Pediatric Hypersensitivity Pneumonitis Clinical Presentation

  • Author: Harold J Farber, MD; Chief Editor: Michael R Bye, MD   more...
 
Updated: Mar 1, 2010
 

History

A comprehensive environmental history and high index of suspicion are critical for diagnosis. Hypersensitivity pneumonitis (HP) should be considered in patients with chronic or recurrent cough, shortness of breath, or a history of recurrent acute respiratory symptoms without definite infectious triggers.

Inquire about specific exposures; the patient may not volunteer them. Because bird fancier’s lung is the most common hypersensitivity pneumonitis in children, a specific inquiry must be made about bird exposure. Contact may not necessarily be in the home and may not be obvious. Exposures in or near the home, at school, as a part of hobbies, at the place of employment, or anywhere else the child spends time must be explored. Repeated questioning, home inspection, and/or inspection of sites where the child spends time may be needed to identify the causative antigen.

Clues that suggest the diagnosis of hypersensitivity pneumonitis are as follows:

  • History of recurrent pneumonia, particularly with regularity or a pattern
  • Other people at home or school who have similar symptoms
  • Development of respiratory symptoms after the patient moves to a new home or new school
  • Improvement of symptoms when the patient is away from home or school for an extended period
  • Contact with birds
  • Water damage to the patient's home or school facility
  • Use of a hot tub, sauna, or swimming pool

The key to diagnosing hypersensitivity pneumonitis lies in a detailed history. The clinician has to maintain a high index of suspicion. Reaching the diagnosis can be difficult because symptoms are often nonspecific and the available diagnostic tests are imperfect. Taking appropriate, effective action to eliminate the inciting exposure can prevent substantial pulmonary morbidity and mortality.

A multicenter study was designed to derive and validate a clinical prediction rule in adult patients who presented with a pulmonary condition for which hypersensitivity pneumonitis was in the differential diagnosis. The study noted 6 significant predictors of a final diagnosis of hypersensitivity pneumonitis, as follows:[27]

  • Exposure to a known offending antigen
  • Positive precipitating antibodies to the offending antigen
  • Recurrent episodes of symptoms
  • Inspiratory crackles upon physical examination
  • Symptoms occurring 4-8 hours after exposure
  • Weight loss

Although the associated probabilities of hypersensitivity pneumonitis from these predictors cannot be generalized to children who have a different spectrum of illnesses, they are useful questions to incorporate into the history.

Manifestations of hypersensitivity pneumonitis are classified as acute, subacute, or chronic. These classifications should be considered as points along a spectrum of illness rather than clearly delineated, discrete types of illness.[28] This classification is based on clinical presentation, not histopathology. In patients with acute disease, a temporal relation between the respiratory symptoms and antigenic exposure can usually be identified. In cases of subacute or chronic exposure, the association between antigenic exposure and development of disease may not be obvious.

Next

Physical

Acute hypersensitivity pneumonitis is characterized by the abrupt onset (4-6 h after exposure) of fever, chills, malaise, nausea, dry cough, chest tightness, and dyspnea. Physical examination may reveal tachypnea and fine crackles localized to the lung bases; wheezing is unusual. The presentation is easily confused with that of an infectious pneumonia. Removal from exposure usually results in resolution of symptoms within hours to days.

Subacute hypersensitivity pneumonitis is characterized by the gradual development of productive cough, dyspnea, fatigue, anorexia, weight loss, and low-grade fever. Physical examination and chest auscultation may reveal tachypnea and diffuse crackles. In patients with very severe disease, cyanosis may be present.[1] Resolution of disease may take weeks to months after removal from exposure.

Chronic hypersensitivity pneumonitis may be difficult to diagnose in its early stages. A chronic cough with normal physical examination findings may be the first presentation. Over time, the disease may progress to dyspnea, fatigue, weight loss, and exercise intolerance. Auscultation of the chest may reveal crackles. An “inspiratory squawk” or “chirping rales” have been described.[29, 30] Digital clubbing may be seen in the advanced stages of the disease.

Previous
Next

Causes

Types and causes of hypersensitivity pneumonitis in children

A wide spectrum of respirable antigens can trigger hypersensitivity pneumonitis, including avian antigens, rodent antigens, fungi, bacteria, and low molecular weight chemicals. Fungal spores can be present wherever sufficient humidity is present; for example, in piles of moldy hay (farmer's lung), in mold-contaminated ventilation systems (humidifier lung), or in old homes seasonally contaminated by mold (summer-type pneumonitis).[5, 31] Mycobacterial antigens aerosolized by the mist that surrounds an operating hot tub can cause hypersensitivity pneumonitis, colorfully described as hot-tub lung.

