A first look at the reliability, validity and responsiveness of L-PF-35 dyspnea domain scores in fibrotic hypersensitivity pneumonitis

BACKGROUND

Dyspnea impairs quality of life (QOL) in patients with fibrotic hypersensitivity pneumonitis (FHP). The Living with Pulmonary Fibrosis questionnaire (L-PF) assesses symptoms, their impacts and PF-related QOL in patients with any form of PF. Its scores have not undergone validation analyses in an FHP cohort.

METHODS

We used data from the Pirfenidone in FHP trial to examine reliability, validity and responsiveness of the L-PF-35 Dyspnea domain score (Dyspnea) and to estimate its meaningful within-patient change (MWPC) threshold for worsening. Lack of suitable anchors precluded conducting analyses for other L-PF-35 scores.

RESULTS

At baseline, Dyspnea's internal consistency (Cronbach's coefficient alpha) was 0.85; there were significant correlations with all four anchors (University of California San Diego Shortness of Breath Questionnaire scores r = 0.81, St. George's Activity domain score r = 0.82, percent predicted forced vital capacity r = 0.37, and percent predicted diffusing capacity of the lung for carbon monoxide r = 0.37). Dyspnea was significantly different between anchor subgroups (e.g., lowest percent predicted forced vital capacity (FVC%) vs. highest, 33.5 ± 18.5 vs. 11.1 ± 9.8, p = 0.01). There were significant correlations between changes in Dyspnea and changes in anchor scores at all trial time points. Longitudinal models further confirmed responsiveness. The MWPC threshold estimate for worsening was 6.6 points (range 5-8).

CONCLUSION

The L-PF-35 Dyspnea domain appears to possess acceptable psychometric properties for assessing dyspnea in patients with FHP. Because instrument validation is never accomplished with one study, additional research is needed to build on the foundation these analyses provide.

TRIAL REGISTRATION

The data for the analyses presented in this manuscript were generated in a trial registered on ClinicalTrials.gov; the identifier was NCT02958917.

Concurrent features of sarcoidosis and hypersensitivity pneumonitis in two patients exposed to fungal antigens

BACKGROUND

Sarcoidosis and hypersensitivity pneumonitis (HP) are two distinct clinical entities that share granulomatous inflammation, although each of them has specific clinical, radiologic and pathologic profiles. Coexistence of the two diseases have been described, suggesting, at least in some cases, a common biologic background.

CASE PRESENTATION

We describe two patients showing the concurrent diagnosis of sarcoidosis and hypersensitivity pneumonitis. Case 1: a 51-year old never smoker man had a history of occupational exposure, episodes of acute exacerbations and positive serum precipitins to Penicillium spp suggestive of HP, while the positivity of serum angiotensin converting enzyme (ACE) favored sarcoidosis. Case 2: a 42-year old non-smoker woman with occasional finding of enlarged mediastinal lymph nodes had a history of domestic exposure to molds and positive serum precipitins to Aspergillus spp suggestive of HP. In both cases high resolution computed tomography (HRCT) together with broncoscopy findings allowed to maintain both the diagnoses: HRCT showed both enlarged hilar/mediastinal limph nodes and intersitial lung involvement typical of HP; bronchoalveolar lavage presented marked lymphocytosis and granulomatous nodal lesions were observed at transbronchial needle aspiration.

CONCLUSIONS

Sarcoidosis and HP share some clinical findings and the differential diagnosis may be difficult. Our cases suggest that a common trait may be responsible for the concurrent diagnosis of sarcoidosis and hypersensitivity pneumonitis in the same patient.

Activation of Downstream mTORC1 Target Ribosomal Protein S6 Kinase (S6K) Can Be Found in a Subgroup of Dutch Patients with Granulomatous Pulmonary Disease

Mechanistic target of rapamycin complex 1 (mTORC1) has been linked to different diseases. The mTORC1 signaling pathway is suggested to play a role in the granuloma formation of sarcoidosis. Recent studies demonstrated conflicting data on mTORC1 activation in patients with sarcoidosis by measuring activation of its downstream target S6 kinase (S6K) with either 33% or 100% of patients. Therefore, the aim of our study was to reevaluate the percentage of S6K activation in sarcoidosis patients in a Dutch cohort. To investigate whether this activation is specific for sarcoid granulomas, we also included Dutch patients with other granulomatous diseases of the lung. The activation of the S6K signaling pathway was evaluated by immunohistochemical staining of its downstream effector phospho-S6 in tissue sections. Active S6K signaling was detected in 32 (43%) of the sarcoidosis patients. Twelve (31%) of the patients with another granulomatous disorder also showed activated S6K signaling, demonstrating that the mTORC1 pathway may be activated in a range for different granulomatous diseases (p = 0.628). Activation of S6K can only be found in a subgroup of patients with sarcoidosis, as well as in patients with other granulomatous pulmonary diseases, such as hypersensitivity pneumonitis or vasculitis. No association between different clinical phenotypes and S6K activation can be found in sarcoidosis.

