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Calaras D, David A, Vasarmidi E, Antoniou K, Corlateanu A. Hypersensitivity Pneumonitis: Challenges of a Complex Disease. Can Respir J 2024; 2024:4919951. [PMID: 38283656 PMCID: PMC10810695 DOI: 10.1155/2024/4919951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/19/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024] Open
Abstract
Hypersensitivity pneumonitis (HP) is a complex interstitial lung disease caused by chronic inhalation of a wide variety of antigens in susceptible and sensitized individuals, commonly associated with an occupational exposure. An impressive number of inciting antigens causing hypersensitivity pneumonitis have been found to cover a wide range of occupations. As working practices have changed over time, especially in industrialized countries, new names for occupational HP have emerged. This review emphasizes the main diagnostic issues arising from the high variability of clinical presentation and the broad spectrum of causal antigens. Furthermore, it provides an overview of current methods to unveil possible causes of hypersensitivity pneumonitis, highlights HP's current diagnostic and treatment challenges and the remaining areas of uncertainty, and presents prevention strategies.
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Affiliation(s)
- Diana Calaras
- Department of Pulmonology and Allergology, State University of Medicine and Pharmacy “Nicolae Testemitanu”, Chisinau, Moldova
| | - Aliona David
- Outpatient Department, Institute of Phtisiopneumology “Chiril Draganiuc”, Chisinau, Moldova
| | - Eirini Vasarmidi
- Department of Respiratory Medicine, Laboratory of Molecular and Cellular Pulmonology, School of Medicine, University of Crete, Heraklion, Greece
| | - Katerina Antoniou
- Department of Respiratory Medicine, Laboratory of Molecular and Cellular Pulmonology, School of Medicine, University of Crete, Heraklion, Greece
| | - Alexandru Corlateanu
- Department of Pulmonology and Allergology, State University of Medicine and Pharmacy “Nicolae Testemitanu”, Chisinau, Moldova
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Rodriguez K, Ashby CL, Varela VR, Sharma A. High-Resolution Computed Tomography of Fibrotic Interstitial Lung Disease. Semin Respir Crit Care Med 2022; 43:764-779. [PMID: 36307108 DOI: 10.1055/s-0042-1755563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
While radiography is the first-line imaging technique for evaluation of pulmonary disease, high-resolution computed tomography (HRCT) provides detailed assessment of the lung parenchyma and interstitium, allowing normal anatomy to be differentiated from superimposed abnormal findings. The fibrotic interstitial lung diseases have HRCT features that include reticulation, traction bronchiectasis and bronchiolectasis, honeycombing, architectural distortion, and volume loss. The characterization and distribution of these features result in distinctive CT patterns. The CT pattern and its progression over time can be combined with clinical, serologic, and pathologic data during multidisciplinary discussion to establish a clinical diagnosis. Serial examinations identify progression, treatment response, complications, and can assist in determining prognosis. This article will describe the technique used to perform HRCT, the normal and abnormal appearance of the lung on HRCT, and the CT patterns identified in common fibrotic lung diseases.
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Affiliation(s)
- Karen Rodriguez
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christian L Ashby
- School of Medicine, Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico
| | - Valeria R Varela
- School of Medicine, Universidad Central del Caribe School of Medicine, Bayamón, Puerto Rico
| | - Amita Sharma
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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Yang MM, Wolters PJ. Cut from the Same Cloth: Similarities between Hypersensitivity Pneumonitis and Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2022; 205:4-6. [PMID: 34748715 PMCID: PMC8865579 DOI: 10.1164/rccm.202109-2211ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Monica M Yang
- Department of Medicine University of California San Francisco San Francisco, California
| | - Paul J Wolters
- Department of Medicine University of California San Francisco San Francisco, California
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4
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Assessment and Management of Occupational Hypersensitivity Pneumonitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3295-3309. [PMID: 33161960 DOI: 10.1016/j.jaip.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
The diagnosis and treatment of occupational hypersensitivity pneumonitis (OHP) remain complex and challenging in the absence of diagnostic gold standards or clinical guidelines. This review provides an update of the recent literature regarding the different presentations of OHP and the diagnostic yield and value of the diagnostic tests currently available, which include occupational and medical history, laboratory tests (serum-specific immunoglobulins, environmental sampling), imaging, bronchoalveolar lavage, transbronchial biopsy, transbronchial cryobiopsy, surgical lung biopsy, and specific inhalation challenges. These tools provide a precise differential diagnosis within the framework of interstitial lung diseases. However, among the chronic fibrotic forms, distinguishing OHP from sarcoidosis, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis remains a diagnostic challenge. Avoidance of exposure is pivotal for OHP management, whereas corticosteroids are fundamental in the pharmacological approach to this disease. In addition, studies describing the long-term benefits of immunosuppressive and antifibrotic agents have increased the use of these treatments in OHP.
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Costabel U, Miyazaki Y, Pardo A, Koschel D, Bonella F, Spagnolo P, Guzman J, Ryerson CJ, Selman M. Hypersensitivity pneumonitis. Nat Rev Dis Primers 2020; 6:65. [PMID: 32764620 DOI: 10.1038/s41572-020-0191-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 02/06/2023]
Abstract
Hypersensitivity pneumonitis (HP) is a complex syndrome caused by the inhalation of a variety of antigens in susceptible and sensitized individuals. These antigens are found in the environment, mostly derived from bird proteins and fungi. The prevalence and incidence of HP vary widely depending on the intensity of exposure, the geographical area and the local climate. Immunopathologically, HP is characterized by an exaggerated humoral and cellular immune response affecting the small airways and lung parenchyma. A complex interplay of genetic, host and environmental factors underlies the development and progression of HP. HP can be classified into acute, chronic non-fibrotic and chronic fibrotic forms. Acute HP results from intermittent, high-level exposure to the inducing antigen, usually within a few hours of exposure, whereas chronic HP mostly originates from long-term, low-level exposure (usually to birds or moulds in the home), is not easy to define in terms of time, and may occur within weeks, months or even years of exposure. Some patients with fibrotic HP may evolve to a progressive phenotype, even with complete exposure avoidance. Diagnosis is based on an accurate exposure history, clinical presentation, characteristic high-resolution CT findings, specific IgG antibodies to the offending antigen, bronchoalveolar lavage and pathological features. Complete antigen avoidance is the mainstay of treatment. The pharmacotherapy of chronic HP consists of immunosuppressive drugs such as corticosteroids, with antifibrotic therapy being a potential therapy for patients with progressive disease.
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Affiliation(s)
- Ulrich Costabel
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany.
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Dirk Koschel
- Department of Internal Medicine and Pneumology, Fachkrankenhaus Coswig, Centre for Pulmonary Diseases and Thoracic Surgery, Coswig, Germany.,Division of Pneumology, Medical Department I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Hospital, University of Essen, Essen, Germany
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Josune Guzman
- General and Experimental Pathology, Ruhr-University, Bochum, Germany
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
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Raghu G, Remy-Jardin M, Ryerson CJ, Myers JL, Kreuter M, Vasakova M, Bargagli E, Chung JH, Collins BF, Bendstrup E, Chami HA, Chua AT, Corte TJ, Dalphin JC, Danoff SK, Diaz-Mendoza J, Duggal A, Egashira R, Ewing T, Gulati M, Inoue Y, Jenkins AR, Johannson KA, Johkoh T, Tamae-Kakazu M, Kitaichi M, Knight SL, Koschel D, Lederer DJ, Mageto Y, Maier LA, Matiz C, Morell F, Nicholson AG, Patolia S, Pereira CA, Renzoni EA, Salisbury ML, Selman M, Walsh SLF, Wuyts WA, Wilson KC. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:e36-e69. [PMID: 32706311 PMCID: PMC7397797 DOI: 10.1164/rccm.202005-2032st] [Citation(s) in RCA: 437] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.
