Hypersensitivity pneumonitis induced by Penicillium expansum in a home environment

An episode of fever, cough, shortness of breath and leucocytosis developed in a 31-year-old atopic housewife from mould exposure in her home environment is evaluated. A chest radiograph revealed diffuse tiny nodular infiltrations in both whole lung fields. Spirometry revealed a severe restrictive type of ventilation impairment. Bronchoalveolar lavage (BAL) showed an increased lymphocyte count with reversed CD4+/CD8+ ratio and transbronchial lung biopsy showed markedly increased lymphocytic infiltration in alveolar septa. Fungal cultures in the air of her home were positive for Penicillium expansum and other fungi. Double immunodiffusion test with the patient's serum showed two precipitin bands to P. expansum antigens. Her symptoms, abnormal findings of radiograph, and spirometric abnormalities disappeared after 2 months' avoidance. The serum precipitin disappeared after 1 month's avoidance. This study indicates that the patient had hypersensitivity pneumonitis (HP) on exposure to P. expansum in her home environment.

Pulmonary inflammation induced by repeated inhalations of beta(1,3)-D-glucan and endotoxin

In an animal model of hypersensitivity pneumonitis (HP) guinea-pigs were exposed for 5 weeks to an aerosol of bacterial endotoxin, beta(1,3)-D-glucan (curdlan) or a combination. Exposure to endotoxin or curdlan showed only small changes in inflammatory cells in airways or the lung wall, histologically or in terms of enzyme secretion from alveolar macrophages. When the two agents were given together, a histology resembling HP was seen with alveolar infiltrates and early granulomas. Inflammatory cells in airways were increased and enzyme production of macrophages was changed, suggesting an effect of curdlan on the inflammatory regulating capacity of airway macrophages. The results suggest that interference with macrophage function and inflammation are important components in the development of HP.

Extrinsic allergic alveolitis and asthma in a sawmill worker: case report and review of the literature

A 34 year old sawmill maintenance engineer developed a dry cough that was associated with widespread wheezes and crackles in his lungs. His symptoms worsened, with work related lethargy, fever, and breathlessness, and the loss of a stone in weight. At that time, while still at work, he had a neutrophil leucocytosis and increased concentration of gamma globulins. When seen subsequently some two months after stopping work, his chest radiograph and lung function tests were normal, but the cells recovered at bronchoalveolar lavage showed an increase in lymphocytes and mast cells, a pattern consistent with extrinsic allergic alveolitis. Serum precipitins were identified to extracts of sawdust, wood chips, and bark from the sawmill, and to eight species of mould grown from these samples. Specific IgG binding inhibition studies suggested that a common epitope present on Trichoderma koningii might be responsible for the cross reactivity of the patient's serum with the wood and fungal extracts. A diagnosis of wood associated extrinsic allergic alveolitis was made and since changing his job the patient has remained well. Wood associated allergic alveolitis has not previously been described in British sawmill workers, but has been reported in Sweden, with a prevalence of 5%-10% in exposed workers. A review of published data suggests extrinsic allergic alveolitis in wood workers is primarily caused by inhalation of the spores of contaminating fungi, but inhaled wood dust may exert a synergistic effect.

Bird droppings contain endotoxin and (1-->3)-beta-D-glucan

Samples of bird droppings were collected and the amount of endotoxin and (1-->3)-beta-D-glucan in these was determined using a specific Limulus assay. All samples contained these agents and calculations on airborne levels demonstrated that doses at risk for inflammation and allergic alveolitis were present. Endotoxin and (1-->3)-beta-D-glucan should be considered in investigations on lung disease induced by bird droppings.

