Neumonitis por hipersensibilidad fibrótica: reporte de casos y propuesta de fuentes de exposición en nuestro medio / Fibrotic hypersensitivity pneumonitis: case report and proposal of sources of exposure in our environment

Una excesiva respuesta inmune a antígenos inhalados en algunos individuos susceptibles puede causar neumonitis por hipersensibilidad, considerada una entidad prevalente entre las enfermedades pulmonares intersticiales difusas. Recientemente, se ha propuesto un cambio radical en la clasificación de esta infravalorada entidad. En este reporte describimos las características clínicas y radiológicas de tres casos de neumonitis por hipersensibilidad fibrótica: pulmón de cuidador de aves, pulmón de almohada de plumas y alveolitis química. Se muestra una tabla con las probables ocupaciones o exposiciones de riesgo en nuestro medio y se realiza una revisión actualizada del tema. Palabras clave:neumonía; enfermedadespulmonaresintersticiales; alveolitis alérgica extrínseca

An excessive immune response to inhaled antigens in some susceptible individuals can cause hypersensitivity pneumonitis, considered a prevalent entity among diffuse interstitial lung diseases. A radical change in the classification of this undervalued entity has recently been proposed. In this report we describe the clinical and radiological characteristics of three cases of fibrotic hypersensitivity pneumonitis: bird keeper's lung, feather pillow lung, and chemical alveolitis. A table is shown with the probable occupations or risk exposures in our environment and an updated review of the subject is carried out.Key Words:pneumonia; interstitial lung diseases; extrinsic allergic alveolitis

Clinical characteristics of hypersensitivity pneumonitis: non-fibrotic and fibrotic subtypes / 中华医学杂志(英文版)

BACKGROUND@#The presence of fibrosis is a criterion for subtype classification in the newly updated hypersensitivity pneumonitis (HP) guidelines. The present study aimed to summarize differences in clinical characteristics and prognosis of non-fibrotic hypersensitivity pneumonitis (NFHP) and fibrotic hypersensitivity pneumonitis (FHP) and explore factors associated with the presence of fibrosis.@*METHODS@#In this prospective cohort study, patients diagnosed with HP through a multidisciplinary discussion were enrolled. Collected data included demographic and clinical characteristics, laboratory findings, and radiologic and histopathological features. Logistic regression analyses were performed to explore factors related to the presence of fibrosis.@*RESULTS@#A total of 202 patients with HP were enrolled, including 87 (43.1%) NFHP patients and 115 (56.9%) FHP patients. Patients with FHP were older and more frequently presented with dyspnea, crackles, and digital clubbing than patients with NFHP. Serum levels of carcinoembryonic antigen, carbohydrate antigen 125, carbohydrate antigen 153, gastrin-releasing peptide precursor, squamous cell carcinoma antigen, and antigen cytokeratin 21-1, and count of bronchoalveolar lavage (BAL) eosinophils were higher in the FHP group than in the NFHP group. BAL lymphocytosis was present in both groups, but less pronounced in the FHP group. Multivariable regression analyses revealed that older age, <20% of lymphocyte in BAL, and ≥1.75% of eosinophil in BAL were risk factors for the development of FHP. Twelve patients developed adverse outcomes, with a median survival time of 12.5 months, all of whom had FHP.@*CONCLUSIONS@#Older age, <20% of lymphocyte in BAL, and ≥1.75% of eosinophil in BAL were risk factors associated with the development of FHP. Prognosis of patients with NFHP was better than that of patients with FHP. These results may provide insights into the mechanisms of fibrosis in HP.

Diagnóstico de las enfermedades pulmonares intersticiales difusas: estudio del BAL - Su utilidad para el diagnóstico / Diagnosis of Diffuse Interstitial Lung Diseases: BAL Study - Its Utility for the Diagnosis

