia, and talc granulomatosis.
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Affiliation(s)
- Sanjay Mukhopadhyay
- Department of Pathology, State University of New York Upstate Medical University, Syracuse, New York 13210, USA.
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Abstract
CONTEXT The term small airways disease encompasses a generally poorly understood group of lung diseases that may arise primarily within the small airways or secondarily from diseases primarily affecting the bronchi or lung parenchyma. Their histology may be confusing; however, because treatments and prognoses vary, correct pathologic diagnosis is important. OBJECTIVE To present a nonexhaustive review of the pathology of primary and secondary small airways diseases, including small airways disease related to tobacco; to various other exposures, including mineral dusts; to diseases involving other areas of the lung with secondary bronchiolar involvement; and to recently described bronchiolitic disorders. DATA SOURCES Current literature is reviewed. CONCLUSIONS Small airways diseases include a wide variety of diseases of which the pathologist must consider. Uncommon conditions such as diffuse idiopathic neuroendocrine cell hyperplasia and diffuse panbronchiolitis may show relatively specific diagnostic features histologically; however, most small airways diseases exhibit nonspecific histologic features. Conditions not considered primary pulmonary diseases, such as collagen vascular diseases, bone marrow transplantation, and inflammatory bowel disease, must also be considered in patients with small airways changes histologically. Clinical and radiologic correlation is important for obtaining the best possible diagnosis.
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Affiliation(s)
- Timothy Craig Allen
- Department of Pathology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708-3154, USA.
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Hirschmann JV, Pipavath SNJ, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics 2010; 29:1921-38. [PMID: 19926754 DOI: 10.1148/rg.297095707] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most cases of hypersensitivity pneumonitis develop only after many years of inhaling allergens, which include microbes, animal or plant proteins, and certain chemicals that form haptens. The initial clinical presentation is either episodes of acute illness with dyspnea and prominent constitutional symptoms, such as fever, or an insidious onset of dyspnea, coughing, and weight loss, sometimes with superimposed acute episodes. The histopathologic process consists of chronic inflammation of the bronchi and peribronchiolar tissue, often with poorly defined granulomas and giant cells in the interstitium or alveoli. Fibrosis and emphysema may develop. The radiologic findings include diffuse ground-glass opacification, centrilobular ground-glass opacities, air trapping, fibrosis, lung cysts, and emphysema. The histologic and radiologic features in some cases may resemble those of usual interstitial pneumonia or nonspecific interstitial pneumonia. The diagnosis usually rests on a variable combination of findings from history, serology, radiography, lung biopsy, and bronchoalveolar lavage, which characteristically reveals a lymphocyte content of more than 30%, often with an increased CD4-to-CD8 ratio of T cells. Treatment includes avoiding the allergen, if possible, and, in severe cases, systemic corticosteroids. The long-term prognosis is usually good, but some patients develop severe respiratory insufficiency, and a few die of the disease.
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Beasley MB. Nonneoplastic lung disease--more than just usual interstitial pneumonia. Arch Pathol Lab Med 2010; 134:665-6. [PMID: 20441498 DOI: 10.5858/134.5.665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mary Beth Beasley
- Department of Pathology, Mount Sinai Medical Center, New York, New York 10029, USA.
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Fong DJ, Hogaboam CM, Matsuno Y, Akira S, Uematsu S, Joshi AD. Toll-like receptor 6 drives interleukin-17A expression during experimental hypersensitivity pneumonitis. Immunology 2010; 130:125-36. [PMID: 20070409 DOI: 10.1111/j.1365-2567.2009.03219.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Hypersensitivity pneumonitis (HP) is a T-cell-driven disease that is histologically characterized by diffuse mononuclear cell infiltrates and loosely formed granulomas in the lungs. We have previously reported that interleukin-17A (IL-17A) contributes to the development of experimental HP, and that the pattern recognition receptor Toll-like receptor 6 (TLR6) might be a factor in the initiation of this response. Using a well-established murine model of Saccharopolyspora rectivirgula-induced HP, we investigated the role of TLR6 in the immunopathogenesis of this disease. In the absence of TLR6 signalling, mice that received multiple challenges with S. rectivirgula-antigen (SR-Ag) had significantly less lung inflammation compared with C57BL/6 mice (wild-type; WT) similarly challenged with SR-Ag. Flow cytometric analysis of whole lung samples from SR-Ag-challenged mice showed that TLR6(-/-) mice had a decreased CD4(+) : CD8(+) T-cell ratio compared with WT mice. Cytokine analysis at various days after the final SR-Ag challenge revealed that whole lungs from TLR6(-/-) mice contained significantly less IL-17A than lungs from WT mice with HP. The IL-17A-driving cytokines IL-21 and IL-23 were also expressed at lower levels in SR-Ag-challenged TLR6(-/-) mice, when compared with SR-Ag-challenged WT mice. Other pro-inflammatory cytokines, namely interferon-gamma and RANTES, were also found to be regulated by TLR6 signalling. Anti-TLR6 neutralizing antibody treatment of dispersed lung cells significantly impaired SR-Ag-induced IL-17A and IL-6 generation. Together, these results indicate that TLR6 plays a pivotal role in the development and severity of HP via its role in IL-17A production.