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Dias OM, Baldi BG, Ferreira JG, Cardenas LZ, Pennati F, Salito C, Carvalho CRR, Aliverti A, Pereira de Albuquerque AL. Mechanisms of exercise limitation in patients with chronic hypersensitivity pneumonitis. ERJ Open Res 2018; 4:00043-2018. [PMID: 30151370 PMCID: PMC6104296 DOI: 10.1183/23120541.00043-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/05/2018] [Indexed: 01/02/2023] Open
Abstract
Small airway and interstitial pulmonary involvements are prominent in chronic hypersensitivity pneumonitis (cHP). However, their roles on exercise limitation and the relationship with functional lung tests have not been studied in detail. Our aim was to evaluate exercise performance and its determinants in cHP. We evaluated maximal cardiopulmonary exercise testing performance in 28 cHP patients (forced vital capacity 57±17% pred) and 18 healthy controls during cycling. Patients had reduced exercise performance with lower peak oxygen production (16.6 (12.3–19.98) mL·kg−1·min−1versus 25.1 (16.9–32.0), p=0.003), diminished breathing reserve (% maximal voluntary ventilation) (12 (6.4–34.8)% versus 41 (32.7–50.8)%, p<0.001) and hyperventilation (minute ventilation/carbon dioxide production slope 37±5 versus 31±4, p<0.001). All patients presented oxygen desaturation and augmented Borg dyspnoea scores (8 (5–10) versus 4 (1–7), p=0.004). The prevalence of dynamic hyperinflation was found in only 18% of patients. When comparing cHP patients with normal and low peak oxygen production (<84% pred, lower limit of normal), the latter exhibited a higher minute ventilation/carbon dioxide production slope (39±5.0 versus 34±3.6, p=0.004), lower tidal volume (0.84 (0.78–0.90) L versus 1.15 (0.97–1.67) L, p=0.002), and poorer physical functioning score on the Short form-36 health survey. Receiver operating characteristic curve analysis showed that reduced lung volumes (forced vital capacity %, total lung capacity % and diffusing capacity of the lung for carbon dioxide %) were high predictors of poor exercise capacity. Reduced exercise capacity was prevalent in patients because of ventilatory limitation and not due to dynamic hyperinflation. Reduced lung volumes were reliable predictors of lower performance during exercise. Besides significant small airway involvement, reduced exercise capacity is due to ventilatory limitation and not due to dynamic hyperinflation in chronic hypersensitivity pneumonitishttp://ow.ly/Ou9230kSBQz
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Affiliation(s)
- Olívia Meira Dias
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Bruno Guedes Baldi
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Jeferson George Ferreira
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Letícia Zumpano Cardenas
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Caterina Salito
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Carlos Roberto Ribeiro Carvalho
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - André Luis Pereira de Albuquerque
- Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sâo Paulo, Sâo Paulo, Brazil
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8
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Peiffer G, Underner M, Perriot J. [The respiratory effects of smoking]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:133-144. [PMID: 29793770 DOI: 10.1016/j.pneumo.2018.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023]
Abstract
A marked increase in the morbidity and mortality of a large number of broncho-pulmonary diseases has been documented in relation to smoking. The influence of tobacco smoking on various respiratory conditions. is discussed: incidence, severity or natural history modification of some respiratory illnesses: obstructive lung diseases (COPD, asthma), lung cancer, bacterial, viral respiratory infections, with the impact of smoking on tuberculosis. Finally, the relationship of tobacco with diffuse interstitial lung disease: protective role of smoking (controversial in sarcoidosis, real in hypersensitivity pneumonitis). The benefits of smoking cessation are described.
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Affiliation(s)
- G Peiffer
- Service de pneumologie, CHR Metz-Thionville, hôpital de Mercy, 1, allée du Château 57085 Metz cedex 3, France.
| | - M Underner
- Unité de recherche clinique, centre hospitalier Henri-Laborit, 86000 Poitiers, France.
| | - J Perriot
- CLAT 63, dispensaire Emile-Roux, 11, rue Vaucanson, 63100 Clermont-Ferrand, France.
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Soumagne T, Dalphin JC. Current and emerging techniques for the diagnosis of hypersensitivity pneumonitis. Expert Rev Respir Med 2018; 12:493-507. [PMID: 29727203 DOI: 10.1080/17476348.2018.1473036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is the result of an immunologically induced inflammation of the lung parenchyma in response to inhalation exposure to a large variety of antigens in genetically susceptible individuals. HP shares clinical and radiological features with other acute and chronic interstitial lung diseases and is sometimes difficult to diagnose if exposure to an antigenic agent is not detected. Several classifications and diagnostic criteria have been proposed but are not currently recommended by guidelines from any scientific society. However, advances have been made over the past ten years in improving the diagnosis of HP. Areas covered: This article will provide a summary of the different classification and diagnostic criteria proposed in acute and chronic forms of HP. In addition, we review current diagnostic procedures including antigen detection, high resolution computed tomography, histopathology and provide an overview of emerging techniques. Expert commentary: Important changes are occurring in the field of HP and knowledge of the disease will likely progress enormously in the coming 5 to 10 years as many techniques continue to be developed, including genomic signature and diagnostic biomarkers.
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Affiliation(s)
- Thibaud Soumagne
- a Service de Pneumologie , CHU de Besançon , Besançon , France.,b UMR 6249 Chrono-environnement , Université de Franche-Comté , Besançon , France
| | - Jean Charles Dalphin
- a Service de Pneumologie , CHU de Besançon , Besançon , France.,b UMR 6249 Chrono-environnement , Université de Franche-Comté , Besançon , France
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Jacob J, Odink A, Brun AL, Macaluso C, de Lauretis A, Kokosi M, Devaraj A, Desai S, Renzoni E, Wells AU. Functional associations of pleuroparenchymal fibroelastosis and emphysema with hypersensitivity pneumonitis. Respir Med 2018; 138:95-101. [PMID: 29724400 PMCID: PMC5948318 DOI: 10.1016/j.rmed.2018.03.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pleuroparenchymal fibroelastosis (PPFE) has been described in hypersensitivity pneumonitis (HP) yet its functional implications are unclear. Combined pulmonary fibrosis and emphysema (CPFE) has occasionally been described in never-smokers with HP, but epidemiological data regarding its prevalence is sparse. CTs in a large HP cohort were therefore examined to identify the prevalence and effects of PPFE and emphysema. Methods 233 HP patients had CT extents of interstitial lung disease (ILD) and emphysema quantified to the nearest 5%. Lobar percentage pleural involvement of PPFE was quantified on a 4-point categorical scale: 0 = absent, 1 = affecting <10%, 2 = affecting 10–33%, 3 = affecting >33%. Marked PPFE reflected a total lung score of ≥3/18. Results were evaluated against FVC, DLco and mortality. RESULTS Marked PPFE prevalence was 23% whilst 23% of never-smokers had emphysema. Following adjustment for patient age, gender, smoking status, and ILD and emphysema extents, marked PPFE independently linked to reduced baseline FVC (p = 0.0002) and DLco (p = 0.002) and when examined alongside the same covariates, independently linked to worsened survival (p = 0.01). CPFE in HP demonstrated a characteristic functional profile of artificial lung volume preservation and disproportionate DLco reduction. CPFE did not demonstrate a worsened outcome when compared to HP patients without emphysema beyond that explained by CT extents of ILD and emphysema. CONCLUSIONS PPFE is not uncommon in HP, and is independently associated with impaired lung function and increased mortality. Emphysema was identified in 23% of HP never-smokers. CPFE appears not to link to a malignant microvascular phenotype as outcome is explained by ILD and emphysema extents. In patients with HP, marked PPFE had a prevalence of 23% in our study cohort. 23% of never-smokers with HP demonstrated emphysema on CT imaging. Outcome in HP patients with CPFE is explained by CT extents of ILD and emphysema. PPFE is independently associated with a worsened outcome in HP.
