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Weinstock LB, Brook JB, Molderings GJ. Efficacy and toxicity of hydroxyurea in mast cell activation syndrome patients refractory to standard medical therapy: retrospective case series. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1441-1447. [PMID: 35982335 PMCID: PMC9388361 DOI: 10.1007/s00210-022-02282-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022]
Abstract
Determine efficacy and adverse events (AEs) of hydroxyurea (HU) in mast cell activation syndrome (MCAS) patients who were refractory to standard medical therapy. An electronic chart review was performed to find MCAS patients who received HU in a MCAS medical practice. Diagnosis of MCAS was established on the basis of mast cell (MC) activation symptoms in ≥ 5 systems plus ≥ 1 abnormal MC mediators and/or ≥ 20 MC/high power field on duodenal biopsies. Medicines not providing significant clinical improvement prior to HU were tabulated. The following symptoms were evaluated by patients on a 0–10 scale prior to and at the study conclusion: bone pain, abdominal pain, diarrhea, bloating, and nausea. Safety labs were obtained on a regular basis. Twenty out of three hundred ten (8.4%) MCAS patients received HU. Patients included 22 females, average age 42.4 years. Dysautonomia was present in 60%. An average of 10.6 (SD 1.7, range 8–13) medications were used prior to adding HU to various concomitant medications. Average dose of HU was 634 mg. In 20 patients who continued therapy for ≥ 2 months, there was statistically significant reduction of bone pain, abdominal pain, diarrhea, bloating, and nausea. Fourteen patients noted prolonged success with therapy. Six patients stopped HU within 6 weeks owing to AEs. Four patients treated ≥ 2 months had AEs and 2 led to HU cessation. All AEs were reversible. Refractory MCAS patients showed clear significant improvement in bone pain and gastrointestinal symptoms on HU. Systematic monitoring was effective in preventing the occurrence of severe HU-induced adverse events.
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Affiliation(s)
- Leonard B Weinstock
- Clinical Medicine, Department of Medicine, Washington University School of Medicine, President, Specialists in Gastroenterology, 11525 Olde Cabin Road, St. Louis, MO, 63141, USA
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Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
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Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
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3
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Galván OP, Moltó HP, Fabià-Mayans A, Xicoy B, Mate JL, Martí PR. Hydroxyurea-Induced Pneumopathy in a Patient With Myeloproliferative Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2018; 11:1179547618770688. [PMID: 29899671 PMCID: PMC5993068 DOI: 10.1177/1179547618770688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022]
Abstract
Hydroxyurea (HU) is a drug frequently used in the treatment of chronic myeloproliferative neoplasms. The most common side effects of this drug are pancytopenia, digestive and skin disorders. Respiratory complications are rare and there are less than 20 cases described, only 5 of which underwent an anatomopathological study. We present the case of a patient with chronic myeloproliferative neoplasm who developed interstitial pneumonitis probably due to HU according to histological study.
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Affiliation(s)
- Oriol Plans Galván
- Department of Intensive and Critical Care, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Hipólito Pérez Moltó
- Department of Intensive and Critical Care, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Blanca Xicoy
- Department of Hematology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - José Luis Mate
- Department of Pathological Anatomy, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Pilar Ricart Martí
- Department of Intensive and Critical Care, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Bargagli E, Palazzi M, Perri F, Torricelli E, Rosi E, Bindi A, Pistolesi M, Voltolini L. Fibrotic Lung Toxicity Induced by Hydroxycarbamide. ACTA ACUST UNITED AC 2017; 31:1221-1223. [PMID: 29102950 DOI: 10.21873/invivo.11194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/08/2017] [Accepted: 09/14/2017] [Indexed: 01/15/2023]
Abstract
A patient treated for 4 months with hydroxycarbamide (hydroxyurea) for chronic myelomonocytic leukemia was admitted to hospital for recently developed severe dyspnea and acute respiratory failure. The computed tomographic scan of the chest showed diffuse ground glass opacities, some centrilobular low-density nodules (resembling hypersensitivity pneumonitis-like pattern), and minimal interstitial reticulation of the subpleural region. The analysis of bronchoalveolar lavage fluid excluded infection, as did serological examinations. The patient was started on oxygen therapy and with relief of thrombocytopenia and suspected hemolytic anemia, hydroxyurea treatment was discontinued. The patient underwent steroid therapy, with a rapid progressive improvement of clinical and radiological features. As hydroxyurea is increasingly used for a number of systemic disorders, physicians must be aware of its potential lung toxicity, requiring immediate cessation of the treatment and empiric corticosteroid therapy.