Resumen Introducción: Las enfermedades pulmonares intersticiales difusas son un grupo heterogéneo de enfermedades respiratorias con difícil diagnóstico. El estudio del lavado broncoalvolar mediante citometría de flujo puede definir patrones celulares típicos en diferentes en fermedades, proporcionando algo de ayuda en el diagnóstico diferencial. El objetivo de este estudio ha sido analizar retrospectivamente la utilidad clínica de las subpoblaciones celulares y linfocitarias detectadas en el lavado broncoalveolar por citometría de flujo, con la finalidad de definir patrones celulares típicos que permitan el diagnóstico diferencial de enfermedades granulomatosas pulmonares. Materiales y métodos: En el estudio se han incluido 44 pacientes retrospectivamente. Los sujetos fueron diagnosticados de sar coidosis o neumonitis por hipersensibilidad durante un periodo de 3 años. Se realizó el análisis celular de lavado broncoalveolar por citometría de flujo, pruebas histológicas y de imagen (TACAR), como parte del diagnóstico. Los porcentajes de células T, células B, células NK, CD4, CD8 y CD4 / CD8 se analizaron por citometría de flujo, a través de los marcadores CD3 +, CD19 + CD4 +, CD8 +, CD3 + CD4-CD8- y CD3 + CD16-CD56-. Resultados: Concluimos que los parámetros de mayor utilidad fueron la linfocitosis y sobre todo, el cociente CD4/CD8. Este cociente se presentó alto en patologías como la sarcoidosis y se invirtió en la neumonitis por hipersensibilidad, con respecto a los valores hallados en sangre periférica. Conclusiones: El estudio de BAL es útil para discriminar entre enfermedades pulmonares intersticiales granulomatosas y otras EPID.

Diagnosis of Diffuse Interstitial Lung Diseases: BAL Study - Its Utility for the Diagnosis

Abstract Introduction: Diffuse interstitial lung diseases are a hard-to-diagnose heterogeneous group of respiratory diseases. The study of bronchoalveolar lavage through flow cytometry may define typical cell patterns in different diseases and so help confirm the differential diagnosis. The purpose of this study was to retrospectively analyze the clinical utility of cell and lymphocyte subpopulations detected in the bronchoalveolar lavage by flow cytometry in order to define typical cell patterns that allow for making a differential diagnosis of granulomatous lung diseases. Materials and methods: The retrospective study included 44 patients. The subjects were diagnosed with sarcoidosis or hypersen sitivity pneumonitis during a period of 3 years. We performed the cellular analysis of bronchoalveolar lavage through flow cytometry and histological and imaging testing (HRCAT, High Resolution Computed Axial Tomography) as part of the diagnosis. The percentages of T cells, B cells, NK cells, CD4, CD8 and CD4/CD8 were analyzed by flow cytometry for the following markers: CD3 +, CD19 + CD4 +, CD8 +, CD3 + CD4-CD8- and CD3 + CD16-CD56-. Results: We conclude that the most important parameters were lymphocytosis and especially the CD4/CD8 quotient. This quotient was high for diseases such as sarcoidosis and low for hypersensitivity pneumonitis, in comparison with the values found in the peripheral blood. Conclusions: The BAL (Bronchoalveolar Lavage) study is useful for differentiating between granulomatous interstitial lung diseases and other DILDs (diffuse interstitial lung diseases).

Carbohydrate antigen 15-3 as a marker of disease severity in patients with chronic hypersensitivity pneumonitis* / Antígeno carboidrato 15-3 como marcador de gravidade da doença em pacientes com pneumonite de hipersensibilidade crônica

ABSTRACT Objective: Biomarkers associated with mucin 1, such as Krebs von den Lungen-6 and carbohydrate antigen (CA) 15-3, are increased in various interstitial lung diseases. Our aim was to determine whether CA 15-3 could be considered a biomarker of disease severity in patients with chronic hypersensitivity pneumonitis (cHP). Methods: This was a prospective observational study involving adult patients with cHP. Serum levels of CA 15-3 were measured and were correlated with variables related to disease severity and extension. HRCT scans were quantitatively analyzed using a computational platform and an image analysis tool (Computer Aided Lung Informatics for Pathology Evaluation and Rating). CA 15-3 levels were normalized by logarithmic transformation. Results: The sample comprised 41 patients. The mean age of the patients was 60.1 ± 11.6 years. The mean FVC in % of predicted was 70.3% ± 17.3%, and the median of the serum level of CA 15-3 was 48.1 U/mL. CA 15-3 levels inversely correlated with FVC in % of predicted (r = −0,30; p = 0,05), DLCO in % of predicted (r = −0,54; p < 0,01), and SpO2 at the end of a 4-min step test (r = −0,59; p < 0,01), but they directly correlated with total quantitative HRCT scores (r = 0,47; p = 0,004), especially regarding ground-glass opacities (r = 0.58; p < 0,001). Conclusions: CA 15-3 is likely to be a biomarker of disease severity of patients with cHP, particularly regarding gas exchange abnormalities.