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Affiliation(s)
- Joseph Jacob
- Department of Respiratory Medicine, University College London, London, UK; Centre for Medical Computing, University College London, London, UK.
| | - Arlette Odink
- Department of Radiology, Erasmus MC Rotterdam, The Netherlands
| | - Anne Laure Brun
- Imaging Department, Hôpital Cochin, Paris-Descartes University, France
| | - Claudio Macaluso
- Department of Respiratory Medicine, Ospedale "Luigi Sacco", University of Milan, Italy; Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Angelo de Lauretis
- Division of Pneumology, "Guido Salvini" Hospital, Garbagnate Milanese, Italy
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sujal Desai
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Baqir M, White D, Ryu JH. Emphysematous changes in hypersensitivity pneumonitis: A retrospective analysis of 12 patients. Respir Med Case Rep 2018; 24:25-29. [PMID: 29977751 PMCID: PMC6010618 DOI: 10.1016/j.rmcr.2018.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 02/04/2023] Open
Abstract
Introduction Emphysema is most commonly associated with smoking but also occurs in hypersensitivity pneumonitis (HP). The aim of this study was to further explore this relationship. Methods A retrospective, computer-assisted search was performed to identify patients with HP seen at Mayo Clinic in Rochester, Minnesota, from January 1997 through February 2014. Demographic, clinical, and imaging features were analyzed. Patients were excluded if they had a smoking history of 10 pack-years or more. Results Twelve patients (9 males) with HP and computed tomographic evidence of emphysema were identified. Ten were never smokers and 2 were ex-smokers. The median age at diagnosis was 47 (range, 29-77) years; median symptom duration was 2.2 (range, 0.2-13.4) years. The most common presenting symptoms were dyspnea (83%) and cough (67%). On pulmonary function testing, 6 patients (50%) had a restrictive defect, 2 (17%) had airflow obstruction, and 4 (33%) had an isolated reduction in diffusing capacity of lung for carbon monoxide. The severity of emphysema ranged from mild to severe to focal bullae. All patients had chronic hypersensitivity pneumonitis (CHP). Centrilobular emphysema was most commonly seen with coexistent paraseptal emphysema in 5 patients.Emphysema was most frequent in the upper lung but could be seen in any lobe. Conclusion Emphysema can occur in patients with CHP independently of smoking history and exposure to specific types of antigens. Emphysematous changes seem to progress at a slower pace compare to reticulations/fibrosis.
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Affiliation(s)
- Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Corresponding author. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Darin White
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Jay H. Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity Pneumonitis: Perspectives in Diagnosis and Management. Am J Respir Crit Care Med 2017; 196:680-689. [PMID: 28598197 DOI: 10.1164/rccm.201611-2201pp] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Martina Vasakova
- 1 Department of Respiratory Medicine, First Faculty of Medicine of Charles University, Thomayer Hospital Prague, Prague, Czech Republic
| | - Ferran Morell
- 2 Vall d'Hebron Institut de Recerca, Servei de Pneumología, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autonóma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Respiratoria, Barcelona, Catalonia, Spain
| | - Simon Walsh
- 3 King's College National Health Service Hospital Foundation Trust, Denmark Hill, London, United Kingdom
| | | | - Ganesh Raghu
- 5 Center for Interstitial Lung Diseases, University of Washington Medical Center, Seattle, Washington
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Ley B, Newton CA, Arnould I, Elicker BM, Henry TS, Vittinghoff E, Golden JA, Jones KD, Batra K, Torrealba J, Garcia CK, Wolters PJ. The MUC5B promoter polymorphism and telomere length in patients with chronic hypersensitivity pneumonitis: an observational cohort-control study. THE LANCET RESPIRATORY MEDICINE 2017. [PMID: 28648751 PMCID: PMC5555581 DOI: 10.1016/s2213-2600(17)30216-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with hypersensitivity pneumonitis are at risk of developing pulmonary fibrosis, which is associated with reduced survival. In families with multiple affected members, individuals might be diagnosed as having idiopathic pulmonary fibrosis (IPF) or chronic (fibrotic) hypersensitivity pneumonitis, which suggests these disorders share risk factors. We aimed to test whether the genomic risk factors associated with the development and progression of IPF are also associated with the development of fibrosis and reduced survival in people with chronic hypersensitivity pneumonitis. METHODS We did an observational study of two independent cohorts of patients with chronic hypersensitivity pneumonitis, one from the University of California San Francisco, CA, USA (UCSF), and one from the University of Texas Southwestern, TX, USA (UTSW). We measured two common single-nucleotide polymorphisms associated with IPF (MUC5B rs35705950 and TOLLIP rs5743890) and telomere length in peripheral blood leucocytes, and assessed their associations with chronic hypersensitivity pneumonitis risk, survival, and clinical, radiographic, and pathological features. We compared findings with those in patients with IPF from the UCSF and UTSW cohorts, and healthy controls from the European population of the 1000 Genomes Project Phase 3, version 1. FINDINGS The cohorts included 145 patients from UCSF and 72 from UTSW. The minor allele frequency (MAF) was greater for MUC5B rs35705950 in patients with chronic hypersensitivity pneumonitis than in healthy controls (24·4% in UCSF and 32·3% in UTSW vs 10·7%, both p<0·0001), but not for TOLLIP rs5743890. The MAFs were similar to those for IPF (UCSF 33·3%, p=0·09; UTSW 32·0%, p=0·95). In the combined UCSF and UTSW chronic hypersensitivity pneumonitis cohort, we saw associations between extent of radiographic fibrosis and MUC5B rs35705950 minor alleles (adjusted odds ratio [OR] 1·91, 95% CI 1·02-3·59, p=0·045) and short telomere length (adjusted OR per unit change in mean natural logarithm-transformed ratio of telomere repeat copy number to single gene copy number 0·23, 0·09-0·59, p=0·002). Telomere length less than the tenth percentile for age was also significantly associated with reduced survival (log-rank p=0·006). INTERPRETATION The associations between MUC5B rs35705950 and short telomere length with extent of fibrosis, histopathological features of usual interstitial pneumonia, and reduced survival in patients with chronic hypersensitivity pneumonitis suggest shared pathobiology with IPF, and might help to stratify risk. FUNDING National Institutes of Health and Nina Ireland Program for Lung Health.
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Affiliation(s)
- Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Chad A Newton
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Isabel Arnould
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christine Kim Garcia
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Abstract
BACKGROUND Farmer's lung (FL) is a common type of hypersensitivity pneumonitis. It is often considered that fibrosis is the most frequent finding in chronic FL. Nevertheless, three cohort studies have suggested that some patients with chronic FL may develop emphysema. We aimed to evaluate the current prevalence of emphysema in active FL, to describe the radiological and functional features of emphysema in active FL, and to identify risk factors associated with emphysema in this population. METHODS Patients aged over 18 years with active FL were prospectively recruited through the SOPHIA study (CPP Est; P-2009-521), between 2007 and 2015. Each patient had complete medical history screening, clinical examination, high resolution computed tomodensitometry, bronchoalveolar lavage, pulmonary function tests and serum precipitins. RESULTS Among 33 patients with active FL, the prevalence of emphysema in this series of incident active FL cases was higher (48.5%) than that of fibrosis (12%) and was not dependent on smoking habits. Most patients with emphysema did not have lung hyperinflation. The possible risk factors for emphysema in active FL were a longer duration of exposure to organic dusts, and at a higher level. CONCLUSION Emphysema is found in half of patients with active FL and may be influenced by exposure patterns.