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Affiliation(s)
- Elena Bargagli
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Marco Palazzi
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Francesco Perri
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Elena Torricelli
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Elisabetta Rosi
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Alessandra Bindi
- Section of Radiology, Careggi University Hospital, Florence, Italy
| | - Massimo Pistolesi
- Section of Respiratory Medicine, Department of Clinical and Experimental Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
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Imai H, Matsumura N, Yamazaki Y, Kanayama Y, Masuda T, Kuwako T, Kamide Y, Tomizawa T, Matsumoto S, Mitsui T, Kaira K, Ono A, Koga Y, Shibusawa N, Sunaga N, Hisada T, Yokoo H, Yamada M. Hydroxyurea-induced Pneumonitis in a Patient with Chronic Myelomonocytic Leukemia: An Autopsy Case. Intern Med 2015; 54:3171-6. [PMID: 26666606 DOI: 10.2169/internalmedicine.54.5069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe the case of an 85-year-old man diagnosed with chronic myelomonocytic leukemia whose disease was treated with hydroxyurea for 3 months. He developed respiratory symptoms that were extensively investigated. Despite the intensive treatment, he died of respiratory failure eleven days later. An autopsy revealed diffuse interstitial inflammation of both lungs consistent with drug-induced inflammation. A drug lymphocyte stimulation test was positive for hydroxyurea. Taken together these findings demonstrated that severe interstitial pneumonitis was induced by this drug. Physicians using hydroxyurea must be aware of its potentially life-threatening pulmonary toxicity.
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Affiliation(s)
- Hisao Imai
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Japan
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6
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Matthews A, Wylie G. Hydroxycarbamide-induced cutaneous ulceration with a difference. Br J Dermatol 2014; 171:1572-4. [DOI: 10.1111/bjd.13151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A.G. Matthews
- Alan Lyell Centre for Dermatology; Southern General Hospital; 1345 Govan Road Glasgow G51 4TF U.K
| | - G. Wylie
- Alan Lyell Centre for Dermatology; Southern General Hospital; 1345 Govan Road Glasgow G51 4TF U.K
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Baldo BA, Pham NH. Adverse reactions to targeted and non-targeted chemotherapeutic drugs with emphasis on hypersensitivity responses and the invasive metastatic switch. Cancer Metastasis Rev 2013; 32:723-61. [PMID: 24043487 PMCID: PMC7102343 DOI: 10.1007/s10555-013-9447-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
More than 100 drugs are used to treat the many different cancers. They can be divided into agents with relatively broad, non-targeted specificity and targeted drugs developed on the basis of a more refined understanding of individual cancers and directed at specific molecular targets on different cancer cells. Individual drugs in both groups have been classified on the basis of their mechanism of action in killing cancer cells. The targeted drugs include proteasome inhibitors, toxic chimeric proteins and signal transduction inhibitors such as tyrosine kinase (non-receptor and receptor), serine/threonine kinase, histone deacetylase and mammalian target of rapamycin inhibitors. Increasingly used targeted vascular (VEGF) and platelet-derived endothelial growth factor blockade can provoke a range of pathological consequences. Many of the non-targeted drugs are cytotoxic, suppressing haematopoiesis as well as provoking cutaneous eruptions and vascular, lung and liver injury. Cytotoxic side effects of the targeted drugs occur less often and usually with less severity, but they show their own unusual adverse effects including, for example, a lengthened QT interval, a characteristic papulopustular rash, nail disorders and a hand-foot skin reaction variant. The term hypersensitivity is widely used across a number of disciplines but not always with the same definition in mind, and the terminology needs to be standardised. This is particularly apparent in cancer chemotherapy where anti-neoplastic drug-induced thrombocytopenia, neutropenia, anaemia, vascular disorders, liver injury and lung disease as well as many dermatological manifestations sometimes have an immune basis. The most insidious of all adverse consequences of targeted therapies, however, are tumour adaptation, increased malignancy and the invasive metastatic switch seen with anti-angiogenic drugs that inhibit the VEGF-A pathway. Adverse reactions to 44 non-targeted and 33 targeted, frequently used, chemotherapeutic drugs are presented together with discussions of diagnosis, premedications, desensitizations and importance of understanding the mechanisms underlying the various drug-induced reactions. There is need for wide-ranging acceptance of what constitutes a hypersensitivity reaction and for allergists to be more involved in the diagnosis, treatment and prevention of chemotherapeutic drug-induced hypersensitivity reactions.
