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.

Extrinsic allergic alveolitis caused by goose feathers in a duvet

A patient with extrinsic allergic alveolitis had precipitating antibodies to many avian antigens. A duvet containing goose feathers proved to be the source of antigenic material.

Hypersensitivity pneumonitis

Hypersensitivity pneumonitis is an immunologic mediated response in the lung to inhaled organic antigen. Farmer's lung and pigeon breeder's lung are the two most widely know disorders. The chest radiograph usually is normal in hypersensitivity pneumonitis. When abnormal, the distribution of disease favors the lung bases with acute disease and the upper lung zones with chronic disease. Computed tomography (CT) may be more sensitive in detecting parenchymal abnormalities, although the characteristic findings of hypersensitivity pneumonitis at CT or high-resolution CT are nonspecific.

[Salami and extrinsic allergic alveolitis: a new occupational disease in Switzerland]

The authors report a case of extrinsic allergic alveolitis in a patient working in an industrial butchery where she is involved in the preparation of dry sausages. The molds proliferating at the surface of these sausages, molds from the Penicillium family, are responsible for the disease. The respective value of laboratory tests such as the presence of precipitating antibodies and the analysis of the cellularity of the bronchoalveolar lavage are discussed. Whenever a patient presents with clinical symptoms suggestive of extrinsic allergic alveolitis a detailed search for any type of exposure linked to the professional milieu is required, so as to propose adequate modifications in work conditions or work place.

Hypersensitivity pneumonitis induced by Shiitake mushroom spores

Hypersensitivity pneumonitis due to the inhalation of Shiitake mushroom spores was demonstrated in a 38-year-old woman. Symptoms of cough, nausea and malaise, and clinical findings of cyanosis, bibasilar crackles, reduced lung volumes, hypoxemia, leukocytosis, elevated ESR, positive C-reactive protein, and bilateral diffuse reticulonodular shadows on chest roentgenogram improved after the patient was removed from exposure. Alveolitis was demonstrated by transbronchial lung biopsy, as well as an increase in lymphocytes in bronchoalveolar lavage. Serum precipitins and specific IgG antibodies to an extract of Shiitake mushroom spores, but not to other common molds or mushroom body, were detected in serum. Provocative inhalation test with the extract of mushroom spores caused the same clinical symptoms and signs as experienced in the workroom. This is the first report of typical hypersensitivity pneumonitis induced by Shiitake mushroom spores. Mushroom spores as well as thermophilic actinomycetes must be considered a causative agents for mushroom worker's lung.

Interstitial pneumonitis induced in guinea-pigs by the antigens of Periplaneta americana

Data concerning the experimental induction in guinea-pigs of hypersensitivity pneumonitis with a cockroach antigen are presented. A glycoprotein obtained from the chitinous structures of Periplaneta americana was aerosolized daily to guinea-pigs during 12 weeks. The presence of specific antibodies (IgG) was detected by serological techniques; histopathological studies of the lungs showed interstitial infiltrates of macrophages and LT-CD8+ cells, as revealed by the MoAb used. Single non-necrotizing granulomas were characteristic from the 10th week to the end of the experiment. The results from this animal model suggest that this hypersensitivity pneumonitis is a typical delayed-type reaction due to chronic contact with the heterologous glycoproteins of P. americana.