RESUMO Objetivo: Biomarcadores associados à mucina-1, tais como Krebs von den Lungen-6 e carbohydrate antigen (CA, antígeno carboidrato) 15-3, encontram-se aumentados em diversas doenças pulmonares intersticiais. Nosso objetivo foi determinar se CA 15-3 poderia ser considerado um biomarcador de gravidade de doença em pacientes com pneumonite de hipersensibilidade crônica (PHc). Métodos: Estudo prospectivo observacional envolvendo pacientes adultos com PHc. Os níveis séricos de CA 15-3 foram medidos e correlacionados com variáveis relacionadas à gravidade e extensão da doença. As imagens de TCAR foram analisadas quantitativamente utilizando uma plataforma computacional e uma ferramenta de análise de imagem (Computer-Aided Lung Informatics for Pathology Evaluation and Rating). Os níveis de CA 15-3 foram normalizados por transformação logarítmica. Resultados: A amostra foi composta por 41 pacientes. A média de idade dos pacientes foi de 60,1 ± 11,6 anos. A média da CVF em % do previsto foi de 70,3% ± 17,3%, e a mediana do nível sérico de CA 15-3 foi de 48,1 U/mL. Os níveis de CA 15-3 se correlacionaram inversamente com CVF em % do previsto (r = −0,30; p = 0,05), DLCO em % do previsto (r = −0,54; p < 0,01) e SpO2 ao final de um teste de degrau de 4 minutos (r = −0,59; p < 0,01), mas se correlacionaram diretamente com a pontuação quantitativa total da TCAR (r = 0,47; p = 0,004), especialmente quanto a opacidades em vidro fosco (r = 0,58; p < 0,001). Conclusões: É provável que o CA 15-3 seja um biomarcador de gravidade de doença em pacientes com PHc, particularmente quanto a anormalidades nas trocas gasosas.

Diagnóstico diferencial de la fibrosis pulmonar idiopática / Differential diagnosis of idiopathic pulmonary fibrosis

Para el diagnóstico certero de fibrosis pulmonar idiopática (FPI) es de vital importancia la presencia de un patrón tomográfico definitivo de neumonía intersticial usual (NIU), en un contexto clínico adecuado. El interrogatorio dirigido, el uso de cuestionarios validados, una evaluación reumatológica acuciosa y exámenes complementarios son importantes para descartar causas secundarias de fibrosis pulmonar como neumonitis por hipersensibilidad (NHS), enfermedades del tejido conectivo (ETC), toxicidad por drogas y algunas neumoconiosis que pueden imitar el patrón radiológico y muchas veces dificultar un diagnóstico adecuado de FPI.

For the accurate diagnosis of idiopathic pulmonary fibrosis (IPF), the presence of a definitive tomographic pattern of usual interstitial pneumonia (UIP) is of vital importance, in an appropriate clinical context. Targeted interrogation, the use of valid questionnaires, an acute rheumatologic evaluation and complementary examinations are important to rule out secondary causes such as hypersensitivity pneumonitis (HP), connective tissue diseases (CTD), drug toxicity and some pneumoconiosis that can mimic the radiological pattern and often hinder a clear diagnosis of IPF.

Enfermedades pulmonares intersticiales. Una perspectiva actual / Update on interstitial lung diseases

Interstitial lung diseases are a broad, diverse, challenging group of diseases, most of them chronic whose prognosis is not good. In the last two decades there have been considerable advances in the knowledge of the epidemiology, pathological and genetic bases and treatment of several of these diseases. This article summarizes and presents updated information about their classification, new knowledge on genetics and treatments in idiopathic pulmonary fibrosis, advances in the diagnosis and management of hypersensitivity pneumonitis and a review of the broad spectrum of interstitial diseases associated with connective tissue diseases. Several clinical trials are currently underway whose results will be available in the coming years and will provide more information and tools to improve the treatment of these patients.