[Adenopathy and mammary carcinoma: It is sometimes in the details that one encounters hypersensitivity pneumonitis!]

INTRODUCTION

Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown.

CASE REPORT

We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance.

CONCLUSION

Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.

Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline

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.

Environmental, Inhaled and Ingested Causes of Pulmonary Fibrosis

Pulmonary fibrosis is a general term that refers to a collection of connective tissue around alveolar structures. There are over 200 disorders where the lungs may be involved in a fibrotic response. To determine the cause of pulmonary fibrosis requires an in depth understanding of the pathogenesis of pulmonary fibrosis and breadth of knowledge of the causative agents and associated disorders that may lead to pulmonary fibrosis. A comprehensive evaluation of the patient is absolutely essential, starting with detailed history that includes an occupational and environmental history because fibrogenic exposures can occur in many settings. Equally important is a history of ingestion of pharmaceutical or nonpharmaceutical substances. A physical examination and judicious investigations are always a part of any comprehensive clinical assessment but they are not commonly helpful in elucidating the cause of most pulmonary fibrotic disorders. Although, a chest film is invariably done, a logical and strongly recommended next step is a high-resolution computed tomography (HRCT). HRCT provides a better assessment of the radiological pattern, may suggest a diagnosis as well as direct the site, and type of lung biopsy. If the history and investigations do not lead to a diagnosis then a lung biopsy is required. Prevention or removal of the inciting agent is critical to the treatment of these disorders and in some instances corticosteroids may be of help.

Familial Summer-type Hypersensitivity Pneumonitis: A Review of 25 Families and 50 Cases in Japan

Summer-type hypersensitivity pneumonitis (SHP) is the most common form of pneumonitis in Japan; it accounts for 74% of all cases. It has been reported that 19.5-23.8% of SHP cases occur in families who live in the same house. We present our SHP cases and review 50 familial cases in 23 families that were reported in Japan (including our own) and 48 cases that were previously described in 22 articles published between January 1982 and October 2011. To the best of the authors' knowledge, this is the first review article in English to document the familial occurrence of SHP in Japan.

[Prolonged disease in a farmer with simultaneous Q fever pneumonia and subacute hypersensitivity pneumonitis]

This case report describes the first incident of a patient with simultaneous occurrence of Q fever pneumonia and subacute hypersensitivity pneumonitis (HP). The 52-year-old patient was from his occupation as a farmer exposed to agents causing both diseases. Except for a weight loss in subacute/chronic incidents of HP the symptoms of Q fever and HP are similar. However, differences in CT findings and histopathology make it possible to differentiate between the two diseases. This report highlights the importance of a thorough occupational history.

[Difficulties in the radiodiagnosis of lung injuries in phthisiatric practice]

The paper describes clinical cases of concomitant lung and intrathoracic lymph node involvements as evidenced by conventional radiography and computed tomography (CT). It shows difficulties in the differential diagnosis of different nosological entities in pulmonary tuberculosis. The x-ray semiotics of concomitant lung injuries is also depicted.

Fatal hypersensitivity pneumonitis associated with docetaxel

We present a patient with advanced breast cancer treated with three cycles of docetaxel who developed repeated episodes of hypersensitivity pneumonitis, progressed to respiratory failure and death despite treatment with corticosteroids and supportive care. Docetaxel-induced hypersensitivity pneumonitis was diagnosed by excluding infection and tumor spread with bronchoalveolar lavage and lung biopsy. Physicians should consider such a condition in all patients who present with interstitial pneumonitis and respiratory failure when they are receiving docetaxel and treat them aggressively with steroids and supportive care, as it can be fatal.

Angioimmunoblastic T cell lymphoma: an unusual presentation of posttransplant lymphoproliferative disorder in a pediatric patient

Posttransplant lymphoproliferative disorders (PTLD) are a potentially life-threatening complication of immunosuppression in transplant recipients. The majority of cases are Epstein-Barr virus-associated lesions of B cell origin. T cell PTLD is rare, particularly in pediatric patients. We present an unusual case of monomorphic T cell PTLD with features of angioimmunoblastic T cell lymphoma in an 8-year-old heart transplant patient, presenting with cranial nerve palsy.

