Bird fanciers lung in mushroom workers

Hypersensitivity pneumonitis has been described in mushrooms workers caused by exposure to mushroom or fungal spores in the compost used to grow mushrooms. We describe two mushroom workers who developed hypersensitivity pneumonitis due to exposure to avian proteins found in poultry manure which was used in producing mushroom compost. Both workers were employed in the compost production area. Both presented with typical features of HP. Both workers had negative serological and precipitin studies to Apergillus fumigatus, Saccarhopolyspora rectivirgula and thermophilic actinomycetes but had positive responses to poultry antibodies. Neither was exposed to mushroom spores. Both workers required initial therapy with corticosteroids. Relocation with avoidance of further exposure resulted in complete cure in one worker and change in work practice with the use of personal protections equipment resulted in the second workerclinical stabilisation. These are the first reported cases of bird fanciers lung in mushroom workers.

[Coronary artery bypass grafting in a patient with chronic bird fancier's lung]

Acute exacerbation is a devastating and fatal event of hypersensitivity pneumonitis. We report an 80-year-old man with chronic bird fancier's lung which acutely exacerbated after off-pump coronary artery bypass grafting. Our perioperative management included avoidance of inhalation of high concentration oxygen, administration of neutrophil elastase inhibitor, and long-term administration of antibiotics. Nevertheless, the patient experienced severe respiratory failure after influenza infection. High-resolution computed tomography (CT) showed new ground-glass opacities overlying fibrosis and traction bronchiectasis. We diagnosed acute exacerbation of hypersensitivity pneumonitis. Immediate steroid pulse therapy with empirical antibiotic administration was effective, and he recovered from critical respiratory failure. High-resolution CT was very helpful in the early detection of acute exacerbation of pneumonitis.

Environmental triggers of autoimmunity in anti-synthetase syndrome: the lungs under the spot light

The prevalence of interstitial lung involvement in anti-synthetase syndrome (anti-SS) may be as high as 70% and is a major contributor to morbidity and mortality. Histidyl-tRNA synthetase (Jo-1) is the most common autoantigenic target among the aminoacyl-tRNA synthetases. We report two well documented anti-SS cases where it was observed significant exposure to a known inhaled offending antigen, development of a lymphocytic interstitial lung disease (ILD) and negative auto-antibodies, interpreted at first as hypersensitivity pneumonitis. Only after 14 and 30 months, respectively, the development of systemic symptoms compatible with anti-SS and anti-Jo-1 was observed. A growing body of evidence suggests that the lungs are the environment in which Jo-1 autoimmunity may be initiated and propagated. The description of the clinical and laboratorial evolution of these patients together with accumulated evidence of biological plausibility support the hypothesis that anti-SS can follow an episode of lung inflammation secondary to inhaled antigen exposure.

Hypersensitivity pneumonitis in children: pigeon breeders disease

Hypersensitivity pneumonitis (HP), an extrinsic allergic alveolitis, is a group of immunologically mediated, diffuse inflammatory lung parenchymal diseases. Pigeon breeder's disease (PBD) is one of the most common clinical forms of HP. It is caused by inhalation of various pigeon-derived materials and can present in different clinical forms. The diagnosis is difficult and the best diagnostic tool is correlation of onset of symptoms with time of exposure. Precipitating antibodies against the avian proteins form the characteristic precipitin reactions. The most effective treatment is avoidance of the antigens. Steroids, either systemic or topical (inhalational), can be used to treat HP. We report five children with different clinical forms of PBD in whom the diagnosis was confirmed by positive serum precipitating antibodies to avian proteins. Although the disease is rarely seen in children, it should be considered in any child with recurrent or unexplained respiratory symptoms. Nebulising steroids might be a useful alternative treatment for allergic alveolitis.

[A small bird gives severe consequences]

In this case we report how a 31 year-old woman developed hypersensitivity pneumonitis due to her budgerigar. The suspicion that her pet was the reason for her symptoms was confirmed by the finding of specific IgG antibodies against budgerigar proteins. Clinical studies demonstrated a restrictive lung disorder, increased lymphocytes in bronchoalveolar lavage and ground glass changes in high-resolution computed tomography. The patient's symptoms receded over the course of a few days after removal of the animal, and subsequent IgG levels fell.

Pigeon breeder's lung in childhood: is family screening necessary?