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Abstract
Allergic asthma refers to a chronic reversible bronchoconstriction influenced by an allergic trigger, leading to symptoms of cough, wheezing, shortness of breath, and chest tightness. Allergic bronchopulmonary aspergillosis is a complex hypersensitivity reaction, often in patients with asthma or cystic fibrosis, occurring when bronchi become colonized by Aspergillus species. The clinical picture is dominated by asthma complicated by recurrent episodes of bronchial obstruction, fever, malaise, mucus production, and peripheral blood eosinophilia. Hypersensitivity pneumonitis is a syndrome associated with lung inflammation from the inhalation of airborne antigens, such as molds and dust.
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Affiliation(s)
- Jason Raymond Woloski
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA.
| | - Skye Heston
- Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, PO Box 850, Hershey, PA 17033-0850, USA
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Tumor necrosis factor-alpha and CD4/CD8 ratio in patients with hypersensitivity pneumonitis. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Elevated levels of FN1 and CCL2 in bronchoalveolar lavage fluid from sarcoidosis patients. Respir Res 2016; 17:69. [PMID: 27259755 PMCID: PMC4893268 DOI: 10.1186/s12931-016-0381-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/23/2016] [Indexed: 12/15/2022] Open
Abstract
Background Sarcoidosis is a granulomatous systemic inflammatory disease in which more than 90 % of all patients develop pulmonary manifestations. Several gene associations have previously been described, but established and clinically useful biomarkers are still absent. This study aimed to find proteins in bronchoalveolar lavage (BAL) fluid that can be associated with the disease. Methods We developed and performed profiling of 94 selected proteins in BAL fluid and serum samples obtained from newly diagnosed and non-treated patients with sarcoidosis. Using multiplexed immunoassays, a total of 317 BAL and 217 serum samples were analyzed, including asthmatic patients and healthy individuals as controls. Results Our analyses revealed increased levels of eight proteins in sarcoidosis patients compared to controls. Out of these, fibronectin (FN1) and C-C motif chemokine 2 (CCL2) revealed the strongest associations. In addition, cadherin 5 (CDH5) was found to correlate positively with lymphocyte cell numbers in BAL fluid. Conclusions Applying a high throughput proteomics screening technique, we found proteins of potential clinical relevance in the context of sarcoidosis. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0381-0) contains supplementary material, which is available to authorized users.
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18
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Quirce S, Vandenplas O, Campo P, Cruz MJ, de Blay F, Koschel D, Moscato G, Pala G, Raulf M, Sastre J, Siracusa A, Tarlo SM, Walusiak-Skorupa J, Cormier Y. Occupational hypersensitivity pneumonitis: an EAACI position paper. Allergy 2016; 71:765-79. [PMID: 26913451 DOI: 10.1111/all.12866] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 12/14/2022]
Abstract
The aim of this document was to provide a critical review of the current knowledge on hypersensitivity pneumonitis caused by the occupational environment and to propose practical guidance for the diagnosis and management of this condition. Occupational hypersensitivity pneumonitis (OHP) is an immunologic lung disease resulting from lymphocytic and frequently granulomatous inflammation of the peripheral airways, alveoli, and surrounding interstitial tissue which develops as the result of a non-IgE-mediated allergic reaction to a variety of organic materials or low molecular weight agents that are present in the workplace. The offending agents can be classified into six broad categories that include bacteria, fungi, animal proteins, plant proteins, low molecular weight chemicals, and metals. The diagnosis of OHP requires a multidisciplinary approach and relies on a combination of diagnostic tests to ascertain the work relatedness of the disease. Both the clinical and the occupational history are keys to the diagnosis and often will lead to the initial suspicion. Diagnostic criteria adapted to OHP are proposed. The cornerstone of treatment is early removal from exposure to the eliciting antigen, although the disease may show an adverse outcome even after avoidance of exposure to the causal agent.
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Affiliation(s)
- S. Quirce
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPAZ) and CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - O. Vandenplas
- Department of Chest Medicine; Centre Hospitalier Universitaire de Mont-Godinne; Université Catholique de Louvain; Yvoir Belgium
| | - P. Campo
- Unidad de Gestión Clínica Allergy-IBIMA; Hospital Regional Universitario; Málaga Spain
| | - M. J. Cruz
- Pulmonology Service; Hospital Universitari Vall d'Hebron; Universitat Autonoma de Barcelona; Barcelona Spain
- CIBER de Enfermedades Respiratorias (CIBERES); Barcelona Spain
| | - F. de Blay
- Division of Asthma and Allergy; Department of Chest Diseases; University Hospital; Fédération de Médecine Translationnelle de Strasbourg; Strasbourg University; Strasbourg France
| | - D. Koschel
- Fachkrankenhaus Coswig GmbH Zentrum für Pneumologie, Allergologie, Beatmungsmedizin, Thorax- und Gefäßchirurgie; Coswig Germany
| | - G. Moscato
- Department of Public Health, Experimental and Forensic Medicine; University of Pavia; Pavia Italy
| | - G. Pala
- Occupational Physician's Division; Local Health Authority of Sassari; Sassari Italy
| | - M. Raulf
- IPA Institute for Prevention and Occupational Medicine of the German Social Accident Insurance; Institute of the Ruhr-Universität Bochum; Bochum Germany
| | - J. Sastre
- Department of Allergy; Fundación Jiménez Díaz, and CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - A. Siracusa
- Formerly Department of Clinical and Experimental Medicine; University of Perugia; Perugia Italy
| | - S. M. Tarlo
- Department of Medicine and Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
- Respiratory Division Toronto Western Hospital; Gage Occupational and Environmental Health Unit; St Michael's Hospital; Toronto ON Canada
| | - J. Walusiak-Skorupa
- Department of Occupational Diseases and Toxicology; Nofer Institute of Occupational Medicine; Lodz Poland
| | - Y. Cormier
- Centre de Pneumologie; Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Québec City QC Canada
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Yamashita M, Mouri T, Niisato M, Nitanai H, Kobayashi H, Ogasawara M, Endo R, Konishi K, Sugai T, Sawai T, Yamauchi K. Lymphangiogenic factors are associated with the severity of hypersensitivity pneumonitis. BMJ Open Respir Res 2015; 2:e000085. [PMID: 26448865 PMCID: PMC4593170 DOI: 10.1136/bmjresp-2015-000085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/08/2015] [Indexed: 11/06/2022] Open
Abstract
Background Antigen presenting cells play a pivotal role in the adaptive immune response in hypersensitivity pneumonitis (HP). It was hypothesised that lymphangiogenesis is involved in the pathophysiology of HP via cell transport. Objective To determine the clinical significance of lymphangiogenic factors in HP. Methods Levels of vascular endothelial growth factors (VEGF)-A, VEGF-C, VEGF-D and CCL21 in the serum and bronchoalveolar lavage fluid (BALF) were measured in 29 healthy volunteers, 14 patients with idiopathic pulmonary fibrosis (IPF) and 26 patients with HP by ELISA. Additionally, immunohistochemical analyses were performed using lung specimens of patients with HP (n=8) and IPF (n=10). Results BALF VEGF-D levels were significantly elevated in patients with HP compared to the other groups. BALF VEGF–D levels in patients with HP correlated significantly with the BALF total cell and lymphocyte counts (r=0.485, p=0.014 and r=0.717, p<0.0001, respectively). BALF VEGF-C and CCL21 levels were increased in patients with HP compared to healthy volunteers, but not patients with IPF. BALF CCL21 levels were negatively correlated with the forced expiratory volume in 1 s percentage and diffuse capacity of the lung for carbon monoxide (r=−0.662, p=0.007 and r=−0.671, p=0.024, respectively). According to the immunohistochemical analyses, CCL21 was expressed in the lymphatic endothelium in both conditions and CCR7+ cells were aggregated around lymphatics in patients with HP, but not in patients with IPF. Conclusions Lymphangiogenic factors might be associated with the inflammatory and functional severity of HP. The increased BALF VEGF-D levels were associated with lymphatic alveolitis intensity, and CCL21 with lung function impairment.