Airflow obstruction and airway lesions in hypersensitivity pneumonitis

Peripheral airways of lung biopsies from patients with HP commonly show several morphologic changes, including inflammation, fibrosis, or both. In most cases, damage of the airways is parallel to damage of surrounding parenchyma and the functional result is lung restriction, perhaps with alterations in the so-called "small airway tests." Chronic cough and phlegm also are more common in subjects exposed to organic antigens. Overt airflow obstruction is present in a number of patients with HP, and they usually have other risk factors, such as asthma, cigarette smoking, or dust inhalation. There are limited studies of patients who have HP and CAO but not concomitant risk factors for CAO, making it difficult to reach any firm conclusion about their association. In most cases, the lesion that could explain severe airflow obstruction seems to be located in bronchioles but, based on several clinical reports, there is the possibility that HP occasionally ends in emphysema.

Inhalational lung injury causing bronchiolitis

Inhalational injury to the respiratory tract is common and can be subtle. The clinical features produced by these injuries are very similar, and pulmonary function tests usually show an obstructive profile. Pathologic reactions also appear to be similar, with the end result airway distortion by inflammation and fibrosis. Rather than postulating that there is a specific airway response to each of a broad range of agents, it is more likely that inflammation and fibrosis are nonspecific and stereotypic responses.

[Thermoactinomyces vulgaris as a cause of extrinsic allergic alveolitis]

Thermoactinomycetes are microorganisms similar to the aerobic actinomycetes that grow at temperatures between 32 65 degrees C and are usually found in soil, hay and warm environment. They are the agent of Extrinsic Allergy Alveolitis producing an interstitial process of immunologic, generated by the inhalation of the environmental dust that contain spores from these fungi. There is one case of a middle age man who works in a boiler of a foundry company of province de Buenos Aires in Argentina. The patient presents a clinical picture compatible with the above mentioned illness and he gets better in vacation periods. The Thermoactinomyces vulgaris was isolated from the dust accumulated in a ceiling light.

Hypersensitivity pneumonitis

Although the cause and development of most inflammatory and fibrotic interstitial lung diseases are unknown, both the antigenic stimuli and the immunopathogenic mechanisms that produce the syndrome of hypersensitivity pneumonitis have been well described. Hypersensitivity pneumonitis is a group of related inflammatory and fibrotic interstitial lung diseases that result from hypersensitivity immune reactions to the repeated inhalation of antigens derived from fungal, bacterial, animal protein, and reactive chemical sources. Immune complex-induced inflammatory reactions initiate acute lung injury; T cell-mediated hypersensitivity reactions perpetuate it and induce chronic inflammatory, granulomatous, and fibrotic responses in the interstitium of the lungs. Because the natural history of many interstitial lung diseases of unknown causes involves the progressive evolution through these same phases, knowledge about immune pathogenesis gained from studies of hypersensitivity pneumonitis may provide a way to understand the causes and development of other interstitial lung diseases.

Organic dust exposures from compost handling: case presentation and respiratory exposure assessment

Inhalation of dust from contaminated organic materials may result in acute respiratory tract illness. Possible mechanisms include toxic and cellular reactions to microbial and other organic products or immunologic responses after prior sensitization to an antigen. A case is presented of a 52 year old male who developed fever, myalgia, and marked dyspnea 12 hr after shoveling composted wood chips and leaves. Inspiratory crackles, hypoxemia, and bilateral patchy pulmonary infiltrates were seen. Precipitating antibody tests for the usual antigens were inconclusive. He improved over 3 days. In order to assess the environmental conditions the patient had experienced, we returned to the site to reproduce and measure respiratory exposures during hand loading of the compost. Visible clouds of fine particulate were easily generated during handling activities. Microscopic examination of these dusts indicated a predominance of spores. Endotoxin concentrations from inspirable and respirable dust samples ranged from 636 to 16,300 endotoxin units/m3. Levels of contaminants found were consistent with those associated with respiratory illness in other agricultural settings. Two respiratory disorders, hypersensitivity pneumonitis (HP) and organic dust toxic syndrome (ODTS), may occur after exposure to organic dusts containing fungal spores and endotoxins. Despite extensive clinical and environmental investigations, we were unable to differentiate these two disorders, and suggest they may represent parts of a spectrum of responses to complex organic dusts, rather than completely distinct clinical entities.