In this paper, we report on clinical and laboratory findings of pigeon breeder's lung (PBL) in a mother and her 2 children: 2 with the chronic recurrent form, and 1 with the chronic insidious form without any symptoms or signs, who was diagnosed during family screening. The index case was diagnosed as having primary pulmonary hypertension on admission. However, on evaluation, the diagnosis was of pigeon breeder's lung in the index case and her symptomatic mother. High-resolution computerized tomography (HRCT) revealed interstitial lung disease in an asymptomatic sister of the index case. All cases responded to steroid treatment, and at the end of the third month, HRCT findings disappeared. In conclusion, in patients with acute respiratory symptoms and rapidly recovering pulmonary hypertension after hospitalization, PBL should be remembered. All family members of the index case should be screened by HRCT in terms of interstitial lung disease, even if they are asymptomatic.

Bird breeder's disease: a rare diagnosis in young children

Bird breeder's lung disease is the most common form of hypersensitivity pneumonitis and is a rare entity in young children. We report three cases of children under 7 years of age in whom this diagnosis was confirmed early in the course of the disease. Three children aged 4.4 to 6.5 years presented with dry cough lasting for more than 1 month, dyspnoea, variable loss of appetite, weight loss, fatigue, fever and mild signs of respiratory distress. Chest X-ray films and CT scans showed a bilateral micronodular infiltrate. All three patients had strongly suggestive bronchoalveolar lavage fluid findings with lymphocytosis; two had elevated cell counts and decreased CD4/CD8 ratios. Lung biopsy confirmed the diagnosis in all children. Contact with allergens was identified in all children: two had spent holidays close to a farm in the previous month and one was living next to a pigeon house. In all children, avian precipitins were positive. The symptoms rapidly resolved after allergen avoidance and treatment with oral prednisone. Corticoid treatment was given between 11 and 15 weeks. One child relapsed and required long-term low-dose corticotherapy for 1 year. Lung function tests were normal in all three patients, 3.9 to 5.7 years after diagnosis.

CONCLUSION

Bird breeder's lung disease is a rare entity but should be considered in young children presenting long lasting cough. While rapid allergen exclusion and start of treatment can avoid the evolution into irreversible lung fibrosis, clinical and biological evolution should be monitored carefully even after stopping corticoid treatment because of the possibility of relapse.

Rosella parrot exposure as a cause of bird fancier's lung

A case of a 30-year-old man who presented with a 2-month history of progressively worsening dyspnoea, cough, and reduced exercise tolerance is discussed. A chest x-ray and computerized tomography of the chest suggested interstitial lung disease, which was confirmed on histology of an open lung biopsy. Careful questioning revealed that the patient had sustained close exposure to a rosella parrot acquired as a pet 9 months prior to presentation, which led to the diagnosis of bird fancier's lung. The case, investigations, and outcome are presented. This is followed by a discussion on extrinsic allergic alveolitis with particular emphasis on the importance of a complete social and environmental history in patients presenting with similar respiratory symptoms.

Clinical features of recurrent and insidious chronic bird fancier's lung

BACKGROUND

Chronic bird fancier's lung (BFL) can be subgrouped into two types. One subgroup of patients develops interstitial pulmonary fibrosis after recurrent acute episodes (recurrent BFL), and the other subgroup of patients has no history of acute episodes but has slowly progressive chronic respiratory disease (insidious BFL).

OBJECTIVE

To define the clinical characteristics of both types of BFL and to provide clues for diagnosis.

METHODS

We performed a retrospective review of the medical records of patients with chronic BFL who were evaluated between October 1992 and March 2001 at the Tokyo Medical and Dental University Hospital in Japan. Patients were evaluated for their clinical characteristics, including history, laboratory, and immunologic findings; imaging; bronchoalveolar lavage; and histologic findings.

RESULTS

Thirty-two patients with chronic BFL were included in this study; 15 patients had recurrent BFL and 17 had insidious BFL. The patients with recurrent BFL tended to breed dozens of pigeons in a loft, whereas the patients with insidious BFL were likely to be exposed to smaller birds kept indoors. Specific antibodies against pigeon dropping extracts or budgerigar dropping extracts were positive in 87% of the recurrent BFL cases and 35% of the insidious BFL cases. Antigen-induced lymphocyte proliferation was positive in more than 90% of both groups. The upper lung field was frequently involved in both groups as demonstrated by chest radiographic findings. In all of the patients with insidious BFL, the diagnosis was confirmed by positive laboratory-controlled inhalation test results.

CONCLUSIONS

Insidious BFL may be misdiagnosed as idiopathic pulmonary fibrosis if a careful history is not taken and antigen-induced lymphocyte proliferation, careful imaging evaluation, and laboratory-controlled inhalation challenge testing are not conducted. In contrast, the clinical findings of recurrent BFL are consistent with hypersensitivity pneumonitis induced by other antigens.