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Affiliation(s)
- Brian A Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, Sydney, New South Wales, Australia,
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Girard A, Ricordel C, Poullot E, Claeyssen V, Decaux O, Desrues B, Delaval P, Jouneau S. [Hydroxyurea-induced pneumonia]. Rev Mal Respir 2013; 31:430-4. [PMID: 24878159 DOI: 10.1016/j.rmr.2013.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 06/26/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Hydroxyurea is an antimetabolite drug used in the treatment of myeloproliferative disorders. Common adverse effects include haematological, gastrointestinal cutaneous manifestations, and fever. Hydroxyurea-induced pneumonitis is unusual. CASE REPORT A female patient was treated with hydroxyurea for polycythemia vera. She was admitted 20 days after commencing treatment with a high fever, productive cough, clear sputum and nausea. A chest CT-scan showed diffuse ground-glass opacities. Microbiological investigations were negative. The symptoms disappeared a few days after discontinuation of the drug and rechallenge led to a relapse of symptoms. CONCLUSION Our case and 15 earlier cases of hydroxyurea-induced pneumonitis are reviewed. Two patterns of this disease may exist: an acute febrile form occurring within 1 month of introduction of hydroxyurea and a subacute form without fever. Even if uncommon, one should be aware of this complication of hydroxyurea.
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Affiliation(s)
- A Girard
- Service de pneumologie, université de Rennes-1, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France.
| | - C Ricordel
- Service de pneumologie, université de Rennes-1, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - E Poullot
- Service d'hématologie, université de Rennes-1, CHU de Rennes, 35033 Rennes, France
| | - V Claeyssen
- Service des urgences, université de Rennes-1, CHU de Rennes, 35033 Rennes, France
| | - O Decaux
- Service de médecine interne, université de Rennes-1, CHU de Rennes, 35033 Rennes, France
| | - B Desrues
- Service de pneumologie, université de Rennes-1, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - P Delaval
- Service de pneumologie, université de Rennes-1, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France; IRSET UMR 1085, université de Rennes-1, 35043 Rennes, France
| | - S Jouneau
- Service de pneumologie, université de Rennes-1, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France; IRSET UMR 1085, université de Rennes-1, 35043 Rennes, France
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Affiliation(s)
- Mark Meadors
- University of Missouri-Columbia, Ellis Fischel Cancer Center, Columbia, MO 65203, USA
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Abstract
Imatinib mesylate, a novel, molecularly targeted agent for the treatment of chronic myeloid leukemia (CML), has expanded the management options for this disease and provided a paradigm for the treatment of other cancers. Imatinib is a potent, specific inhibitor of BCR-ABL, the constitutively active protein tyrosine kinase critical to the pathogenesis of CML. A randomized, phase III comparison of imatinib with interferon-alfa plus cytarabine as initial treatment for newly diagnosed chronic-phase CML, which demonstrated significantly higher rates of disease response with less toxicity, better quality of life, and a significantly longer progression-free survival time, provided the most persuasive data supporting a major role for imatinib. Currently, allogeneic stem cell transplantation is the only treatment modality with long-term data demonstrating curative potential in CML. An option for less than half of CML patients and associated with substantial morbidity and mortality, transplantation may still be appropriate initial therapy for certain patients. Busulfan and hydroxyurea have no demonstrable effect on disease natural history. The interferon-plus-cytarabine combination can induce durable cytogenetic remissions and was previously the CML pharmacotherapy standard of care, but it is often poorly tolerated. Imatinib is now indicated as first-line therapy for CML in all phases.
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Affiliation(s)
- Richard M Stone
- Dana-Farber Cancer Institute, Boston, Massachusetts 02215, USA.