Hypersensitivity pneumonitis secondary to Klebsiella oxytoca. A new cause of humidifier lung

A 30-year-old woman developed recurrent episodes of fever, dyspnea, and nonproductive cough after repeated exposure to a home humidifier. The diagnosis of hypersensitivity pneumonitis was confirmed by detection of serum-binding antibodies at significant titer to Klebsiella oxytoca colonizing the humidifier water but not to other potential antigens. This represents a newly recognized cause of hypersensitivity pneumonitis related to exposure to K oxytoca contaminating a commercially available ultrasonic cold air home humidifier. The potential role for these frequently used home humidifier devices in unexplained pulmonary illness is emphasized.

Hypersensitivity pneumonitis resulting from Aspergillus fumigatus in a greenhouse

A 57-y-old female who had cultivated vegetables in a plastic greenhouse developed a case of hypersensitivity pneumonitis from Aspergillus fumigatus. This report exemplifies a potential hazard caused by a thermotolerant fungus, A. fumigatus, in a poorly constructed greenhouse.

[A case of smoldering ATL associated with hypersensitivity pneumonitis]

A 37-year-old woman was admitted to our hospital with the complaints of cough, lymph node swelling. Chest X-ray film showed diffuse small nodular shadows in the bilateral lower lung fields. Bronchoalveolar lavage fluid revealed an increased proportion of lymphocytes (71%) with low OKT4/T8 ratio (0.26). Lung tissue biopsied by bronchofiberscopy showed the existence of interstitial pneumonia. Precipitating antibodies in this patient's serum against various antigens including Trichosporon cutaneum were positive. After admission, all symptoms resolved gradually without specific therapy. But, as soon as the patient was discharged and returned to her home, all symptoms including fever, cough, dyspnea and lymphadenopathy recurred rapidly. The diagnosis of hypersensitivity pneumonitis was made on the basis of these laboratory findings and clinical course. The patient died from respiratory failure after detection of anti-HTLV-I antibody, and autopsy revealed massive ATL cell infiltration of lung tissue, and immunoenzymatic analysis showed a high OKT4/T8 ratio (3.5). Chronic HTLV-1 infection since infancy was suspected in this case, to have modified the immune regulation of the lung, and to have led to the onset of hypersensitivity pneumonitis and the active immune response in the lungs, finally followed by the acute exacerbation of ATL.

Extrinsic allergic alveolitis after exposure to the yeast Rhodotorula rubra

A case of extrinsic allergic alveolitis following exposure to the red yeast Rhodotorula rubra is reported--to our knowledge, for the first time. Extensive growth of the yeast in the patient's environment was demonstrated, explaining an elevated titer of Rhodotorula-specific precipitating antibodies in his serum. A bronchial provocation test confirmed the diagnosis.

Exposure to microorganisms associated with allergic alveolitis and febrile reactions to mold dust in farmers

STUDY OBJECTIVE

To compare exposure to microorganisms associated with allergic alveolitis (AA) and with febrile reactions to inhaled mold dust (organic dust toxic syndrome [ODTS]) in farmers and in normal subjects.

DESIGN

A prospective study in which exposure was evaluated within two weeks of medical consultation for AA or ODTS. Samples were collected during normal farming (background) and during the handling of materials associated with disease or causing maximal exposure in reference farms (worst case).

SETTING

Swedish farms

PARTICIPANTS

Eleven farmers with a confirmed diagnosis of AA from ten farms, 16 subjects with symptoms of ODTS from 12 farms, and 17 reference farmers.

MEASUREMENTS AND RESULTS

Worst-case samples representative of the exposure preceding disease were obtained on four farms where five farmers had had AA; the samples contained on average 2.6 +/- 1.8 x 10(9) (SD) spores/m3 of air. On six farms where nine farmers had had ODTS, representative samples averaged 13 +/- 13 x 10(9) spores/m3, and on reference farms this figure was 0.12 +/- 0.20 x 10(9) spores/m3. The daily spore dose associated with allergic alveolitis was 2 x 10(9) spores/d, which was ten times higher than on reference farms. The average dose associated with ODTS was 2 x 10(10) spores. Worst-case samples, collected during 10 to 30 min, contributed to more than 90 percent of the day exposure on farms where AA or ODTS had occurred.