[Malignant lymphoma of lung with hypersensitivity pneumonitis]

We report a resected case of malignant lymphoma with hypersensitivity pneumonitis. A 62-year-old woman, who presented with fever, wheeze and dry cough was referred to our department under the diagnosis of malignant B cell lymphoma in lower lobe of the left lung and hypersensitivity pneumonitis. She underwent left lower lobectomy as a therapy for malignant lymphoma. Pathological findings showed multiple small nodules macroscopically, which was observed as bronchiolocentric interstitial pneumonitis with lymphocytes microscopically. Post operative course was uneventful and no sign of acute exacerbation was seen. It is rare that lung with hypersensitivity pneumonitis is observed as a macroscopical specimen. Hypersensitivity pneumonitis differs from idiopathic pulmonary fibrosis, but we have to take care of post operative course because post operative acute exacerbation was reported.

Combined vasomodulatory therapy for severe pulmonary hypertension in chronic hypersensitivity pneumonitis

BACKGROUND

There are only a few reports of pulmonary hypertension (PH) in hypersensitivity pneumonitis (HP) and an approved vasomodulatory therapy for PH does not exist at all for interstitial lung disease (ILD), particularly for HP.

CASE REPORT

The case of a 53-year-old woman with chronic HP and severe life-threatening PH treated with a combined specific vasomodulatory therapy is reported. Sustained clinical and hemodynamic improvement was achieved.

CONCLUSIONS

Further investigation of PH in HP and specific vasomodulatory therapy is necessary.

Bird fancier's lung which developed in a pigeon breeder presenting organizing pneumonia

Bird fancier's lung (BFL) is one of the most common types of hypersensitivity pneumonitis. We report a rare case of acute-on-chronic bird fancier's lung that developed in a pigeon breeder and presented subpleural curvilinear shadow and ground glass opacity on high-resolution computed tomography (HRCT) of the chest. The results of surgical lung biopsy showed mainly intraalveolar organization and alveolitis in addition to the pattern of usual interstitial pneumonia with centrilobular fibrosis. Examination of bronchoalveolar lavage (BAL) fluid revealed an increase in lymphocytes. The results of immunoglobulin (Ig) G and IgA antibodies against pigeon dropping extracts were positive in sera and BAL fluid. Consequently, the patient was diagnosed as having BFL. Avoidance of pigeons and corticosteroid therapy led to rapid improvement.

Case study: the challenges of self-management of exacerbation of pulmonary symptoms

PURPOSE

This case study demonstrates the signs and symptoms of pulmonary exacerbation and the challenges of self-management for a female veteran.

DATA SOURCES

Data were obtained through the author's clinical practice in primary care nursing and research literature sources.

DATA SYNTHESIS

The appropriate nursing diagnosis, nursing interventions, and patient outcomes were identified through the use of NANDA-International, the Nursing Interventions Classification, and the Nursing Outcomes Classification.

CONCLUSIONS

This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with pulmonary exacerbations. It provides a framework for nurses in primary care when caring for individuals with pulmonary exacerbations.

IMPLICATIONS FOR NURSING PRACTICE

Employing the NANDA-International standardized nursing diagnoses, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for improving care for a patient that had pulmonary issues in a primary care setting.

[Clinical interpretation for the pressure-flow relationships in extrinsic allergic alveolitis and in interstitial lung disease pulmonary hypertension patients. Should we care for the lung, the pulmonary artery pressure or both?]

OBJECTIVES

We sought to analyze exercise-derived mean pulmonary artery pressure (mPAP)-cardiac index (CI) relationship to expand the concepts regarding its nature and to better identify pulmonary hemodynamic responders to acute oxygen breathing (AO2B-99.5%) and to hydralazine (H) in extrinsic allergic alveolitis (EAA) and chronic interstitial lung disease (CILD) pulmonary hypertension (PH) patients.

MATERIAL AND METHODS

mPAP/CI and extrapolated pressure (Pext) to zero flow were obtained while breathing room air (BRA) and under AO2B-99.5% in 38 stable (EAA (n = 14) and CILD (n = 24)) patients with resting and exercising PH. Hemodynamic characteristics were analyzed for the entire cohort and separate for EAA and CILD patients. AO2B-99.5% was tested in cohorts, H only in CILD and the effect of long-term corticosteroid treatment in EAA patients. Lung biopsies (LB) were obtained to evaluate the inflammatory-fibrosis stage and the degree of vascular lesion in the entire cohort.