Risk Assessment for Metalworking Fluids and Respiratory Outcomes

BACKGROUND: Metalworking fluids (MWFs) are mixtures with inhalation exposures as mists, dusts, and vapors, and dermal exposure in the dispersed and bulk liquid phase. A quantitative risk assessment was performed for exposure to MWF and respiratory disease.METHODS: Risks associated with MWF were derived from published studies and NIOSH Health Hazard Evaluations, and lifetime risks were calculated. The outcomes analyzed included adult onset asthma, hypersensitivity pneumonitis, pulmonary function impairment, and reported symptoms. Incidence rates were compiled or estimated, and annual proportional loss of respiratory capacity was derived from cross-sectional assessments.RESULTS: A strong healthy worker survivor effect was present. New-onset asthma and hypersensitivity pneumonitis, at 0.1 mg/m3 MWF under continuous outbreak conditions, had a lifetime risk of 45%; if the associated microbiological conditions occur with only 5% prevalence, then the lifetime risk would be about 3%. At 0.1 mg/m3, the estimate of excess lifetime risk of attributable pulmonary impairment was 0.25%, which may have been underestimated by a factor of 5 or more by a strong healthy worker survivor effect. The symptom prevalence associated with respiratory impairment at 0.1 mg/m3 MWF was estimated to be 5% (published studies) and 21% (Health Hazard Evaluations).CONCLUSION: Significant risks of impairment and chronic disease occurred at 0.1 mg/m3 for MWFs in use mostly before 2000. Evolving MWFs contain new ingredients with uncharacterized long-term hazards.

Neumonitis por hipersensibilidad: Reporte de dos casos clínicos / Hypersensitivity pneumonitis: Report of two clinical cases

La neumonitis por hipersensibilidad (NH), también conocida como alveolitis alérgica extrínseca, es una enfermedad pulmonar inflamatoria poco común, con síntomas sistémicos, producto de inhalación reiterada y sensibilización por partículas aéreas antigénicas1. La primera mención de la enfermedad se atribuye a Bernardino Ramazzini, quien en 1700 publicó un libro sobre enfermedades profesionales en el que describió una enfermedad respiratoria característica de manipuladores de granos. Posteriormente, el término "pulmón del granjero" fue acuñado por Pepys y colaboradores como un prototipo de neumonitis por hipersensibilidad2. Las personas que presentan neumonitis por hipersensibilidad generalmente están expuestas a los antígenos en el hogar o en el trabajo y existe una susceptibilidad genética a desarrollar la enfermedad. En este artículo se informan dos casos de neumonitis por hipersensibilidad en la ciudad de Cali, Colombia, relacionados con exposición a antígenos en el hogar, nexo epidemiológico establecido a partir de la convivencia con aves y confirmado por hallazgos en la biopsia pulmonar

Características clínicas, funcionais e sobrevida dos pacientes com pneumonia de hipersensibilidade do Ambulatório de Doenças Pulmonares Intersticiais do Hospital das Clinicas da Universidade Federal de Minas Gerais (HC-UFMG) / Clinical, functional and survival in patients with hypersensitivity pneumonia Center of Pulmonary Interstitial Disease of Hospital das Clínicas da Universidade Federal de Minas Gerais (HC- UFMG)

A pneumonia de hipersensibilidade (PH) constitui síndrome inflamatória causada pela resposta imune exagerada a partículas antigênicas inaladas. Objetivo: descrever características clínicas, radiológicas, funcionais esobrevida de pacientes com PH. Metodologia: estudo retrospectivo, envolvendo pacientes em acompanhamento no ambulatório de doenças pulmonares intersticiais do HC-UFMG no período de 2011 a 2015. Analisados dados clínicos, radiológicos, funcionais e morfológicos coletados através de um protocolo padronizado. Resultados: Dentre 139 pacientes com doenças intersticiais pulmonares, 34 (24%) tinham PH, com idade de 60,7 ± 18,1 anos. Exposição a mofo foi a etiologia mais frequente (19;55%). A forma crônica foi predominante (100% doas casos), assim como a presença de padrão reticular na tomografia de tórax (100%), com ou sem faveolamento. Observou-se distúrbio restritivo leve (CVF=69,00 ± 17,62L) associado a redução moderada da difusão de monóxido de carbono (59,20 ± 16,99%). O lavado broncoalveolar não auxiliou no diagnóstico e a biópsia transbrônquica foi diagnóstica em 5 (55%) casos e a biópsia cirúrgica foi conclusiva em 6 (85,7%). A sobrevida mediana foi de 75 meses. Conclusão: Nesta amostra de um ambulatório de referência, a PH respondeu por cerca de um quarto dos pacientes com doença intersticial pulmonar. A exposição a mofo foi a principal etiologia e a mortalidade significativa, o que reforça a importância da adoção de medidas preventivas através do reconhecimento precoce da exposição aos fatores de risco. (AU)