Murine hypersensitivity pneumonitis: bidirectional role of interferon-gamma

C57BL/6 mice were instilled intranasally with optimal doses [150 micrograms of antigen 3 days a week) of the actinomycete Faeni rectivirgula to induce an experimental hypersensitivity pneumonitis. Some control mice received normal rat IgG as controls, whereas other mice received 1 mg weekly of rat anti-murine interferon gamma (IFN-gamma) antibody by the intraperitoneal route and 200 micrograms by the intranasal route given 2 days before and during the challenge period before each instillation. Control mice developed a clear hypersensitivity pneumonitis characterized by an early neutrophilic response at 3 days and a later influx of mononuclear cells (nine- to tenfold increase in cell number. P less than 0.001 vs saline instilled mice at 4 weeks post-treatment). F. rectivirgula instillation determined a sharp increase in the lung index (80% increase in lung weight, P less than 0.005 vs saline treated mice), as well as a significant fibrosis at 4 weeks (twofold increase in lung hydroxyproline levels). Cytokine measurements showed that tumour necrosis factor alpha (TNF alpha) was present in the broncho-alveolar lavage (BAL) of challenged mice at 4 weeks when the BAL was obtained 8 hr after the last challenge (130 U/ml). Treatment of mice with the monoclonal antibody against IFN-gamma was associated with very few changes in the number of cells in the BAL of challenged mice. The lung index of challenged mice was significantly reduced by infusion of the anti-IFN-gamma antibody. Anti-IFN-gamma treatment resulted in decreased levels of TNF alpha in the BAL of F. rectivirgula after 4 weeks of treatment (56 U/ml, P less than 0.01). Moreover, depletion of endogenous IFN-gamma in F. rectivirgula-instilled mice resulted in a diminished lung fibrotic response (P less than 0.01 vs mice treated with F. rectivirgula and control antibody). We also studied the effect of exogenous IFN-gamma adminstration on the development of lung disease. Groups of mice received recombinant gamma interferon (IFN-gamma) (1000 U) intraperitoneally just before the first treatment and also daily, whereas controls received saline or IFN-gamma alone (no F. rectivirgula challenge). After 4 weeks of treatment, mice were killed and various markers of the disease were evaluated. As mentioned before, bronchoalveolar lavage (BAL) cell number was increased tenfold in mice treated with F. rectivirgula, whereas mice given F. rectivirgula and IFN-gamma had only a threefold increase in BAL cell number, determined mostly by a decrease in alveolar macrophage recruitment in the lungs.(ABSTRACT TRUNCATED AT 400 WORDS)

Extrinsic allergic alveolitis due to exposure to esparto dust

We here describe the case of a patient with a history of exposure to esparto grass for two and a half years, who presented with clinical symptoms, radiological signs, pulmonary function test and histological findings consistent with the diagnosis of hypersensitivity pneumonitis. Signs and symptoms reappeared after re-exposure. There are few reports of stipatosis in the world literature.

Effect of Cigarette Smoking on Prevalence of Summer-type Hypersensitivity Pneumonitis Caused byTrichosporon Cutaneum

We investigated the effect of cigarette smoking on the prevalence of summer-type hypersensitivity pneumonitis (SHP) caused by Trichosporon cutaneum. In the adult family members of SHP patients, we found that 27 of 41 (65.9%) nonsmokers were SHP patients, compared with 3 of 11 (27.3%) smokers (p less than .05). Also, the prevalence of anti-T. cutaneum antibody was significantly lower in the smokers (p less than .05). A questionnaire provided to 209 SHP patients revealed that the smoking rates of male and female SHP patients were significantly lower (p less than .01) than rates in the normal Japanese population. However, no difference was found in serum anti-T. cutaneum antibody activities or the bronchoalveolar lavage lymphocyte phenotypes for smoking and nonsmoking SHP patients. It was concluded that cigarette smoking had a suppressive effect on the outbreak of SHP, but smoking caused no further suppression after the disease was established.

[Changes in type II alveolar epithelial cells in experimental allergic alveolitis]

Changes of type II alveolar epithelial cells (type II cells) were studied in experimental allergic alveolitis by using enzyme histochemical, electron microscopic and morphometric techniques. The results showed that the number of type II cells increased obviously after exposed to thermoactinomyces vulgaris (TV). The peak was on the 15th day and then decreased gradually till to normal on the 180th day. Type II cells could be divided into two populations in TV-treated rats, namely, the large type II cells and the small type II cells. The former ones bore a diameter larger than the value of mean + 2.58s and mean indicated the mean value of type II cells diameters of the controls. The large type II cells are known to be the hypertrophic cells.