RESULTS

LB studies reveal a predominant stage of inflammation associated with grade-I vascular lesion for EAA patients. A predominant stage for fibrosis (although moderate) over inflammation associated with grade-II vascular lesions were documented for CILD patients. mPAP/CI abnormal location were associated with hypoxemia/decreased mixed venous-PO2 and lung mechanics abnormalities for both cohorts. An abnormal slope (Sp: 4.13; 95% CI: 3.42-4.84 mmHg/L/min/m2) and a normal Pext value (7 +/- 1.9 mmHg) were found for EAA patients. On the contrary, a normal slope (Sp: 1.22; 95% CI: 0.47-1.99 mmHg/L/min/m2) and an abnormal Pext value (19.7 +/- 3.5 mmHg) were found for CILD patients. Hemodynamic conditions that did not change for the Sp (4.0; 95% CI: 3.18-4.82 mmHg/L/min/m2); however, were associated with a statistical significant decrease in parallel for mPAP/CI during AO2B-99.5% when compared to BRA (p < 0.01), although not to normal slope values (0.96; 95% CI: 0.41-1.37) or mPAP/CI location. For CILD patients, during AO2B-99.5% no change for the slope, for Pext and mPAP/CI location in relation to BRA were observed. Under the effect of H, no change for the previous mentioned hemodynamic findings were found in relation to the control condition for CILD patients. After long-term corticosteroid treatment, normalization for mPAP/CI location and for the slope value (1.6; 95% CI: 0.91-2.29 mmHg/L/min/m2) were associated with lung mechanics and blood-gas exchange normalization were documented in EAA patients.

CONCLUSIONS

When mPAP/CI exercise derived is analyzed, valuable information for linear-pulmonary vascular resistance-(LPVR) could be obtained for EAA and CILD-PH patients. mPAP/CI-r abnormalities not always reflect "pure arteriolar" increased LPVR for EAA and CILD patients. H is not useful as an adjunct vasodilator therapy for CILD-PH patients. AO2B-99.5% decrease right ventricular afterload for EAA patients, although not to normal. Complete reversibility for PH could result after long-term corticosteroid treatment. We conclude that treatment should focus mainly on the lung and not in the pulmonary artery pressure in interstitial lung disease PH patients.

[Pathologic study of diffuse pulmonary interstitial fibrosis caused by chronic hypersensitivity pneumonitis]

OBJECTIVE

To study the pathologic characteristics of chronic hypersensitivity pneumonitis, especially the pattern of pulmonary interstitial fibrosis; and to compare the histologic features with those of idiopathic interstitial pneumonitis.

METHODS

The HE-stained paraffin sections of 10 cases of chronic hypersensitivity pneumonitis encountered during the period from 2000 to 2008 were retrospectively analyzed.

RESULTS

There were altogether 6 males and 4 females, with age of patients ranging from 23 to 59 years (mean=47.2 years). Clinically, the patients presented with chronic cough and shortness of breath for 4 months to 6 years. Histologically, 7 cases showed usual interstitial pneumonitis (UIP)-like fibrosis. Patchy fibrosis was observed under the pleura, adjacent to interlobular septa and around bronchioles. In all of the 7 cases, foci of fibroblastic proliferation, as well as bronchiolar metaplasia of peribronchiolar alveoli and mild bronchiolitis, were noted. Three cases presented with mild honeycomb changes of lung and 3 cases showed non-specific interstitial pneumonitis (NSIP)-like fibrosis, in which the alveolar septa were expanded by fibrous tissue and collagen, with relative preservation of alveolar architecture. Bronchiolitis and lymphocytic infiltrates in alveolar septa were seen. Schaumann bodies were identified in 1 case. In general, patients with chronic hypersensitivity pneumonitis were younger than patients with idiopathic UIP. Computed tomography often showed upper and middle lobar involvement and mosaic attenuation. Compared with idiopathic UIP, the UIP-like fibrosis of chronic hypersensitivity pneumonitis often occurred not only under the pleura and adjacent to interlobular septa, but also around bronchioles and was accompanied by bronchiolar metaplasia.

CONCLUSIONS

Chronic hypersensitivity pneumonitis can mimic other types of lung conditions with interstitial fibrosis, especially UIP and NSIP. As a result, some cases of chronic hypersensitivity pneumonitis may be misdiagnosed as such.

Chronic summer-type hypersensitivity pneumonitis: clinical similarities to idiopathic pulmonary fibrosis

BACKGROUND

Chronic hypersensitivity pneumonitis (HP) eventually ensues to extensive lung fibrosis when exposure to the causative antigen continues. Differential diagnosis from idiopathic interstitial pneumonias is sometimes difficult especially in the advanced stage.