[Nocardia otitidiscaviarum, cutaneous infection in a patient receiving long-term corticosteroid treatment]

A 62-year-old man, under long-term corticosteroid therapy for pigeon breeder's disease, was admitted to endocrinology disease department for cutaneous abscess on back, limbs and scalp. Culture of various bacteriological samples (cutaneous abscess, blood culture) isolated Nocardia otitidiscaviarum. The patient was treated by trimethoprime-sulfametoxazole during several weeks with abscess disappearance. Our laboratory quickly identificatied a bacteria belonging to the Nocardia genus, with simple technique, later confirmed by a specialized laboratory (Pr. Boiron Claude Bernard University Lyon I) with identification of Nocardia otitidiscaviarum. The proof of pulmonary nocardiosis could not be established despite the existente of several risk factors. Prognosis is poor for immunocompromised patients, but the secondary cutaneous dissemination phase presented a favourable evolution under antibiotic therapy.

[A case of bird fanciers' disease caused by parrot droppings]

A 50-year-old woman who had been treated for Parkinson's disease was admitted to our hospital because of exertional dyspnea and weight loss. Her chest computed tomography showed diffuse ground glass opacities in both lung fields. Bronchofiberscopy was performed, and the bronchoalveolar lavage fluid showed an elevated lymphocyte count. The serum Ouchterlony test yielded positive results for parrot droppings as well as for pigeon serum and droppings. She had had a parrot for several years, but no pigeon, and so we diagnosed bird fanciers' disease associated with parrot droppings. This responded well to steroid therapy. This case of bird fanciers' disease was caused by the droppings of only one parrot.

A family with extrinsic allergic alveolitis caused by wild city pigeons: A case report

We describe a family in which the mother died of unresolved lung disease and whose 5 children, some of whom had previous signs of asthma, were subsequently affected by extrinsic allergic alveolitis caused by contact with wild city pigeon antigens. The children received systemic corticosteroids for 1 month and inhaled steroids for 24 months, while antigen exposure was reduced as much as feasible. This was followed by a quick clinical recovery and a slow normalization of chest radiographs and pulmonary function indices, especially of diffusion capacity, during a follow-up of 24 months. Because pigeon-breeder's lung caused by free-roaming city pigeons has not been previously described, it remains unclear whether this family developed the disease because of high antigen exposure or because of increased susceptibility. None of the supposedly high-risk human leukocyte antigen types were found in the children. Whether human leukocyte antigen B7 in 1 child played a role in the course of the illness remains speculative. It is unknown to what extent pigeon-breeder's lung caused by nondomestic birds remains undetected and misdiagnosed as difficult or steroid-resistant asthma. The question remains whether free-roaming city pigeons are indeed a public health risk. We suggest that atypical outdoor antigens be considered in all patients with nonresolving chest disease or therapy-resistant asthma.

[Asthmatic child without asthma]

Two boys aged 13 and 7 years, displayed chronic coughing, dyspnoea on exertion, anorexia, weight loss, and fatigue. At first a diagnosis of asthma was made. However, a correct interpretation of anamnestic and clinical features, laboratory findings and radiographic results led to the diagnosis of 'pigeon breeder's disease' in both cases. Both patients recovered after drug treatment and avoidance of re-exposure to pigeon antigen.

[Extrinsic allergic alveolitis. Clinical experience at the Instituto National de Enfermedades Respiratorias (INER)]

Extrinsic allergic alveolitis is an interstitial lung disease caused by exposure to a variety of inhaled antigens. In Mexico, the most frequent form is due to the inhalation of avian antigens, markedly pigeon proteins. Depending on type and time exposure, the disease presents different clinical forms usually characterized by progressive dyspnea, ground glass or reticulonodular images on chest x rays, a restrictive functional pattern, rest hypoxemia worsening with exercise, and increase of T lymphocytes in bronchoalveolar lavage with an inversion in the helper/suppressor ratio. In this paper, we discuss a 15-year experience with this pathological problem in Mexico, emphasizing the differences with this disorder in Caucasian populations. Generally, our patients display a chronic form of the disease, which evolves to fibrosis in about one-half of the patients. In this sense, the diagnostic, prognostic, and therapeutic focusing exhibit different elements, and thus the development of clinical and basic research is strongly required.

Bird fanciers' lung: a case report

The clinical course of a case of bird fanciers' lung is described along with the considerations that are important in the management of this form of hypersensitivity pneumonitis. Diagnostic parameters, therapeutic considerations, and environmental issues are discussed in the context of the current literature.

Hypersensitivity pneumonitis due to native birds in a bird ringer

A bird fancier who had only been exposed to native birds, mostly owls, developed a sever hypersensitivity pneumonitis with a very insidious onset.