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Affiliation(s)
- Masahiro Yamashita
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Takashi Mouri
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan ; Department of Respiratory Medicine , Iwate Prefectural Chubu Hospital , Kitakami , Japan
| | - Miyuki Niisato
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Hiroo Nitanai
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Hitoshi Kobayashi
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Masahito Ogasawara
- Department of Pharmacology , Ehime University Graduate School of Medicine , Toon , Japan
| | - Ryujin Endo
- Department of Gastroenterology and Hepatology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Kazuki Konishi
- Department of Pulmonary Medicine , Morioka Tsunagi Onsen Hospital , Morioka , Japan
| | - Tamotsu Sugai
- Department of Pathology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Takashi Sawai
- Department of Pathology , Iwate Medical University School of Medicine , Morioka , Japan
| | - Kohei Yamauchi
- Department of Pulmonary Medicine, Allergy and Rheumatology , Iwate Medical University School of Medicine , Morioka , Japan
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Hypersensitivity pneumonitis (extrinsic allergic alveolitis): a Canadian historical perspective. Can Respir J 2015; 21:277-8. [PMID: 25299221 DOI: 10.1155/2014/128940] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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21
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Cox CW, Rose CS, Lynch DA. State of the Art: Imaging of Occupational Lung Disease. Radiology 2014; 270:681-96. [DOI: 10.1148/radiol.13121415] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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22
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Fernández Pérez ER, Swigris JJ, Forssén AV, Tourin O, Solomon JJ, Huie TJ, Olson AL, Brown KK. Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. Chest 2014; 144:1644-1651. [PMID: 23828161 DOI: 10.1378/chest.12-2685] [Citation(s) in RCA: 234] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The cornerstone of hypersensitivity pneumonitis (HP) management is having patients avoid the inciting antigen (IA). Often, despite an exhaustive search, an IA cannot be found. The objective of this study was to examine whether identifying the IA impacts survival in patients with chronic HP. METHODS We used the Kaplan-Meier method to display, and the log-rank test to compare, survival curves of patients with well-characterized chronic HP stratified on identification of an IA exposure. A Cox proportional hazards (PH) model was used to identify independent predictors in time-to-death analysis. RESULTS Of 142 patients, 67 (47%) had an identified IA, and 75 (53%) had an unidentified IA. Compared with survivors, patients who died (n = 80, 56%) were older, more likely to have smoked, had lower total lung capacity % predicted and FVC % predicted, had higher severity of dyspnea, were more likely to have pulmonary fibrosis, and were less likely to have an identifiable IA. In a Cox PH model, the inability to identify an IA (hazard ratio [HR], 1.76; 95% CI, 1.01-3.07), older age (HR, 1.04; 95% CI, 1.01-1.07), the presences of pulmonary fibrosis (HR, 2.43; 95% CI, 1.36-4.35), a lower FVC% (HR, 1.36; 95% CI, 1.10-1.68), and a history of smoking (HR, 2.01; 95% C1, 1.15-3.50) were independent predictors of shorter survival. After adjusting for mean age, presence of fibrosis, mean FVC%, mean diffusing capacity of the lung for carbon monoxide (%), and history of smoking, survival was longer for patients with an identified IA exposure than those with an unidentified IA exposure (median, 8.75 years vs 4.88 years; P = .047). CONCLUSIONS Among patients with chronic HP, when adjusting for a number of potentially influential predictors, including the presence of fibrosis, the inability to identify an IA was independently associated with shortened survival.
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Affiliation(s)
- Evans R Fernández Pérez
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO.
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Anna V Forssén
- Division of Pulmonary and Critical Care Medicine, and the Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO
| | | | - Joshua J Solomon
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Amy L Olson
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
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Abstract
Asthma is a heterogeneous syndrome of cough, wheeze, dyspnea, and chest tightness. However, in a subset of patients, these symptoms may indicate a different underlying disease process with variable responsiveness to classic asthma therapies. Disease may progress while practitioners attempt conventional asthma therapy. Additionally, some types of asthma may require alternative approaches to relieve symptoms successfully. This article describes the differential diagnosis of asthma and discusses some of the more common asthma variants and asthma mimickers.
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Affiliation(s)
- Patrick R Aguilar
- Department of Internal Medicine, Washington University, 660 Euclid, PO Box 8052, St. Louis, MO 63110, USA
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Human monocyte-derived dendritic cells exposed to microorganisms involved in hypersensitivity pneumonitis induce a Th1-polarized immune response. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 20:1133-42. [PMID: 23720369 DOI: 10.1128/cvi.00043-13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypersensitivity pneumonitis (HP) is an immunoallergic disease characterized by a prominent interstitial infiltrate composed predominantly of lymphocytes secreting inflammatory cytokines. Dendritic cells (DCs) are known to play a pivotal role in the lymphocytic response. However, their cross talk with microorganisms that cause HP has yet to be elucidated. This study aimed to investigate the initial interactions between human monocyte-derived DCs (MoDCs) and four microorganisms that are different in nature (Saccharopolyspora rectivirgula [actinomycetes], Mycobacterium immunogenum [mycobacteria], and Wallemia sebi and Eurotium amstelodami [filamentous fungi]) and are involved in HP. Our objectives were to determine the cross talk between MoDCs and HP-causative agents and to determine whether the resulting immune response varied according to the microbial extract tested. The phenotypic activation of MoDCs was measured by the increased expression of costimulatory molecules and levels of cytokines in supernatants. The functional activation of MoDCs was measured by the ability of MoDCs to induce lymphocytic proliferation and differentiation in a mixed lymphocytic reaction (MLR). E. amstelodami-exposed (EA) MoDCs expressed higher percentages of costimulatory molecules than did W. sebi-exposed (WS), S. rectivirgula-exposed (SR), or M. immunogenum-exposed (MI) MoDCs (P < 0.05, Wilcoxon signed-rank test). EA-MoDCs, WS-MoDCs, SR-MoDCs, and MI-MoDCs induced CD4(+) T cell proliferation and a Th1-polarized immune response. The present study provides evidence that, although differences were initially observed between MoDCs exposed to filamentous fungi and MoDCs exposed to bacteria, a Th1 response was ultimately promoted by DCs regardless of the microbial extract tested.
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Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest 2012; 142:208-217. [PMID: 22796841 DOI: 10.1378/chest.11-2479] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an allergen to which the subject has been previously sensitized. The diagnosis of HP most often relies on an array of nonspecific clinical symptoms and signs developed in an appropriate setting, with the demonstration of interstitial markings on chest radiographs, serum precipitating antibodies against offending antigens, a lymphocytic alveolitis on BAL, and/or a granulomatous reaction on lung biopsies. The current classification of HP in acute, subacute, and chronic phases is now challenged, and a set of clinical predictors has been proposed. Nonspecific interstitial pneumonitis, usual interstitial pneumonia, and bronchiolitis obliterans organizing pneumonia may be the sole histologic expression of the disease. Presumably, like in idiopathic interstitial pneumonia, acute exacerbations of chronic HP may occur without further exposure to the offending antigen. New offending antigens, such as mycobacteria causing hot tub lung and metalworking fluid HP, have recently been identified and have stimulated further research in HP.