AIM OF THE WORK

To describe the clinical course of chronic summer-type HP, which is the most prevalent type of HP in Japan, in terms of early diagnosis and similarity to idiopathic pulmonary fibrosis (IPF).

METHODS

14 patients with chronic summer-type HP diagnosed between 2000 and 2005 were reviewed retrospectively.

RESULTS

KL-6, a mucin-like glycoprotein, and surfactant protein-D (SP-D) were elevated in most cases. Specific antibodies against Trichosporon asahii (T. asahii) and T. mucoides in sera and BAL fluids were positive in 12 of 14 cases. A lymphocyte proliferation test induced by Trichosporon related antigen was positive in all examined cases (n=5). On high-resolution CT, traction bronchiectasis and honeycombing were observed in more than 70% of cases. By video-assisted thoracoscopic surgery (VATS) and autopsy specimens, honeycombing, fibroblastic foci, centrilobular fibrosis, and bridging fibrosis between bronchiolar and subpleural areas were observed. Antigen avoidance by improving domestic environments kept patients stable without decline in vital capacity (VC). However, 3 of the 4 patients who did not remedy their houses died of respiratory failure after progression of this disease.

CONCLUSION

Correct diagnosis in the early stage is crucial, since chronic summer-type HP can result in a fatal outcome after continuous exposure to the causative antigen.

Acute Exacerbation (Acute Lung Injury of Unknown Cause) in UIP and Other Forms of Fibrotic Interstitial Pneumonias

Acute exacerbation of usual interstitial pneumonia (UIP) is a condition in which patients with UIP, and occasionally other forms of fibrotic interstitial lung disease, develop rapid respiratory failure, accompanied by extensive radiologic infiltrates. The pathologic features of this condition are ill-defined in the literature and the outcome is unclear. We report 12 such patients, 9 with underlying UIP, 2 with underlying fibrotic nonspecific interstitial pneumonia, and 1 with underlying chronic hypersensitivity pneumonitis, who underwent surgical lung biopsy for diagnosis. High-resolution computed tomography data were available in 11 cases and showed the presence of extensive bilateral ground-glass opacities, sometimes accompanied by focal consolidation, superimposed on underlying fibrosis. Three microscopic patterns of acute lung injury were seen: diffuse alveolar damage (DAD), organizing pneumonia (OP), and a pattern of numerous very large fibroblast foci superimposed on underlying fibrosis. After the biopsy, all patients were treated with steroids, in some instances accompanied by cyclophosphamide or azathioprine. Ten patients survived the acute episode and were discharged with survival times of 1 to 11 months; of these cases, 6 showed a pattern of OP or OP plus extensive fibroblast foci; 2 a pattern of extensive fibroblast foci only; and 2 a pattern of DAD. Both patients who died had histologic DAD. We conclude that acute exacerbation of UIP and other fibrotic lung diseases produces a variety of pathologic patterns on biopsy, and that patients with OP or extensive fibroblast foci as the acute pattern seem to do better than those with DAD. Our data also imply that survival (of the acute episode) may be better than the literature suggests.

What the allergist should know about hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) appears to be an underdiagnosed condition. It may masquerade as recurrent pneumonia, idiopathic pulmonary fibrosis, Haman-Rich disease, or interstitial pneumonitis. The nature of the disease depends on the immunologic reactivity of the host and the intensity and chronicity of exposure. Causative agents include thermophilic organisms, mold, animals, and chemicals. Typical symptoms of cough, shortness of breath, chills, and fever typically begin four to six hours after exposure with a remittance on avoidance. Chest x-ray demonstrates interstitial pneumonitis, and pulmonary function testing shows a restrictive component. A precipitating IgG antibody is the immunologic hallmark. The immunopathogenesis appears to represent a combination of type III and IV immune responses. Identifying the offending antigen is vital so that appropriate environmental precautions can be carried out.

[Successful treatment by voliconazole for pulmonary and adductor magnus muscle aspergillosis induced by immunosuppressive therapy for hypersensitivity pneumonia]

A 74-year-old woman was treated with steroid and cyclosporine A for hypersensitivity pneumonia. To examine the causes of general fatigue and increased levels of beta-D glucan in serum, she was admitted to our hospital. Chest computed tomography (CT) scan revealed nodular opacity with a well-defined margin in the right S1. 67Ga scintigraphy image showed high uptake in the left thigh and CT showed circularly enhanced lesions in the thigh. An ultrasonography-guided needle aspiration and biopsy of the muscle abscess allowed isolation of Aspergillus fumigatus and evidence of necrotic tissues around the granuloma formation. We therefore diagnosed invasive aspergillosis. Because of the poor response to initial therapy with micafungin and itraconazole for 4 weeks, we treated her with voliconazole (VCZ). Spectacular regression of lung lesions and muscle abscesses was rapidly achieved. Furthermore, the high level of beta-D glucan in serum decreased gradually. This case suggests that administration of VCZ can be recommended for deep seated mycoses.