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Affiliation(s)
- Daniel J Fong
- Immunology Program, Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109-0602, USA
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Wang P, Xu ZJ, Xu WB, Shi JH, Tian XL, Feng RE, Zhu YJ. Clinical Features and Prognosis in 21 Patients with Extrinsic Allergic Alveolitis. ACTA ACUST UNITED AC 2009; 24:202-7. [DOI: 10.1016/s1001-9294(10)60002-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fabreguet I, Francis F, Lemery M, Choudat L, Papo T, Sacre K. A 76-year-old man with multiple pulmonary nodules. Chest 2009; 135:1094-1097. [PMID: 19349406 DOI: 10.1378/chest.08-2049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Isabelle Fabreguet
- Department of Internal Medicine, Hospital Bichat-Claude Bernard, Paris, France
| | - Fady Francis
- Department of Thoracic Surgery, Hospital Bichat-Claude Bernard, Paris, France
| | - Marie Lemery
- Department of Pathology, Hospital Bichat-Claude Bernard, Paris, France
| | - Laurence Choudat
- Department of Pathology, Hospital Bichat-Claude Bernard, Paris, France
| | - Thomas Papo
- Department of Internal Medicine, Hospital Bichat-Claude Bernard, Paris, France
| | - Karim Sacre
- Department of Internal Medicine, Hospital Bichat-Claude Bernard, Paris, France.
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Joshi AD, Fong DJ, Oak SR, Trujillo G, Flaherty KR, Martinez FJ, Hogaboam CM. Interleukin-17-mediated immunopathogenesis in experimental hypersensitivity pneumonitis. Am J Respir Crit Care Med 2009; 179:705-16. [PMID: 19151189 DOI: 10.1164/rccm.200811-1700oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE T cells play a critical role in the development of Saccharopolyspora rectivirgula-induced hypersensitivity pneumonitis (HP) but little is known about the role of IL-17A in this disease. OBJECTIVES We examined the role of IL-17A in a murine model of S. rectivirgula antigen (SR-Ag)-induced HP. METHODS Experimental HP was induced by oropharyngeal instillation of SR-Ag in wild-type and IL-17 gene-deficient mice. MEASUREMENTS AND MAIN RESULTS SR-Ag-induced murine HP was characterized by increased transcript levels of IFN-gamma and IL-12p35 compared with saline-treated control mice. Furthermore, mice with HP showed increased IL-17 in lung homogenates, bronchoalveolar lavage fluid, and ex-vivo lung cultures compared with control mice. Flow cytometric analysis of SR-Ag-challenged lungs revealed increased Th17 and CD11c(+) cells. The role of IL-17 in SR-induced HP was examined in IL-17 deficient (IL17(-/-)) and in wild-type (IL-17(+/+)) mice immunodepleted of IL-17. Histological examination of IL17(-/-) mice challenged with SR-Ag revealed reduced inflammatory cell infiltration, decreased CD11c(+) cells, and reduced levels of inflammatory mediators such as IL-12p70, CCL3, and CXCL9 compared with similarly treated IL17(+/+) mice. Anti-IL-17 antibody treatment of IL-17(+/+) mice with HP resulted in reduced inflammation and a lower percentage of CD11c(+) cells compared with IgG-treated IL-17(+/+) mice with HP. CONCLUSIONS SR-Ag-induced IL-17 plays a pivotal role in the immunopathology of HP and targeting IL-17 is an attractive therapeutic option for this disease.
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Affiliation(s)
- Amrita D Joshi
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109-0602, USA
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Bak JY, Kim KS, Park IN, Yum HK, Lee SH, Lee HK, Lee YM, Jung H, Hur JW, Lee SS, Lee HP, Choi SJ, Shin EA, Choi SB. Two Cases of Hot Tub Lung in Bodyscrubbers Working in a Public Bath. Tuberc Respir Dis (Seoul) 2009. [DOI: 10.4046/trd.2009.66.1.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Young Bak
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Kwang Sil Kim
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - I-Nae Park
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Ho-Kee Yum
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Seung Heon Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hyun-Kyung Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Young Min Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hoon Jung
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Jin-Won Hur
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Seong Soon Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Hyuk Pyo Lee
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Soo Jeon Choi
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Eun Ah Shin
- Department of Pathology, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
| | - Sang Bong Choi
- Department of Internal Medicine, Paik Hospital, Inje University Collage of Medicine, Seoul, Korea
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