Experimental models of hypersensitivity pneumonitis

Experimental models of hypersensitivity pneumonitis are important tools for the study of the pathogenesis of this disease. In this paper we review the characteristics of the main animal models developed until now. The HP models in rats seem to be particularly appropriate for studying pigeon fancier's disease and the HP induced by chemicals, as well as for studying mediators of acute lesions induced by immunocomplexes. However, the HP models developed in rats are of less value in the evaluation of other aspects of the pathogenesis of this clinical entity in humans. The murine models of HP offer several advantages: the ease and simplicity of intranasal administration, the ability to produce acute and subacute pulmonary lesions similar to those found in humans, the possibility of reproducing lesions similar to those of nonaffected exposed subjects and the possibility of pharmacologically modulating the process. Their disadvantages lie in the different pulmonary lymphocyte response and the difficulty in reproducing a model of chronic fibrosis. The HP models in rabbits are extraordinarily useful for evaluating the immunological mechanisms through which subjects repeatedly exposed to the antigen do not develop clinical manifestations. However, the rabbit has several immunological differences when compared to humans, and the effect of some immunomodulators in this animal is different. The models of HP in guinea-pigs have as advantages the ease in handling the animals, the possibility of pharmacological manipulation, and the ability to induce an acute phase that is very similar to that observed in humans. The drawback, however, is the low lymphocyte response and the striking eosinophilic reaction that contrast with the bronchoalveolar data found in HP in humans. In conclusion, there is no ideal model to reproduce all the findings observed in humans, suggesting that the experimental animal and the method of developing HP should be selected on the basis of concrete research aims.

Hypersensitivity pneumonitis

Hypersensitivity pneumonitis is a syndrome caused by sensitization to any of a wide variety of environmental antigens and results in a pulmonary immunologic inflammatory process. The clinical syndrome occurs in a temporal relationship to exposure to the offending agent with resultant systemic or respiratory symptoms with defined chest radiographic and pulmonary function abnormalities. Definitive immune responses include those of the humoral and cellular system. Avoidance of exposure as treatment results in reversal of the clinical abnormalities.

A raised level of soluble CD8 in bronchoalveolar lavage fluid in summer-type hypersensitivity pneumonitis in Japan

We used ELISA to measure soluble CD8 (sCD8) in the bronchoalveolar lavage fluid (BALF) and serum of patients with summer-type hypersensitivity pneumonitis (HP). The sCD8 levels in BALF were significantly higher in the patients with summer-type HP, surpassing those found in sarcoidosis and the other pulmonary diseases studied; however, the sCD8 levels in the serum of patients with summer-type HP did not differ from the levels of the healthy controls. The numbers of CD8+ T cells were increased in the BALF of the patients with summer-type HP, and there was a correlation between the sCD8 levels and the concentrations of CD8+ T cells. Gel filtration and polyacrylamide gel electrophoresis of the fluid revealed that the anti-CD8 monoclonal antibody-reactive components in the BALF of patients with pneumonitis corresponded to a protein with a molecular weight of between 52 and 54 kDa. Soluble CD8-rich fraction purified from the BALF of patients with summer-type HP augmented in vitro lymphocytes' proliferative responses stimulated with Cryptococcus neoformans, one of the causative agents for summer-type HP. Our result suggests that soluble CD8 in the BALF may play an important role in the pathogenesis of summer-type HP.

Allergic alveolitis in a 12-year-old boy: treatment with budesonide nebulizing solution

Allergic alveolitis due to bird antigens was diagnosed in a 12-year-old boy. He suffered from cough, dyspnea, easy fatigue, anorexia, and severe weight loss. The diagnosis was verified by a gradual improvement when he was removed from the birds, exacerbation upon re-exposure, and the demonstration of serum precipitating antibodies against bird antigens. The patient recovered completely after a short course of oral prednisolone, treatment with inhaled nebulized budesonide for 3 months, and removal of the birds from his home.

Water-related lung diseases

A variety of water sources can act as reservoirs and vectors for contaminants associated with acute and chronic lung diseases. Inhalation of contaminated aerosols is the most important route of exposure leading to water-related lung disease. However, dermal absorption, disseminated marine-acquired wound infections, and ingestion or aspiration of water containing harmful contaminants have been associated with pulmonary disease as well. This article discusses these routes of infection and describes the infectious and noninfectious lung diseases associated with exposure to water.