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Affiliation(s)
- Yves Lacasse
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada.
| | - Mélissa Girard
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
| | - Yvon Cormier
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Hôpital Laval), Québec, QC, Canada
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Ohshimo S, Bonella F, Guzman J, Costabel U. Hypersensitivity pneumonitis. Immunol Allergy Clin North Am 2012; 32:537-56. [PMID: 23102065 DOI: 10.1016/j.iac.2012.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Clinical manifestations of hypersensitivity pneumonitis may closely mimic other interstitial lung diseases, and the disease onset is usually insidious. High-resolution computed tomography and bronchoalveolar lavage are the sensitive and characteristic diagnostic tests for hypersensitivity pneumonitis. The relevant antigen to hypersensitivity pneumonitis cannot be identified in up to 20% to 30% of patients. Clinicians should be aware that hypersensitivity pneumonitis must be considered in all cases of interstitial lung disease, and a detailed environmental exposure history is mandatory.
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Affiliation(s)
- Shinichiro Ohshimo
- Department of Molecular and Internal Medicine, Graduate School of Biomedical Sciences, Hiroshima University, Japan
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Simonian PL, Wehrmann F, Roark CL, Born WK, O'Brien RL, Fontenot AP. γδ T cells protect against lung fibrosis via IL-22. J Exp Med 2010; 207:2239-53. [PMID: 20855496 PMCID: PMC2947077 DOI: 10.1084/jem.20100061] [Citation(s) in RCA: 193] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 08/30/2010] [Indexed: 12/14/2022] Open
Abstract
Inflammation-induced pulmonary fibrosis (PF) leads to irreversible loss of lung function and is a predictor of mortality in numerous lung diseases. Why some subjects with lung inflammation but not others develop PF is unclear. In a mouse model of hypersensitivity pneumonitis that progresses to lung fibrosis upon repeated exposure to the ubiquitous microorganism Bacillus subtilis, γδ T cells expand in the lung and inhibit collagen deposition. We show that a subset of these γδ cells represents the predominant source of the Th17 cytokine IL-22 in this model. Preventing expression of IL-22, either by mutating the aryl hydrocarbon receptor (AhR) or inhibiting AhR signaling, accelerated lung fibrosis. Direct blockade of IL-22 also enhanced collagen deposition in the lung, whereas administration of recombinant IL-22 inhibited lung fibrosis. Moreover, the presence of protective γδ T cells and IL-22 diminished recruitment of CD4(+) T cells to lung. These data reveal a protective pathway that involves the inhibition of αβ T cells by regulatory IL-22-secreting γδ T cells.
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Affiliation(s)
- Philip L Simonian
- Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
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Abstract
PURPOSE OF REVIEW To bring readers up to date on recent reports, both clinical and basic understanding, on hypersensitivity pneumonitis. RECENT FINDINGS Although many antigens and environmental settings have already been described as sources of this hyperimmune pulmonary disease, the literature continues to bring forth other conditions that can cause hypersensitivity pneumonitis. We also highlight new findings in the diagnosis of hypersensitivity pneumonitis, its histopathology, insight into its potential outcomes, and understanding of its immune mechanisms that could lead to new treatments. SUMMARY The review will help clinicians in their diagnostic approach to hypersensitivity pneumonitis and lead them to look for other potential sources of the disease. The findings described will help guide further research on the pathophysiology and seek new treatments for this worldwide orphan disease.
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Hirschmann JV, Pipavath SNJ, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics 2010; 29:1921-38. [PMID: 19926754 DOI: 10.1148/rg.297095707] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most cases of hypersensitivity pneumonitis develop only after many years of inhaling allergens, which include microbes, animal or plant proteins, and certain chemicals that form haptens. The initial clinical presentation is either episodes of acute illness with dyspnea and prominent constitutional symptoms, such as fever, or an insidious onset of dyspnea, coughing, and weight loss, sometimes with superimposed acute episodes. The histopathologic process consists of chronic inflammation of the bronchi and peribronchiolar tissue, often with poorly defined granulomas and giant cells in the interstitium or alveoli. Fibrosis and emphysema may develop. The radiologic findings include diffuse ground-glass opacification, centrilobular ground-glass opacities, air trapping, fibrosis, lung cysts, and emphysema. The histologic and radiologic features in some cases may resemble those of usual interstitial pneumonia or nonspecific interstitial pneumonia. The diagnosis usually rests on a variable combination of findings from history, serology, radiography, lung biopsy, and bronchoalveolar lavage, which characteristically reveals a lymphocyte content of more than 30%, often with an increased CD4-to-CD8 ratio of T cells. Treatment includes avoiding the allergen, if possible, and, in severe cases, systemic corticosteroids. The long-term prognosis is usually good, but some patients develop severe respiratory insufficiency, and a few die of the disease.
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Wang P, Xu ZJ, Xu WB, Shi JH, Tian XL, Feng RE, Zhu YJ. Clinical Features and Prognosis in 21 Patients with Extrinsic Allergic Alveolitis. ACTA ACUST UNITED AC 2009; 24:202-7. [DOI: 10.1016/s1001-9294(10)60002-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Simonian PL, Roark CL, Born WK, O'Brien RL, Fontenot AP. Gammadelta T cells and Th17 cytokines in hypersensitivity pneumonitis and lung fibrosis. Transl Res 2009; 154:222-7. [PMID: 19840763 PMCID: PMC2766087 DOI: 10.1016/j.trsl.2009.08.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 07/29/2009] [Indexed: 02/06/2023]
Abstract
Hypersensitivity pneumonitis (HP) is an inflammatory lung disease caused by the repeated inhalation of aerosolized antigens. With chronic exposure to an inhaled antigen, patients are at risk of developing irreversible pulmonary fibrosis as well as an increased morbidity and mortality. Although alphabeta T cells have been shown to be important in the pathogenesis of HP, gammadelta T cells also accumulate in the bronchoalveolar lavage of patients with HP. gammadelta T cells represent a distinct lymphocyte subset, whose primary function is not well understood. In contrast to alphabeta T cells, gammadelta T cells recognize unprocessed antigens, such as those upregulated on injured or stressed epithelial cells. In a murine model of HP induced by exposure to the ubiquitous microorganism Bacillus subtilis, gammadelta T cells expressing the canonical Vgamma6/Vdelta1 T cell receptor were dramatically expanded in the lung. The predominant cytokines expressed by this gammadelta T-cell subset were T-helper 17 (Th17) cytokines that were critical for bacterial clearance and the resolution of lung inflammation. Th17-expressing gammadelta T cells are also expanded in other murine models of lung infection and inflammation, which suggests that these cells play a sentinel role in mucosal immunity. Thus, an increased understanding of gammadelta T cells that express Th17 cytokines in HP and other inflammatory lung diseases may lead to the development of novel therapeutic and clinical strategies that prevent the development of fibrotic lung disease.