A woman with cough, fever, and micronodular infiltrates on chest radiograph

Hot tub lung is a form of hypersensitivity pneumonitis (HP) reported to be associated with exposure to large aerosolized inocula of Mycobacterium avium complex (MAC). Although the pathogenesis of the disease is still poorly understood, the pathology of MAC-related HP can be similar to that of sarcoidosis, with well-formed granulomas. We describe a patient with HP featuring well-formed granulomas on transbronchial biopsy specimens, a finding believed to be unique to MAC-related HP, also referred to as "hot tub lung".

Chronic hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is traditionally divided on clinical grounds into acute, subacute, and chronic stages. Most biopsy specimens come from patients in the subacute stage, in which there is a relatively mild, usually peribronchiolar, chronic interstitial inflammatory infiltrate, accompanied in most cases by poorly formed interstitial granulomas or isolated giant cells. However, the pathologic features in the chronic, ie, fibrotic stage, are poorly defined in the literature. These features are important to recognize because the chronic stage of HP is often associated with a poor prognosis. We reviewed 13 cases of chronic HP. Where information was available, exposures to the sensitizing agent had generally occurred over a long period of time. Three patterns of fibrosis were seen: 1) predominantly peripheral fibrosis in a patchy pattern with architectural distortion and fibroblast foci resembling, microscopically, usual interstitial pneumonia (UIP); 2) relatively homogeneous linear fibrosis resembling fibrotic nonspecific interstitial pneumonia (NSIP); and 3) irregular predominantly peribronchiolar fibrosis. In some instances, mixtures of the UIP-like and peribronchiolar patterns were found. In all cases, the presence of scattered poorly formed granulomas, or isolated interstitial giant cells, or sometimes only Schaumann bodies indicated the correct diagnosis. In 7 cases, areas of typical subacute HP were present as well. High-resolution CT scans showed variable patterns ranging from severe fibrosis, in some instances with an upper zone predominance, to predominantly ground glass opacities with peripheral reticulation. We conclude that, at the level of morphology, chronic HP may closely mimic UIP or fibrotic NSIP. If no areas of subacute HP are evident, the presence of isolated giant cells, poorly formed granulomas, or Schaumann bodies is crucial to arriving at the correct diagnosis, and the finding of peribronchiolar fibrosis may be helpful. Despite the presence of extensive fibrosis, some patients responded to removal from exposure and steroid therapy.

[Bird fancier's lung--an allergic alveolitis]

BACKGROUND

Bird fancier's lung is globally the second most frequent cause of extrinsic allergic alveolitis.

MATERIAL

For many years, the patient had influenza-like symptoms and developed progressing pulmonary fibrosis. Over a period of 10 years she had been exposed to up to 43 birds in the house at any one time and serum precipitates against avian proteins had been found. After sanitation of the house of birds and avian proteins, the pulmonary function has not deteriorated further in 5 years.

INTERPRETATION

A thorough environmental history is essential in the diagnosis of extrinsic allergic alveolitis; at an earlier stage it would have made us think about this possible etiological factor. This could have prevented the development of permanent pulmonary fibrosis if the patient had been advised to avoid further exposure to antigens. There should be greater awareness of this disease among general practitioners as well as among chest consultants in Norway.

Hypersensitivity pneumonitis associated with the use of trofosfamide

Trofosfamide (Ixoten; Baxter Oncology, Germany) is an alkylating agent that, as with other oxazaphosphorine derivatives, has to be activated by hepatic cytochrome P450 oxidases. The bioavailability is nearly 100% after oral application, and the main metabolites are 4-hydroxytrofosfamide, and 4-hydroxyifosfamide. The main side-chain metabolites ifosfamide and cyclophosphamide can be further activated by oxidation and formation of their respective phosphoramide mustards. Oral continuous low-dose therapy has been the most widely used schedule. The toxicity profile consists mainly of dose-dependent hematotoxicity and, rarely, hemorrhagic cystitis. Nausea and vomiting are infrequently seen. Higher grades of nephrotoxicity or neurotoxicity--side-effects that typically limit the use of ifosfamide-have not been reported with low-dose continuous trofosfamide treatment. We report herein a case of a 83-year-old female patient with a disseminated malignant peripheral nerve sheath tumor treated with trofosfamide developing pulmonal toxicity. To our knowledge, this is the first reported case of exogenous allergic alveolitis after exposure to this drug.