Hypersensitivity pneumonitis (HP) inflammatory is a syndrome caused by an excessive immune response to inhaled antigen particles. Objective:To describe clinical, radiological and functional characteristics and survival in patients with HP. Methodology: Retrospective study involving patients followed up at the pulmonary interstitial diseases clinic of the HC-UFMG from 2011 to 2015. Clinical, radiological, functional and morphological data were analysed from a standardized protocol. Results: Among 139 patients with interstitial lung disease, 34 (24%) had HP, aged 60.7 ± 18.1 years. Mold exposure was the most frequent cause (19; 55%). The chronic form predominated (100% donate cases), as well as the presence of reticular pattern on the chest tomography (100%), with or without honeycombing. There was mild restrictive lung disease (FVC = 69.00 ± 17,62L) associated with moderate reduction in carbon monoxide diffusion (59.20 ± 16.99%). Bronchoalveolar lavage did not help in the diagnosis and transbronchial biopsy was diagnostic in 5 (55%) cases; surgical biopsy was conclusive in 6 (85.7%). Median survival was 60 months. Conclusion: In this sample of a reference clinic, HP accounted for about a quarter of the patients with interstitial lung disease. The mold exposure was the main etiology and the mortality rate was significant, what reinforces the importance of adopting preventive measures through early recognition of exposure to risk factors. (AU)

Neumonitis por hipersensibilidad: Serie de nueve casos con biopsia pulmonar quirúrgica / Hypersensitivity pneumonitis. A series of nine cases with surgical lung biopsy

En una serie de nueve pacientes con diagnóstico histopatológico de neumonitis por hipersensibilidad, se revisaron en forma retrospectiva la historia clínica, los factores de exposición, las pruebas de función pulmonar y las tomografías computarizadas de tórax. La función pulmonar evidenció principalmente compromiso restrictivo con disminución de la difusión de monóxido de carbono. Las tomografías de tórax mostraron patrones fibróticos en la mayoría de los casos; áreas de vidrio esmerilado con patrón en mosaico y áreas de consolidación en el resto. Pudo detectarse exposición a antígenos aviarios, granos de cereales y acondicionadores de aire contaminados con esporas de hongos y bacterias, en dos tercios de los casos. Dado que no existen características únicas que permitan diferenciar la neumonitis por hipersensibilidad de otras enfermedades del intersticio pulmonar, se requiere de un alto índice de sospecha clínica y de una detallada búsqueda de exposición ambiental que deberán complementarse con los datos clínicos, radiológicos y de anatomía patológica para llegar al diagnóstico.

In a series of nine patients with histopathological diagnosis of hypersensitivity pneumonitis, we retrospectively evaluated clinical data, exposure related factors, pulmonary function tests and chest computed tomography scans. A restrictive abnormality with reduction of diffusion capacity for carbon monoxide was mainly found. Chest scans showed fibrotic patterns in most cases; ground glass attenuation areas with mosaic pattern and consolidation in the rest. Exposure to avian antigens, cereal grains and air conditioners contaminated with fungi yeasts and bacteria, were suspected from clinical data in two-thirds of the cases. Since there are no unique features that allow differentiation from other interstitial lung diseases, a high clinical suspicion is required and a careful search of environmental exposure to possible antigens is needed that, together with clinical, radiological and pathological data, may lead to diagnosis.