CONCLUSION

Allergic alveolitis was associated with high exposure levels on most weekdays for weeks, and ODTS was associated with extreme exposure occurring on a single day. There was no correlation with individual spore types and disease and the present results are compatible with a hypothesis that common cell wall components of microorganisms may cause "toxic" symptoms and stimulate immune reactions.

Respiratory disorders in agriculture

Work in agriculture is associated with exposure to respiratory biohazards. The most important airborne substances include grain dust and its constituents, bacteria and metabolites (endotoxin), fungi and metabolites (glucan), and storage mites. The degree of dysfunction in exposed persons depends on the biological potency and concentration of exposure as well as on individual susceptibility. Airborne contaminants frequently occur in concentrations and compositions that challenge the defence mechanisms of the lung. This may be of particular importance in the case of susceptible workers and minors, whose exposure by the virtue of family-type operations is difficult to avoid. Epidemiological and clinical studies have contributed to the identification of associations between respiratory disorders and agricultural exposures. Chronic bronchitis, asthma, hypersensitivity pneumonitis, organic dust toxic syndrome and chronic airflow limitation have been found to occur in agricultural workers. Clinical and experimental studies have advanced the understanding of immunologic and non-immunologic mechanisms involved in respiratory responses to a wide spectrum of inhaled organic dusts. Although the evidence has provided substantial insight into the occurrence and pathogenesis of respiratory disorders in agriculture, further investigation is necessary. There is a need for research involving accurate assessment of exposures and their respiratory effects. There is also a need for the establishment of preventive programs, with emphasis on reduction of harmful exposures. Increasing concern about respiratory disorders in agriculture justifies further scientific effort in both areas.

[A case of hypersensitivity pneumonitis in Pholiota nameko's manufacturer]

A 58-year-old female was admitted to our hospital because of fever and dyspnea on exertion. She has been working in the factory making Pholiota nameko for 8 years. Her chest X-ray revealed diffuse linear and fine nodular shadows in both lower lung fields. Hypoxemia was seen on blood gas analysis. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were performed. Differential cell count of the BAL fluid showed lymphocytosis and CD4/8 was decreased. TBLB specimens revealed bronchioloalveolitis. Precipitins against Trichosporon cutaneum were detected by Ouchterlony method. These findings are compatible with hypersensitivity pneumonitis, and Trichosporon cutaneum may have been causative antigen in this case. Trichosporon cutaneum is often detected in the Japanese summer-type hypersensitivity pneumonitis. This case suggests that Trichosporon cutaneum is one cause of hypersensitivity pneumonitis in workers at factories making Pholiota nameko.

Inhaled aeroallergen and storage mite reactivity in a Wisconsin farmer nested case-control study

A nested case-control study was undertaken to assess the role of antibody (Ab) to a panel of antigens associated with hypersensitivity pneumonitis in the development of lung disease among Wisconsin dairy farmers. Immunologic reactivity to a panel of inhaled allergens was assessed in the Ab+ cases and compared to the Ab+ control, Ab- control, and Ab- blue-collar control subjects by skin tests, RAST assays, and a modified American Thoracic Society questionnaire. The most prevalent allergens among the cases as determined by either skin test or RAST assays were the house dust mites (HDM) (21.6%), storage mites (11.2%), grain smuts (11.2%), Cladosporium (7.5%), Aspergillus (6.0%), and cattle (5.2%). No other allergens appeared to be different from in nonfarming populations. Of the storage mite reactors, IgE to Lepidoglyphus destructor (7 of 8) was the most frequently found, followed by Tyrophagus putrescentiae (6 of 8), Glycyphagus domesticus (5 of 8), Chortoglyphus arcuatus (5 of 8), and Acarus siro (2 of 8). L. destructor was also isolated from the farm of one of the cases. There was no difference in the total IgE levels among the groups. Reactions to HDM, storage mites, and grain smuts were significantly more frequent among the cases (p < 0.05). We conclude from this study that there is a significant increase in reactivity to certain inhaled allergens among those dairy farmers reporting barn-associated respiratory symptoms that is unrelated to past exposure to the causative agents of farmer's lung disease.