[Pulmonary fibrosis in young patients with hypersensitivity pneumonitis]

Hypersensitivity pneumonitis (HP) is more common in middle-aged individuals but has been also diagnosed in patients of all ages including infants and children. Host risk factors are poorly characterized. The aim of this paper is presentation of 6 young patients in whom HP was diagnosed at the stage of lung fibrosis. There were 5 females at the age of 16-35 years and 1 male at the age of 28 years. All of them were exposed to organic dust for many years. Three of them were asthenic with scoliosis, 5 had clubbing. All patients were released from sport exercises in school due to fatigue but the diagnostic procedures were started at that time only in 2 patients. One woman had been ill from early childhood (recurrent pneumonia was recognised). In the another girl (16 years old) the spontaneous pneumothorax was the cause of the first chest X-ray examination. In the next woman (21 years old) marked dyspnea was connected with pregnancy and massive fibrotic lesions were recognised after delivery of her child. The only man was diagnosed before change of his job; he had no complaints. Two oldest women (34 and 35 years old) were diagnosed in childhood but avoidance of antigen exposure and corticotherapy were not effective. In all patients precipitins against farmer's lung and pigeon fancier's lung antigens were found. In all patients chest X-ray showed features of advanced lung fibrosis. All patients were treated with steroids without improvement. Two patients died during corticotherapy.

CONCLUSIONS

1) HP could be taken into consideration during differential diagnosis of interstitial lung diseases, 2) Cough and dyspnea on exertion could be the first symptoms of chronic HP in children also.

Lung cysts in subacute hypersensitivity pneumonitis

PURPOSE

To determine the frequency of cystic lesions on high-resolution computed tomography (CT) in patients with subacute hypersensitivity pneumonitis.

METHODS

High-resolution CT scans in 182 patients with proven subacute hypersensitivity pneumonitis were retrospectively evaluated for the presence of lung cysts. Patients with CT evidence of emphysema or interstitial fibrosis and patients with connective tissue disease were excluded from the study. Two thoracic radiologists reviewed the thoracic CT scans for the presence and location of lung cysts.

RESULTS

Thin-walled lung cysts were identified in 24 (13%) of 182 patients and ranged in size from 3 to 25 mm in maximal diameter. The patients included 16 men and 8 women (age range, 30-79 years; mean age, 48 years). The cysts ranged from 1 to 15 in number (mean, 4 cysts) and had a random distribution. Sixteen of the 24 patients also had areas of decreased attenuation and vascularity consistent with air trapping.

CONCLUSIONS

Thin-walled cysts can be seen in a small percentage of patients with subacute hypersensitivity pneumonitis. The cysts resemble those seen in lymphocytic interstitial pneumonia, and their pathogenesis is uncertain.

Hypersensitivity pneumonitis with normal high resolution computed tomography scans

A case of symptomatic hypersensitivity pneumonitis with normal high resolution computed tomography (CT) scans is presented. The patient, a 32-year-old man with systemic lupus erythematosus, had a chronic, progressive history of respiratory symptoms, abnormal findings on examination and abnormal pulmonary function tests but normal high resolution CT scans of the chest. Diagnosis was made through open lung biopsy. Clinical improvement was seen on removal of the offending antigen. The literature on the utility of high resolution CT scans in hypersensitivity pneumonitis is reviewed.

[Hypersensitivity peumonitis in a patient with rheumatoid arthritis]

We report a case with rheumatoid arthritis and hypersensitivity pneumonitis. A 66-year-old female was admitted to our hospital because of fever, cough, and progressive dyspnea on October 10, 1997. She had a history of rheumatoid arthritis from 1987 and was treated with cyclophosphamide when she developed pulmonary symptoms in September 1997. On admission arthritis was subsided. Fine crackles on ausculation of lung, hypoxia, ground-glass appearance on chest X-ray were detected. The computed tomography of the chest disclosed diffuse interstitial shadow with patchy destruction of alveolar structures. Bronchoalveolar lavage demonstrated an increase in lymphocytes with predominance of suppressor-cytotoxic T cell subset (CD 8+). The histopathological examination of transbronchial lung biopsy showed interstitial inflammation with marked predominance of lymphocyte with intraalveolar exudate. Her condition got better and she discharged without definitive diagnosis and treatment for her respiratory symptoms. Eight hours after she went back home, she suddenly presented high fever and cough and gradually developed dyspnea. She was readmitted 5 days after the previous discharge. Although no specific precipitin antibody against various microorganisms was detected in her sera, the diagnosis of hypersensitivity pneumonitis was made. Thirty mg per day of prednisolone was resolved her symptoms promptly. There was no reported case with hypersensitivity pneumonitis and rheumatoid arthritis of other collagen diseases. The clinical course that arthritis and pulmonary symptoms appeared alternatively is of considerable interest to investigate for the pathogenesis of these two immune disorders.