Pleuroparenchymal fibroelastosis: report of two cases in Brazil / Fibroelastose pleuroparenquimatosa: relato de dois casos no Brasil

ABSTRACT Pleuroparenchymal fibroelastosis (PPFE) is a rare lung disease. It can be idiopathic or associated with any one of various conditions. To our knowledge, this is the first report of two cases of PPFE in Brazil. Our first patient presented with pleural and subpleural fibrosis in the upper lobes; a spiculated nodule in the left upper lobe; and a mild reticular pattern in the lower lobes. Surgical lung biopsy revealed PPFE in the upper lobes, including the nodule, and unclassified interstitial pneumonia in the left lower lobe. Our second patient had a history of exposure to domestic birds, indicating a risk of hypersensitivity pneumonitis, and presented with advanced lung disease, predominantly in the upper lobes, together with subpleural fibrosis.That patient underwent lung transplantation. In the explant specimen, PPFE and granulomas were identified, suggesting hypersensitivity pneumonitis as an associated cause.

RESUMO A fibroelastose pleuroparenquimatosa (FEPP) é uma doença pulmonar rara, podendo ser idiopática ou associada a diversas condições. Pelo que sabemos, este é o primeiro relato de dois casos de FEPP no Brasil. Nosso primeiro paciente apresentava fibrose pleural e subpleural nos lobos superiores, um nódulo espiculado no lobo superior esquerdo e um padrão reticular discreto nos lobos inferiores. A biópsia pulmonar cirúrgica demonstrou FEPP nos lobos superiores, incluindo no nódulo, e pneumonia intersticial não classificada no lobo inferior esquerdo. Nosso segundo paciente tinha história de exposição a aves domésticas, indicando um risco de pneumonite de hipersensibilidade, e doença pulmonar avançada predominando em lobos superiores, com fibrose subpleural. Esse paciente foi submetido a transplante pulmonar. No espécime do explante, FEPP e granulomas foram identificados, sugerindo pneumonite de hipersensibilidade como causa associada.

Evaluation of CD3+CD4-CD8- (Double-negative) T Cells in Bronchoalveolar Lavage Fluid: an Effective Tool for Pulmonary Disease Diagnosis

BACKGROUND: Cellular analysis of bronchoalveolar lavage fluid (BALF) is a useful diagnostic tool for interstitial lung diseases (ILDs). The lymphocytes in BALF consist of CD3+CD4+ T cells (T4), CD3+CD8+ T cells (T8), and a few B cells. However, sometimes, an increased number of CD3+CD4-CD8- T cells (double-negative T cells, DNTs) are noted in BALF. It is known that DNTs in the blood are associated with immunoregulation and autoimmune diseases. However, there are only few studies on DNTs in BALF. We evaluated the DNTs in BALF in patients with pulmonary diseases. METHODS: Immunophenotyping results of the BALF obtained from 122 pulmonary disease patients over an 8-yr period were reviewed. T-lymphocyte subsets (T4, T8, and DNT) and inflammatory markers were analyzed for each group of clinical diagnosis. T-lymphocyte percentage of more than 15% of the total cells was defined as BALF lymphocytosis, and DNT percentage of more than 5% of T lymphocytes was defined as high DNT. RESULTS: The most frequent diseases found in the patients were pneumonia (31.6%), autoimmune-related ILDs (18.0%), hypersensitivity pneumonitis (10.7%), and organizing pneumonia (10.7%). However, the occurrence of autoimmune-related ILDs was significantly high (40%) in patients with lymphocytosis and high DNT (P=0.002). All lung cancer patients showed lymphocytosis with high DNT. In addition, CD3-signal intensities of DNTs were significantly higher than those of other T-lymphocyte subtypes (P=0.003). CONCLUSION: The number of DNTs in BALF was increased in patients with autoimmune-related ILDs and lung cancer. High DNTs in BALF are useful as supportive diagnostic tools for autoimmune-related ILDs.

A Suspected Case of Cutaneous Mycobacterium immunogenum Infection / 나학회지

M. immunogenum was identified as the etiologic agent of a variety of hospital-acquired infections, including an outbreak of keratitis, and as the potential cause of hypersensitivity pneumonitis in industrial metal-grinding machinists. This microorganism appears to differ from other members of the M. chelonae?abscessus group. Clinically significant isolates have been recovered from skin lesions, corneal ulcers, joint fluid, central venous catheter sites, and blood. There have been some cases of M. immunogenum skin infection reported. We report a suspected case of cutaneous Mycobacterium immunogenum infection in a 23-year-old male, migrant Workers from Sri Lanka, who presented with an erythematous plaque on his right ear. M. immunogenum was suspected by PCR-restriction fragment length polymorphism & sequencing of PCR product. The patient was treated with clarithromycin & ofloxacin. The lesion started to improve 4 weeks after initiation of the therapy. We have the patient in therapy for 3 months, and the lesion is slowing disappeared.