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Affiliation(s)
- Philip L Simonian
- Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
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Simonian PL, Roark CL, Wehrmann F, Lanham AM, Born WK, O'Brien RL, Fontenot AP. IL-17A-expressing T cells are essential for bacterial clearance in a murine model of hypersensitivity pneumonitis. THE JOURNAL OF IMMUNOLOGY 2009; 182:6540-9. [PMID: 19414809 DOI: 10.4049/jimmunol.0900013] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hypersensitivity pneumonitis (HP) is an inflammatory lung disease characterized by a diffuse mononuclear cell infiltrate in the lung that can progress to pulmonary fibrosis with chronic exposure to an inhaled Ag. We previously reported that C57BL/6 mice repeatedly exposed to the ubiquitous microorganism Bacillus subtilis develop mononuclear infiltrates in the lung that contain Vgamma6/Vdelta1(+) gammadelta T cells. In the absence of this T cell subset, mice treated with B. subtilis had significantly increased collagen deposition in the lung, suggesting a regulatory role for Vgamma6/Vdelta1(+) gammadelta T cells. To further investigate the role of Vgamma6/Vdelta1(+) gammadelta T cells in B. subtilis-induced lung fibrosis, we exposed transgenic Vgamma6/Vdelta1 mice to this microorganism and found decreased collagen content in the lung compared with wild-type C57BL/6 mice. Cytokine analysis of lung homogenates from wild-type C57BL/6 mice demonstrated increased IL-17A concentrations with repeated exposure to B. subtilis. In the absence of IL-17 receptor signaling, IL-17ra(-/-) mice had delayed clearance of B. subtilis with increased lung inflammation and fibrosis. Although IL-17A was predominantly expressed by Vgamma6/Vdelta1(+) T cells, a compensatory increase in IL-17A expression by CD4(+) T cells was seen in the absence of gammadelta T cells that resulted in similar levels of IL-17A in the lungs of TCRdelta(-/-) and wild-type C57BL/6 mice. In combination, our data suggest an important role for IL-17A-expressing T lymphocytes, both gammadelta and alphabeta T cells, in eliminating this microorganism that prevents excessive inflammation and eventual lung fibrosis in this murine model of B. subtilis-induced hypersensitivity pneumonitis.
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Affiliation(s)
- Philip L Simonian
- Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
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Abstract
The first few cases of hypersensitivity pneumonitis (HP) were described in the early 20th century in farmers exposed to moldy hay or straw. As then, HP has been ascribed to multiple inhaled antigens found in a large variety of environmental settings. Hypersensitivity pneumonitis results from an exaggerated immune response, which gives rise to acute infection-like symptoms or to progressive, sometimes irreversible lung damage. The diagnosis is based on a combination of clinical characteristics of the disease. Clinical diagnostic criteria have recently been published. The immune mechanisms leading to HP are still incompletely understood. Initially, believed to be a classes III and IV immune response, we now have a clearer understanding of the complex inflammatory events involved. These include the release of pro inflammatory cytokines and a decrease in the immune control mechanisms via surfactant, dendritic and T-regulatory cells. Despite the improved understanding, the treatment and outcome of HP have not changed. Oral corticosteroids remain the only effective drugs and contact withdrawal constitutes the ideal solution. If unchecked, HP can lead to irreversible lung damage in the form of fibrosis or emphysema, respiratory insufficiency and even death.
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Affiliation(s)
- M Girard
- Centre de recherche, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l'Université Laval, Québec, QC, Canada
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Abstract
Pulmonary fibrosis and architectural remodeling of tissues can severely disrupt lung function, often with fatal consequences. The etiology of pulmonary fibrotic diseases is varied, with an array of triggers including allergens, chemicals, radiation and environmental particles. However, the cause of one of the most common pulmonary fibrotic conditions, idiopathic pulmonary fibrosis (IPF), is still unclear. This review examines common mechanisms of pulmonary wound-healing responses following lung injury, and highlights the pathogenesis of some of the most widespread pulmonary fibrotic diseases. A three phase model of wound repair is reviewed that includes; (1) injury; (2) inflammation; and (3) repair. In most pulmonary fibrotic conditions dysregulation at one or more of these phases has been reported. Chronic inflammation can lead to an imbalance in the production of chemokines, cytokines, growth factors, and disrupt cellular recruitment. These changes coupled with excessive pro-fibrotic IL-13 and/or TGFbeta1 production can turn a well-controlled healing response into a pathogenic fibrotic response. Endogenous regulatory mechanisms are discussed including novel areas of therapeutic intervention. Restoring homeostasis to these dysregulated healing responses, or simply neutralizing the key pro-fibrotic mediators may prevent or slow the progression of pulmonary fibrosis.
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Simonian PL, Roark CL, Wehrmann F, Lanham AK, Diaz del Valle F, Born WK, O’Brien RL, Fontenot AP. Th17-Polarized Immune Response in a Murine Model of Hypersensitivity Pneumonitis and Lung Fibrosis. THE JOURNAL OF IMMUNOLOGY 2008. [DOI: 10.4049/jimmunol.182.1.657] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Thaon I, Reboux G, Moulonguet S, Dalphin J. Les pneumopathies d’hypersensibilité en milieu professionnel. ARCH MAL PROF ENVIRO 2007. [DOI: 10.1016/s1775-8785(07)78223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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La bronchopneumopathie chronique obstructive professionnelle : une maladie méconnue. ARCH MAL PROF ENVIRO 2007. [DOI: 10.1016/s1775-8785(07)78222-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sahin H, Brown KK, Curran-Everett D, Hale V, Cool CD, Vourlekis JS, Lynch DA. Chronic hypersensitivity pneumonitis: CT features comparison with pathologic evidence of fibrosis and survival. Radiology 2007; 244:591-8. [PMID: 17641377 DOI: 10.1148/radiol.2442060640] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively compare in patients with chronic hypersensitivity pneumonitis (HP) the computed tomographic (CT) imaging features suggestive of fibrosis with pathologic evidence of fibrosis at surgical lung biopsy and to compare a usual interstitial pneumonia (UIP) pattern at CT with survival. MATERIALS AND METHODS Institutional review board approval and informed consent were obtained for this study, which was HIPAA compliant. Twenty-six patients (15 women, 11 men; age range, 37-76 years) with chronic HP had their surgical lung biopsy results reviewed by two pathologists for the presence of fibrosis. Two radiologists systematically reviewed the CT scans. The two radiologists were blinded to all clinical information, including pathologic diagnosis, patient information, and outcomes. The combination of a subpleural reticular pattern and lower zone predominance was considered a UIP pattern. CT findings were compared with the histopathologic presence of fibrosis, physiologic parameters, symptoms, and survival. The chi(2) or Fisher exact test (each two-tailed) was used to compare nominal and ordinal variables. A t test (with unequal variances) was used to compare continuous variables. The log-rank procedure was used to compare Kaplan-Meier survival curves. RESULTS Fifteen patients had fibrotic HP at biopsy, and 11 had nonfibrotic HP. Patients with fibrotic HP had more extensive reticular pattern and were more likely to have traction bronchiectasis, honeycombing, and a UIP pattern than those with nonfibrotic HP (P = .015, P = .007, P = .007, respectively). Although the presence of histologic fibrosis was associated with decreased survival (P = .003), the CT features were not associated with decreased survival. CONCLUSION CT findings of extensive reticular pattern, traction bronchiectasis, and honeycombing are closely related to the presence of histologic fibrosis in chronic HP.
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Affiliation(s)
- Hakan Sahin
- Department of Radiology, National Jewish Medical and Research Center, 1400 Jackson St, Denver, CO 80206, USA.