[Summer-type hypersensitivity pneumonitis with remarkable obstructive impairment of pulmonary function]

A 57-year-old-man was admitted because of persistent cough and progressive dyspnea over a period of 2 months. Examination revealed wheezing in both lungs, severe hypoxemia, and marked obstructive impairment of pulmonary function. A chest CT scan showed diffuse small nodular lesions with patchy air space opacifications. The patient was initially given a diagnosis of bronchiolitis of unknown cause. He showed marked improvement after treatment with oral prednisolone, but developed fever and dyspnea after returning home. This episode indicated hypersensitivity pneumonitis, a diagnosis supported by findings of increased CD 8 positive T-lymphocytes in bronchoalveolar lavage fluid, and a high titer of serum anti-Trichosporon antibody. Lung biopsy samples obtained under video-assisted thoracoscopy disclosed noncaseating granulomas in terminal and respiratory bronchioles, which resulted in marked narrowing of the lumen. The pathologic changes seemed to be consistent with obstructive impairment of pulmonary function in this patient.

[Pulmonary elastic pressure as an indicator of lung tissue morpho-functional restructure]

The examination of 100 patients with tuberculosis and exogenous allergic alveolitis showed it expedient to study pulmonary elastic pressure in patients without or with or X-ray signs of pneumosclerosis and pulmonary emphysema. Its exploration could diagnose initial (pre-X-ray) manifestations of pneumosclerosis and pulmonary emphysema in the former patients and specify the extent and relatively significant manifestations of these abnormalities at the subsequent (X-ray detected) stages in the others.

A case of acute eosinophilic pneumonia. Evidence for hypersensitivity-like pulmonary reaction

We examined an 86-year-old man with acute respiratory failure. A chest roentgenogram showed diffuse reticular shadows. Transbronchial biopsy revealed thickening of the alveolar septa accompanied by moderate eosinophil infiltration. After admission to the hospital, the patient's symptoms immediately improved without any medication. Clinical course and pathologic findings suggested acute eosinophilic pneumonia caused by a hypersensitivity reaction.

[Acute viral respiratory infections and asthma]

Respiratory viral infections are very important triggers of asthma exacerbation. Recent epidemiologic studies support the hypothesis that they are associated with 80 to 85% of acute attacks of asthma in children. The respiratory syncytial and parainfluenza viruses are predominantly detected in infants, while rhinovirus and mycoplasma are the commonest in children. In practice for an asthmatic child, it is necessary: 1. to vaccinate against influenza; 2. resume or increase the inhaled antiinflammatory therapeutics in moderate to severe asthma, before the viral epidemic season; 3. teach the child and his family on the attitude to have during an upper respiratory infection and when to visit a physician.

[Subacute extrinsic allergic alveolitis with lesion edema]

BACKGROUND

Extrinsic allergic alveolitis may have a chronic, subacute or acute course. Its fulminant form with interstitial edema is unusual.

CASE REPORT

An 11-year-old girl was referred to our intensive care unit because she suffered from high fever. Chest X-rays showed bilateral alveolitis. History revealed home exposure to several birds for many years, and episodes of dyspnea and fever for a few months. Diagnosis of extrinsic allergic alveolitis was confirmed by strongly positive results of precipitins to avian antigens. In addition, a paramyxovirus influenzae was recovered from broncho-alveolar lavage. Treatment, including high dose steroids, hydroxychloroquine, and suppression of antigenic exposure allowed weaning from mechanical ventilation after 50 days. Severe pulmonary restriction was disclosed by lung function testing following weaning and slow improvement occurred 5 months later, despite persistent interstitial lesions on chest X-rays.

CONCLUSION

Extrinsic allergic alveolitis may mimic an acute respiratory distress syndrome. Documenting bird exposure in such a case helps to achieve appropriate diagnosis which requires early administration of steroids in order to improve vital and functional prognosis.