The sick building syndrome. I. Definition and epidemiological considerations

It has been difficult to confirm that a given building is responsible for allergic symptomatology, exacerbation of asthma, or immunological dysfunction. In fact, in most studies, few objective immunological parameters have been studied and only rarely has there been any quantitation of IgE or secondary mediators. Furthermore, although many studies deal with rhinitis or respiratory tract irritation, there is a misconception that all such symptoms are allergic in nature, and studies attempting to prove that allergies are caused by buildings frequently neglect to prove that these are indeed true allergic responses. In addition, many of the symptoms that people attribute to sick building syndrome (SBS) or building-related illness, such as headaches, dizziness, fatigue, nausea, cough, and eye irritation, are subjective, and studies often fail to take into account other possible causes that may be inherent in the subjects, such as sinusitis, hyperventilation syndrome, or psychosomatic illness. Unfortunately, most clinical studies on SBS pay little attention to the preexisting conditions that a subject may have and discount the possibility that the inciting agent does not cause symptoms, but merely exacerbates a preexisting condition. Moreover, they offer no information about the nature of the mechanisms of action or pathophysiological relationships. Clearly, further studies are necessary to further explain the complexity of complaints that currently exist. Indeed, SBS might properly be paraphrased as "what is it?--if it is!"

The role of complement-derived chemotactic factors in lung injury induced by preformed immune complexes

Our previous studies have suggested a role for complement fragments presumably activated by immune complexes in patients with hypersensitivity pneumonitis. The present study has shown that circulating complement depletion by cobra venom factor resulted in the reduction in severity of immune-complex-mediated pulmonary inflammation. The activity of chemotactic factors for neutrophils generated in bronchoalveolar lavage fluids in complement-depleted animals was significantly diminished to 61.2% compared to the undepleted animals. In addition, reduced activity of chemotactic factors resulted in a marked reduction of accumulation of neutrophils in bronchoalveolar lavage fluids indicating that chemotactic factors play an important role in the sequestration of neutrophils on the alveolar side of the lung. In conclusion, chemotactic factors in bronchoalveolar lavage fluids which preceded the accumulation of polymorphonuclear cells are partially derived from complement.

Tachyphylaxis to capsaicin-induced cough and its reversal by indomethacin, in patients with the sinobronchial syndrome

Cough reflex testing with capsaicin has been used to study the pathophysiology of the cough reflex and the antitussive effects of various drugs. Although the reproducibility of capsaicin-induced cough has been well established in normal subjects, it is not known if prior challenge with capsaicin reduces the subsequent cough response to inhaled capsaicin in patients with the sinobronchial syndrome, a condition characterized by chronic upper and lower airway inflammation. Measurement of the capsaicin cough threshold, defined as the lowest concentration of capsaicin eliciting five or more coughs, was repeated four times at intervals of 15, 30 and 60 min in eleven patients with the SBS and ten normal subjects. The cough thresholds at 15, 30 and 60 min were greater than the initial value in patients with the SBS but not in normal subjects. In addition, we examined the effect of 4 days treatment with indomethacin (100 mg/day) on the cough thresholds measured twice at an interval of 15 min in eight patients with the SBS. Indomethacin increased the initial cough threshold and reduced the increment in the post-15 min cough threshold from the initial value compared with placebo, thus reducing the tachyphylaxis. These results indicate that chronic airway inflammation may be responsible for the decreased response (tachyphylaxis) to repeated inhalation of capsaicin, and suggest that cyclooxygenase products released by the airway inflammation may be involved in tachyphylaxis, cough receptor sensitivity to inhaled capsaicin, or both, in patients with the SBS.