Hypersensitivity Pneumonitis Caused by Cephalosporins With Identical R1 Side Chains

Drug-induced hypersensitivity pneumonitis results from interactions between pharmacologic agents and the human immune system. We describe a 54-year-old man with hypersensitivity pneumonitis caused by cephalosporins with identical R1 side chains. The patient, who complained of cough with sputum, was prescribed ceftriaxone and clarithromycin at a local clinic. The following day, he complained of dyspnea, and chest X-ray revealed worsening of inflammation. Upon admission to our hospital, antibiotics were changed to cefepime with levofloxacin, but his pneumonia appeared to progress. Changing antibiotics to meropenem with ciprofloxacin improved his symptoms and radiologic findings. Antibiotics were de-escalated to ceftazidime with levofloxacin, and his condition improved. During later treatment, he was mistakenly prescribed cefotaxime, which led to nausea, vomiting, dyspnea and fever, and indications of pneumonitis on chest X-ray. We performed bronchoalveolar lavage, and the findings included lymphocytosis (23%), eosinophilia (17%), and a low cluster of differentiation (CD) 4 to CD8 ratio (0.1), informing a diagnosis of drug-induced pneumonitis. After a medication change, his symptoms improved and he was discharged. One year later, he was hospitalized for acute respiratory distress syndrome following treatment with ceftriaxone and aminoglycosides for an upper respiratory tract infection. After steroid therapy, he recovered completely. In this patient, hypersensitivity reaction in the lungs was caused by ceftriaxone, cefotaxime, and cefepime, but not by ceftazidime, indicating that the patient's hypersensitivity pneumonitis was to the common R1 side chain of the cephalosporins.

The value of family history in the diagnosis of hypersensitivity pneumonitis in children / O valor da história familiar no diagnóstico de pneumonite de hipersensibilidade em crianças

Hypersensitivity pneumonitis (HP), or extrinsic allergic alveolitis, is an immunologically mediated disease resulting from the inhalation of organic substances that trigger an inflammatory response in the alveolar wall, bronchioles, and interstitium in susceptible individuals. Although HP is predominantly an occupational disease, seen in adulthood, cases in children have been described. The diagnosis of HP requires a high degree of suspicion. The treatment consists in avoiding contact with the antigen, and, in some cases, systemic corticosteroids might be necessary in order to prevent its progression to pulmonary fibrosis. We report the clinical cases of three children with a history of contact with birds and a family history of HP. All three patients presented with cough and dyspnea on exertion. The disease was diagnosed on the basis of the clinical history and ancillary diagnostic test results consistent with the diagnosis, including a predominance of lymphocytes (> 60%, CD8+ T lymphocytes in particular) in bronchoalveolar lavage fluid and a ground-glass pattern seen on HRCT of the chest. Early diagnosis is crucial in order to prevent HP from progressing to pulmonary fibrosis. Hereditary factors seem to influence the onset of the disease.

A pneumonite de hipersensibilidade (PH), ou alveolite alérgica extrínseca, é uma doença imunologicamente mediada, resultante da inalação de substâncias orgânicas que desencadeiam uma reação inflamatória na parede dos alvéolos, bronquíolos e interstício em indivíduos susceptíveis. Apesar de ser uma doença ocupacional de predomínio na idade adulta, estão descritos casos em crianças. O diagnóstico de PH requer grande suspeição, e seu tratamento consiste na ausência de contato com o antígeno e, em alguns casos, pode ser necessária corticoterapia sistêmica, evitando-se a progressão para fibrose pulmonar. Relatamos três casos clínicos de crianças com história de contato com aves e história familiar de PH. Todos os casos se apresentaram com tosse e dispneia aos esforços. O diagnóstico foi possível por história clínica e exames auxiliares de diagnóstico compatíveis, incluindo lavado broncoalveolar com predomínio de linfócitos (> 60%, especialmente linfócitos T CD8+) e TCAR de tórax com padrão em vidro fosco. O diagnóstico precoce é fundamental na PH para se prevenir a evolução para fibrose pulmonar. Fatores hereditários parecem influenciar seu aparecimento.