Hypersensitivity systemic reaction following intravesical bacillus Calmette-Guerin: successful treatment with steroids

Intravesical bacillus Calmette-Guerin (BCG) is an effective treatment for superficial bladder carcinoma. Serious complications, including disseminated BCG infection, are infrequent. We report a case of granulomatous hepatitis with pneumonitis following intravesical administration of BCG. Cultures for mycobacteria were negative in sputum, bronchoalveolar lavage, liver and blood specimens. All symptoms disappeared within days after steroid therapy. Hypersensitivity reaction should be considered in patients with systemic symptoms after immunotherapy with BCG.

Increased prevalence of IgG-induced sensitization and hypersensitivity pneumonitis (humidifier lung) in nonsmokers exposed to aerosols of a contaminated air conditioner

Specific IgG antibodies against antigens of a contaminated air conditioner were estimated in serum of 134 workers of a printing company. Altogether 64% of the workers investigated revealed significantly elevated levels (> 3 U/ml) of IgG antibodies specific to these antigens as compared to a nonexposed control group. The occurrence of IgG antibodies for microbial extracts were 25% for Fusarium, 23% for Penicillium notatum, 13% for Alternaria tenuis, 12% for Aureobasidium pullulans, 9% for Sphaeropsidales species, 3% for Micropolyspora faeni, 2% for Aspergillus fumigatus and 2% for Thermoactionomyces vulgaris. Out of the 86 workers with elevated IgG antibodies for air conditioner antigens, 59 were nonsmokers. Considering a cut-off level of 10 U/ml IgG for high values, the proportion of smokers to nonsmokers becomes even more pronounced (6 to 36 respectively, binominal test p < 0.001). This is despite the fact that the distribution of smokers and nonsmokers among the 134 workers is approximately equal (60 to 74). All 3 workers with clinical diagnosis of humidifier lung or humidifier fever belonged to the nonsmoker group. Our findings indicate that crude water extracts of contaminated air conditioners are the best choice as antigen source for the diagnosis of humidifier lung in exposed workers. Nonsmokers are shown to have a high risk for immunological sensitization.

Zoonotic diseases of birds

Numerous diseases are shared by birds and humans. Many of them are true zoonosis. Chlamydiosis, salmonellosis, and tuberculosis are the primary infectious diseases. Allergic alveolitis in humans, induced by exposure to bird dander and protein, is also of great significance. The other diseases are of less common occurrence or represent oddities. [Editor's note: However, the increased incidence of AIDS and the increased use of immune system-compromising medications in humans have resulted in a drastic increase in the zoonotic diseases. Formerly rare diseases are becoming more common.]

Tumor necrosis factor plays an essential role in determining hypersensitivity pneumonitis in a mouse model

We examined the importance of the cytokine tumor necrosis factor-alpha (TNF-alpha) in a mouse model of hypersensitivity pneumonitis (HP). Mice of the C57BL/6 strain were instilled intranasally 3 days/wk for 3 wk with 150 micrograms of the actinomycete Faenia rectivirgula (Micropolyspora faeni) to induce HP as a model of farmer's lung. This experimental model was associated with a progressive inflammation in the lungs of challenged mice, seen histologically as cellular infiltrates of large quantities of macrophages and lymphocytes and some neutrophils. The disease in challenged mice treated with a control rabbit serum was also associated with a substantial release of tumor TNF-alpha (up to 80 U/ml of TNF-alpha in the bronchoalveolar lavage [BAL] at 3 wk after beginning of treatment) and interleukin-1, which peaked at 1 wk (approximately 300 U/ml) and diminished thereafter. A very large increase in BAL cell number (11-fold increase versus saline controls) and an enhanced release potential for TNF-alpha by alveolar macrophages was also seen. Lung fibrosis was also evident in challenged animals, as demonstrated by a 2-fold increase in hydroxyproline levels. Infusion of challenged mice with a rabbit polyclonal antibody against TNF-alpha (2 mg/wk) completely abrogated the disease, as mice so treated had normal lung histology. Anti-TNF-alpha blocked cellular recruitment in the lungs (only a 2-fold increase at week 3); it also completely abolished TNF-alpha secretion in the BAL and drastically reduced interleukin-1 levels in this fluid. Anti-TNF-alpha also abolished lung index increases and lung fibrosis, with both parameters similar to that of saline-instilled mice.(ABSTRACT TRUNCATED AT 250 WORDS)