Pigeon-breeder's lung. Extensive workup clarifies the clinical picture

Pigeon-breeder's lung should be included in the differential diagnosis when patients present with interstitial lung disease or intermittent cough and dyspnea. No single test confirms the diagnosis. Rather, careful attention must be given to results of history taking, physical examination, pulmonary function and precipitin testing, chest radiography, and, if indicated, lung biopsy. Symptoms usually resolve when exposure to suspected antigens is avoided.

[Exogenous allergic alveolitis (bird fancier's lung)]

A 13 year old boy was admitted to our clinic because of caugh, dyspnoe, tachypnoe and bilateral fine moist rales since more than 6 months. Pulmonary function studies showed a restrictive lung disease. Lung biopsy revealed an interstitial pneumonitis. These findings together with a hypergammaglobulinemia and precipitating antibodies were highly suggestive of an extrinsic allergic alveolitis i.e. pigeon breeder's disease. The patient was treated with corticosteroids and is well after 1 year without any therapy except prevention of further exposure.

[Hypersensitivity pneumopathies ("bird fancier's lung") in children. Diagnostic value of bronchoalveolar lavage]

A current view of "pigeon fancier's lung" in children is reported through a familial case presenting as a severe denutrition in a 9 year-old boy. Cellular and biochemical analysis of broncho-alveolar lavage fluid is essential to proper diagnosis. Treatment is based upon the eviction of inhaled antigenic organic materials issued from pigeon's droppings, corticosteroid treatment being only additional. Pulmonary fibrosis is a rare but possible complication in the outcome of the disease.

[Bird breeder's lung with conversion to fatal fibrosing alveolitis]

An 11-year-old girl developed typical symptoms of bird breeder's lung after several years of contact with budgerigars and other birds. The clinical diagnosis was confirmed by immunological and lung-function tests. Despite exclusion of exposure to allergens and treatment with steroids and D-penicillamine no improvement occurred, the exogenous allergic alveolitis progressing to fibrosing alveolitis of which the girl died.

Budgerigar fancier's lung. The persistence of budgerigar precipitins and the recovery of lung function after cessation of avian exposure

Forty-eight budgerigar fanciers have been studied and twenty-five (52%) of these lost their serum budgerigar precipitins after cessation of avian exposure. Twenty (80%) subjects lost their precipitins within 2 years. The lung function was assessed serially in seventeen patients with allergic alveolitis and correlated with the persistence of their serum precipitins. There was no difference in the lung function at presentation or in the incidence of complete recovery between the ten subjects, whose precipitins persisted for longer than 2 years, and the seven individuals in whom the precipitins had disappeared within this time. These observations suggest that budgerigar precipitins do not have a major role to play in the continuing pathogenesis of allergic alveolitis.

[Respiratory function in extrinsic allergic alveolitis caused by pigeons. Clinical, pathological and functional correlation]

Lung function tests (LFT) were performed in 71 patients with proven extrinsic allergic alveolitis due to pigeons (EAA-P), and they were correlated with lung biopsy (LB) findings. Lung function studies were analyzed to evaluate the clinical course of these patients treated with corticosteroids. Restrictive pulmonary function impairment was found in all cases (vital capacity 38 +/- 4%), residual volume was increased in 9 out of 14 patients (64%) (RV = 0.51 +/- 0.06 L.) and bronchial obstruction was a feature in 11/14 patients (78%) (MMEF = 53 +/- 4%). In all cases a low Pa02 was observed (44 +/- 2 mmHg) and in six an increase in PaC02 was detected. The vital capacity did not correlate with the degree of inflammation or fibrosis observed by LB. A significant negative correlation was found between Pa02 and the degree of inflammation (r = 0.68, p X 0.05) as well as with fibrosis + inflammation degrees (r = -0.63, p less than 0.05). In general, initial LFT and clinical improvement occur simultaneously. Lung function tests support the diagnosis of EAA-P, but are not capable of separating inflammation from lung fibrosis.

Bird breeder's hypersensitivity pneumonitis: progress studies of lung function after cessation of exposure to the provoking antigen

Lung function and immunologic studies have been performed in 9 patients with bird breeder's hypersensitivity pneumonitis at the time of diagnosis and at intervals from 8 to 30 months after they ceased exposure to the provoking antigen. All 9 patients had evidence of small airway obstruction at the time of diagnosis. Complete recovery of lung function occurred in 4 patients. The other 5 all had evidence of interstitial damage; 3 of them had progressive increase in the degree of airway obstruction, and one had progressive loss of elastic recoil. The patients were nonsmokers, and these progressive changes could not be explained by occult exposure to antigen because the tests of immunologic sensitivity to relevant avian antigens became negative. Neither the nature or degree of lung function abnormality nor the form of clinical presentation was related to the development of residual damage. The period of exposure to antigen after symptoms developed and the age of the patient appeared to be the most important factors determining recovery of lung function.