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Sterclova M, Vasakova M, Dutka J, Kalanin J. Extrinsic allergic alveolitis: comparative study of the bronchoalveolar lavage profiles and radiological presentation. Postgrad Med J 2006; 82:598-601. [PMID: 16954458 PMCID: PMC2585727 DOI: 10.1136/pgmj.2005.044735] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Extrinsic allergic alveolitis (EAA) is an immunologically mediated interstitial lung disease. The abnormalities in the bronchoalveolar lavage (BAL) fluid cell counts are almost always seen in patients with EAA according to the stage of the disease. The aim of this retrospective study was to find out how the BAL lymphocyte count, percentage of lymphocytes expressing HLA-DR, CD4/CD8 T cell ratio in BAL fluid, and the concentration of immunoglobulin G in serum correspond to the inflammatory activity of the disease. METHODS The study included 14 patients with EAA. BAL fluid samples were obtained and processed for cytological and cytometric analysis. Immunoglobulin G serum concentrations were measured. High resolution computed tomography (HRCT) scoring system modified by Gay was used for establishing the alveolar and interstitial score in each patient. CONCLUSIONS It was found that subjects with normal value of CD4/CD8 ratio in BAL fluid had higher interstitial HRCT score. Clinical presentation, continuous exposure to the causative antigens, and BAL lymphocyte count positively correlated with the alveolar HRCT score. It is proposed that the increased BAL lymphocyte count could be the predictor of the inflammatory activity of the disease, especially in people with lasting exposure to the offending antigen.
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Affiliation(s)
- M Sterclova
- Department of Respiratory Medicine, Thomayer's Faculty Hospital, Videnska 800, 140 00 Prague, Czech Republic.
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Pneumopathies d'hypersensibilité et exposition aux moisissures et actinomycètes de l'environnement. J Mycol Med 2006. [DOI: 10.1016/j.mycmed.2006.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Thaon I, Reboux G, Moulonguet S, Dalphin JC. Les pneumopathies d’hypersensibilité en milieu professionnel. Rev Mal Respir 2006; 23:705-25. [PMID: 17202974 DOI: 10.1016/s0761-8425(06)72084-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is a granulomatous disease of the lungs due to immune reactions following chronic inhalation of organic dusts or chemicals especially encountered in the occupational environment. The main purpose of this review is to report current concepts regarding aetiologies, epidemiology, diagnosis, treatment as well as legal aspects of HP. STATE OF THE ART The following aspects will be focused: (1) increase in new etiological circumstances, especially occupational and news antigens, (2) for diagnosis, the major contribution of chest high resolution CT scan which often shows characteristic images but also recent developments in simple diagnostic criteria that may be used for an epidemiological approach, (3) importance of bronchial obstruction and even emphysema as a long term sequelae, finally (4) the possibility of continuing occupational activities in certain circumstances where preventive measures can be used. PERSPECTIVES The increasing knowledge of etiological agents and circumstances as well as the development of secondary and especially primary preventive measures should lead to reduce the frequency of this disease and of its medico-social consequences.
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Affiliation(s)
- I Thaon
- Service des Maladies Professionnelles, CHU de Besançon, France
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Ameille J, Dalphin J, Descatha A, Pairon J. La bronchopneumopathie chronique obstructive professionnelle : une maladie méconnue. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)71803-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Hypersensitivity pneumonitis (HP) is a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an antigen to which the subject has been previously sensitized. The incidence of HP is unknown. A population-based study estimated the annual incidence of interstitial lung diseases as 30:100,000 and HP accounted for less than 2% of these cases. The diagnosis of HP can often be made or rejected with confidence, especially in areas of high or low prevalence respectively, using simple diagnostic criteria. Chest X-rays may be normal in active HP; High Resolution Computed Tomography is sensitive but not specific for the diagnosis of HP. The primary use of pulmonary function tests is to determine the physiologic abnormalities and the associated impairment. Despite the pitfalls of false positive and false negatives, antigen-specific IgG antibodies analysis can be useful as supportive evidence for HP. Bronchoalveolar lavage plays an important role in the investigation of patients suspected of having HP. A normal number of lymphocytes rules out all but residual disease. Surgical lung biopsy should be reserved for rare cases with puzzling clinical presentation or for verification the clinical diagnosis when the clinical course or response to therapy is unusual. Being an immune reaction in the lung, the most obvious treatment of HP is avoidance of contact with the offending antigen. Systemic corticosteroids represent the only reliable pharmacologic treatment of HP but do not alter the long-term outcome. The use of inhaled steroids is anecdotal. Treatment of chronic or residual disease is supportive.
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Affiliation(s)
- Yves Lacasse
- Centre de Pneumologie, Université Laval, Hôpital Laval, 2725 Chemin Ste-Foy, Ste-Foy, Quebec, G1V 4G5, Canada
| | - Yvon Cormier
- Centre de Pneumologie, Université Laval, Hôpital Laval, 2725 Chemin Ste-Foy, Ste-Foy, Quebec, G1V 4G5, Canada
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Ameille J, Descatha A, Pairon JC, Dalphin JC. Bronchopneumopathies chroniques obstructives professionnelles. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/s1155-1925(05)38960-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Hypersensitivity pneumonitis (HP) is an uncommon, non-IgE-mediated interstitial lung disease caused by the inhalation of a variety of organic dusts, most commonly from exposure at work or in the pursuit of hobbies. Typically, after the disease is recognized, the causative allergen or environment is identified and treatment initiated through avoidance measures and corticosteroids. Progression of the disease is then usually halted and even reversed. Fatal cases of HP are unusual. OBJECTIVE To report a case of progressive and deadly HP in a 40-year-old printer who developed subacute bird fancier's disease with its clinical characteristics and positive precipitins to pigeon proteins. METHODS Chest x-ray examinations and tests of lung function were performed in the patient. Two months after initial consultation, when the diagnosis was still elusive, an open lung biopsy was performed and the patient was treated with prednisone for 3 months. A subsequent chest x-ray examination was performed 4 months after the biopsy. RESULTS With avoidance of birds and treatment with corticosteroids, the patient's symptoms resolved and lung function normalized. He was subsequently diagnosed as having asthma followed by bronchitis and 2 episodes of pneumonia. He did not fully recover from these but developed progressive dyspnea. After linking his symptoms to work by history, he underwent lung biopsy with findings consistent with chronic HP. Serum antibody titers were positive for Aspergillus but not pigeon proteins. Based on exposure to water-based coolants, he was suspected of having chronic occupational HP, although this could not be confirmed. Despite aggressive treatment, he developed a progressive course that was ultimately fatal. CONCLUSIONS This report details the progressive disease course in an individual who presented initially with subacute HP. Unfortunately, even after appropriate diagnosis and management, the course of the disease can be fatal.
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Affiliation(s)
- Michael Zacharisen
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin 53201, USA.
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Roussel S, Reboux G, Dalphin JC, Piarroux R. Alvéolites Allergiques Extrinsèques Et Exposition Aux Moisissures. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0338-9898(05)80235-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ, Kreiss K, Kunkel S, Lynch D, Quirce S, Rose C, Schleimer RP, Schuyler MR, Selman M, Trout D, Yoshizawa Y. Needs and Opportunities for Research in Hypersensitivity Pneumonitis. Am J Respir Crit Care Med 2005; 171:792-8. [PMID: 15657460 DOI: 10.1164/rccm.200409-1205ws] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) develops after inhalation of many different environmental antigens, causing variable clinical symptoms that often make diagnosis uncertain. The prevalence of HP is higher than recognized, especially its chronic form. Mechanisms of disease are still incompletely known. Strategies to improve detection and diagnosis are needed, and treatment options, principally avoidance, are limited. A workshop recommended: a population-based study to more accurately document the incidence and prevalence of HP; better classification of disease stages, including natural history; evaluation of diagnostic tests and biomarkers used to detect disease; better correlation of computerized tomography lung imaging and pathologic changes; more study of inflammatory and immune mechanisms; and improvement of animal models that are more relevant for human disease.
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Affiliation(s)
- Jordan N Fink
- DLD/NHLBI, Two Rockledge Center, 6701 Rockledge Drive, Bethesda, MD 20892-7952, USA
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