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Wong CC, Brown D, Howling SJ, Parker NE. Hydroxyurea-induced pneumonitis in a patient with chronic idiopathic myelofibrosis after prolonged drug exposure. Eur J Haematol 2003; 71:388-90. [PMID: 14667203 DOI: 10.1034/j.1600-0609.2003.00123.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We describe a 63-yr-old patient diagnosed with chronic idiopathic myelofibrosis whose disease was treated with hydroxyurea for 2 yr. He developed respiratory symptoms that were extensively investigated including lung biopsy. Clinical, radiological and histological features were compatible with a diagnosis of hydroxyurea-induced pneumonitis. Following drug withdrawal there was remarkable improvement in clinical and radiological findings.
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Affiliation(s)
- Chi C Wong
- Department of Haematology, The Whittington Hospital, London, UK.
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Raghavan M, Mazer MA, Brink DJ. Severe hypersensitivity pneumonitis associated with anagrelide. Ann Pharmacother 2003; 37:1228-31. [PMID: 12921504 DOI: 10.1345/aph.1d071] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of severe life-threatening hypersensitivity pneumonitis temporally associated with the use of anagrelide in a patient with myeloproliferative disorder. CASE SUMMARY A 60-year-old white woman with chronic myeloid leukemia who had been treated with hydroxyurea for 7 years was offered anagrelide to control thrombocytosis. She developed severe hypersensitivity pneumonitis soon after the drug was initiated and required intubation and mechanical ventilation. A high-resolution computed tomography scan of the chest demonstrated extensive multifocal ground glass attenuation and patchy alveolar consolidation involving both lungs. Bronchoalveolar lavage revealed a preponderance of lymphocytes, suggesting hypersensitivity phenomenon, but was otherwise negative for malignancy and other causes of interstitial pneumonitis. An objective causality assessment revealed that an adverse drug event was probable. Discontinuation of anagrelide and hydroxyurea, and institution of corticosteroid therapy resulted in dramatic improvement. DISCUSSION To our knowledge, this is the first case report of severe hypersensitivity pneumonitis closely related to anagrelide therapy. Pulmonary infiltrates have rarely been noted in patients treated with anagrelide. Anagrelide does not depress white blood cell production, causes mild anemia, and is devoid of the leukemogenic potential characteristic of radioactive phosphorus and other alkylating agents. Common adverse effects to anagrelide include headache, nausea, diarrhea, peripheral edema, and palpitations. Frank congestive heart failure and cardiomyopathy have occurred in a small number of patients, but severe pulmonary adverse effects have not emerged as a frequent problem. CONCLUSIONS Vigilance is advised in patients who develop dyspnea while taking anagrelide and hydroxyurea. Healthcare providers need to be aware of the possibility of the development of serious life-threatening hypersensitivity pneumonitis. These patients may benefit from serial chest X-rays, pulmonary function testing, and echocardiography.
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Affiliation(s)
- Murugan Raghavan
- Department of Critical Care Medicine, Conemaugh Valley Memorial Hospital, Johnstown, PA 15905, USA
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Abstract
Hypersensitivity pneumonitis (HP) is a group of immunologically mediated lung diseases caused by the inhalation of environmental agents in susceptible individuals. Most HP patients are non-smokers and have been exposed to organic dusts from vegetable or animal products. Some HP cases are associated with exposures to relatively simple chemical compounds. HP may present as an acute, subacute, or chronic disease and may follow various clinical courses. The type of exposure is thought to be more important in the clinical outcome than the nature of the antigen. A diagnosis of HP is often considered on the basis of clinical history of exposure with resulting respiratory symptoms, but the definitive diagnosis requires a constellation of clinical, radiologic, laboratory, and pathologic findings. The characteristic histologic triad in HP includes bronchiolitis, interstitial lymphocytic infiltration, and granulomas; however, biopsy in HP cases may lack the diagnostic triad and manifest as nonspecific interstitial pneumonia (NSIP). Avoiding exposure to the offending antigen(s) is usually sufficient to resolve symptoms and physiological abnormalities. Pulmonary fibrosis and physiological abnormalities occurring in chronic HP may be irreversible. Steroid therapy is helpful for symptomatic relief, but probably does not affect the long-term prognosis. Type III and type IV hypersensitivity reactions are involved in the pathogenesis; alveolar macrophages and T cells (Th-1 type) play a central role in the immune responses after antigen exposure via their increased interaction and secretion of regulatory mediators.
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Affiliation(s)
- Eunhee S Yi
- Department of Pathology, University of California, San Diego, School of Medicine, San Diego 92103-8720, CA, USA.
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