Table 1. Commonly Described Causes of Hypersensitivity Pneumonitis[32] (Open Table in a new window)

Exposure Disease Source of Antigen
AvianBird fancier's lung, pigeon breeder's lung, poultry worker's lungFeathers, droppings, serum proteins, intestinal mucins, avian immunoglobulin A
AgricultureFarmer's lung, Bagasse (sugar cane) lung, mushroom worker's lung, potato riddler's lung, paprika slicer's lung, wine maker's lung Thermophilic actinomycetes, Aspergillus species, and other fungi in moldy hay or grains; moldy sugar cane; mushroom spores and thermophilic actinomycetes; moldy hay around potatoes, thermophilic actinomycetes, and others; Mucor stolonifer (on moldy paprika pods); B cinerea (noble rot on grapes)
Water-based systemsHumidifier lung, hot-tub lung, sauna taker's lung, lifeguard's lung, sewage pneumonitisAerosolized molds, endotoxins, mycobacteria, thermophilic actinomycetes, Penicillium species, others
Home environmentSummer-type pneumonitis, mold-contaminated walls, humidifiers, wallpaperTrichosporon species, mold contamination in older and/or water-damaged homes
ChemicalsChemical worker's lung, epoxy-resin lung, pyrethrum pneumonitisExposure to chemicals in manufacturing, laboratories, spray paints, heated epoxy resins, insecticides

The most common type of hypersensitivity pneumonitis in children is bird fancier's lung. Most often, the contact is with identified household pets, but, in many cases, the contact may be less obvious. hypersensitivity pneumonitis has been reported after bird exposure from parental hobbies or occupations, including parental pigeon breeding,[33] pheasant raising,[34] and working on a turkey farm.[35]

Relevant exposures may be from nearby bird activity, with reported cases of hypersensitivity pneumonitis resulting from birds congregating by a backyard pool,[33] goose droppings tracked inside from a contaminated outdoor environment,[36] wild city pigeons nesting just outside the home,[37] birds nesting near the air intake of an air-conditioning system,[38] and neighbors engaged in bird breeding.[39] Live birds are not necessary to cause bird fancier's lung. Exposure to avian antigens from a feather duvet (feather duvet lung) has been linked to hypersensitivity pneumonitis.[40, 41]

Exposure to mold–contaminated moist organic material is a frequent cause of hypersensitivity pneumonitis. Farmer's lung has been reported among children living on farms, especially in children exposed to moist or moldy hay or grains.[42, 43] Summer-type pneumonitis is classically described in the mid and southern parts of Japan, although not exclusively, with onset during summer, resolution by mid autumn, and recurrence the following summer. It is caused by fungal growth (Trichosporon cutaneum) in older wooden homes stimulated by warm, moist summers.[31, 44, 45]

Sources of mold in the child's environment may not be obvious. A compost heap in a play area caused hypersensitivity pneumonitis in one child.[46] Hypersensitivity pneumonitis was diagnosed in a child exposed to moldy hay at a horseback-riding school.[47] A familial cluster of chronic hypersensitivity pneumonitis was caused by mold that collected behind torn wallpaper and beneath worn carpets.[48] Mold that contaminated a basement shower was identified as the cause of hypersensitivity pneumonitis in several children.[49]

Wherever aerosolized water is present, hypersensitivity pneumonitis can occur. Mold contamination of humidifiers has led to the disease in adults and children.[50, 51] A central humidification system that nebulized water into the heating system caused a cluster of hypersensitivity pneumonitis cases in a family.[50] Aerosolized endotoxin generated from a water spray in an indoor swimming pool has been implicated in lifeguard's lung.[52] Hot-tub lung is believed to be a hypersensitivity reaction to contamination of hot-tub water by Mycobacterium avium intracellulare complex or mold in a hot tub.[53, 54] One case report described antibody-confirmed chronic hypersensitivity pneumonitis to Aureobasidium pullulans, a fungus associated with indoor hydroponics, in a 14 year-old girl. Her lung function normalized after removal of the hydroponics from the home.[55]

Low molecular weight chemicals, such as isocyanates (eg, in spray paint and glue), phthalic anhydride (in epoxy resin), and pyrethrum (an insecticide), are thought to cause hypersensitivity pneumonitis by combining with human proteins to form complete antigens.[56]

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Harold J Farber, MD  Associate Professor, Section of Pediatric Pulmonology, Baylor College of Medicine, Texas Children's Hospital

Harold J Farber, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nidhy Paulose Varghese, MD  Assistant Professor of Pediatrics, Division of Pulmonology, Baylor College of Medicine, Texas Children's Hospital

Disclosure: Nothing to disclose.