Workers' Compensation for Occupational Respiratory Diseases

The respiratory system is one of the most important body systems particularly from the viewpoint of occupational medicine because it is the major route of occupational exposure. In 2013, there were significant changes in the specific criteria for the recognition of occupational diseases, which were established by the Enforcement Decree of the Industrial Accident Compensation Insurance Act (IACIA). In this article, the authors deal with the former criteria, implications of the revision, and changes in the specific criteria in Korea by focusing on the 2013 amendment to the IACIA. Before the 2013 amendment to the IACIA, occupational respiratory disease was not a category because the previous criteria were based on specific hazardous agents and their health effects. Workers as well as clinicians were not familiar with the agent-based criteria. To improve these criteria, a system-based structure was added. Through these changes, in the current criteria, 33 types of agents and 11 types of respiratory diseases are listed under diseases of the respiratory system. In the current criteria, there are no concrete guidelines for evaluating work-relatedness, such as estimating the exposure level, latent period, and detailed examination methods. The results of further studies can support the formulation of detailed criteria.

A Case of Cutaneous Infection by Alternaria alternata / 대한의진균학회지

Alternaria(A.) species are common saprophyte found in the environment such as soil, air, and plants. They are not usually pathogenic in humans but recently, infections by these fungi have occasionally been reported, occurring mostly in immunocompromised patients. They can cause hypersensitivity pneumonitis, bronchial asthma, or allergic rhinitis and rarely skin infection. A 76-year-old man presented with multiple erythematous papules, plaque and pustules with purpuric patches on both forearms and dorsal hands for 6 months. He had been treated for Parkinson's disease and dementia for 3 years but had not been taking any immunosuppressants. Direct smear with KOH was negative. Histopatholoigically, neutrophilic abscess, suppurative granulomatous inflammation and round spores were observed in the dermis. Periodic acid-Schiff and Methenamine silver stains revealed round to oval shaped spores. The biopsy specimen was cultured in potato dextrose agar and a cottony olive green to gray colored colony with black to brown reverse grew at 7 days of culture. The slide culture stained with lactophenol-cotton blue showed brown septated hyphae and obclavate conidia with brown muriform septation. The nucleotide sequences of the ribosomal internal transcribed spacer region of cultured colonies and paraffin blocks of biopsy specimen were identical to that of A. alternata. He was treated with topical ketoconazole cream application for 4 months, and healed leaving hyperpigmentation with scales.

A Case of Occupational Hypersensitivity Pneumonitis Associated with Trichloroethylene / 결핵및호흡기질환

Trichloroethylene (TCE) is a toxic chemical commonly used as a degreasing agent, and it is usually found in a colorless or blue liquid form. TCE has a sweet, chloroform-like odor, and this volatile chlorinated organic chemical can cause toxic hepatitis, neurophysiological disorders, skin disorders, and hypersensitivity syndromes. However, the hypersensitivity pneumonitis (HP) attributed to TCE has rarely been reported. We hereby describe a case of HP associated with TCE in a 29-year-old man who was employed as a lead welder at a computer repair center. He was installing the capacitors on computer chip boards and had been wiped down with TCE. He was admitted to our hospital with complaints of dry coughs, night sweats, and weight losses for the past two months. HP due to TCE exposure was being suspected due to his occupational history, and the results of a video-associated thoracoscopic biopsy confirmed the suspicions. Symptoms have resolved after the steroid pulse therapy and his occupational change. TCE should be taken into consideration as a potential trigger of HP. Early recognition and avoidance of the TCE exposure in the future is important for the treatment of TCE induced HP.

A Case of Venlafaxine-Induced Interstitial Lung Disease / 결핵및호흡기질환

A patient treated with venlafaxine for major depression developed an interstitial lung disease (ILD) with the characteristic clinical, radiological and pathological features of chronic hypersensitivity pneumonitis. A high resolution computed tomography scan demonstrated ground glass opacity, mosaic perfusion with air-trapping and traction bronchiectasis in both lungs. The pathological findings were consistent with a nonspecific interstitial pneumonia pattern. Clinical and radiological improvements were noted after the discontinuation of venlafaxine and the administration of a corticosteroid. This report provides further evidence that the anti-depressant venlafaxine can cause ILD.