Bettina C Hilman, MD  Consulting Staff, The Asthma and Allergy Center

Bettina C Hilman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Chest Physicians, American Heart Association, American Medical Association, American Pediatric Society, American Thoracic Society, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Girish D Sharma, MD  Associate Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush University Medical Center

Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Charles Callahan, DO  Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

References

  1. Krasnick J, Patterson R, Stillwell PC, Basaran MG, Walker LH, Kishore R. Potentially fatal hypersensitivity pneumonitis in a child. Clin Pediatr (Phila). Jul 1995;34(7):388-91. [Medline].

  2. Farber HJ, Budson D. A pediatric case of severe chronic interstitial lung disease presenting as spontaneous pneumothorax: blame it on the birds. Pediatr Asthma Allergy Immunol. 2000;14(1):75-85.

  3. Vergesslich KA, Gotz M, Kraft D. [Bird breeder's lung with conversion to fatal fibrosing alveolitis]. Dtsch Med Wochenschr. Aug 19 1983;108(33):1238-42. [Medline].

  4. King TE. Epidemiology and causes of hypersensitivity pneumonitis (extrinsic allergic alveolitis) 2005. Up to Date. Available at http://www.uptodate.com/. Accessed January 30, 2006.

  5. Selman M. Hypersensitivity pneumonitis: a multifaceted deceiving disorder. Clin Chest Med. Sep 2004;25(3):531-47, vi. [Medline].

  6. Lacasse Y, Assayag E, Cormier Y. Myths and controversies in hypersensitivity pneumonitis. Semin Respir Crit Care Med. Dec 2008;29(6):631-42. [Medline].

  7. Korosec P, Osolnik K, Kern I, Silar M, Mohorcic K, Kosnik M. Expansion of pulmonary CD8+CD56+ natural killer T-cells in hypersensitivity pneumonitis. Chest. Oct 2007;132(4):1291-7. [Medline].

  8. Korosec P, Osolnik K, Kern I, Silar M, Mohorcic K, Kosnik M. Expansion of pulmonary CD8+CD56+ natural killer T-cells in hypersensitivity pneumonitis. Chest. Oct 2007;132(4):1291-7. [Medline].

  9. Kronenberg M, Gapin L. The unconventional lifestyle of NKT cells. Nat Rev Immunol. Aug 2002;2(8):557-68. [Medline].

  10. Vourlekis JS, Schwarz MI, Cool CD, Tuder RM, King TE, Brown KK. Nonspecific interstitial pneumonitis as the sole histologic expression of hypersensitivity pneumonitis. Am J Med. Apr 15 2002;112(6):490-3. [Medline].

  11. Gudmundsson G, Monick MM, Hunninghake GW. Viral infection modulates expression of hypersensitivity pneumonitis. J Immunol. Jun 15 1999;162(12):7397-401. [Medline].

  12. Denis M. Proinflammatory cytokines in hypersensitivity pneumonitis. Am J Respir Crit Care Med. Jan 1995;151(1):164-9. [Medline].

  13. Mroz RM, Korniluk M, Stasiak-Barmuta A, Chyczewska E. Upregulation of Th1 cytokine profile in bronchoalveolar lavage fluid of patients with hypersensitivity pneumonitis. J Physiol Pharmacol. Dec 2008;59 Suppl 6:499-505. [Medline].

  14. Ye Q, Nakamura S, Sarria R, Costabel U, Guzman J. Interleukin 12, interleukin 18, and tumor necrosis factor alpha release by alveolar macrophages: acute and chronic hypersensitivity pneumonitis. Ann Allergy Asthma Immunol. Feb 2009;102(2):149-54. [Medline].

  15. Schaaf BM, Seitzer U, Pravica V, Aries SP, Zabel P. Tumor necrosis factor-alpha -308 promoter gene polymorphism and increased tumor necrosis factor serum bioactivity in farmer's lung patients. Am J Respir Crit Care Med. Feb 2001;163(2):379-82. [Medline].

  16. Gudmundsson G, Hunninghake GW. Interferon-gamma is necessary for the expression of hypersensitivity pneumonitis. J Clin Invest. May 15 1997;99(10):2386-90. [Medline].

  17. Arima K, Ando M, Ito K, et al. Effect of cigarette smoking on prevalence of summer-type hypersensitivity pneumonitis caused by Trichosporon cutaneum. Arch Environ Health. Jul-Aug 1992;47(4):274-8. [Medline].

  18. Cormier Y, Israel-Assayag E, Bedard G, Duchaine C. Hypersensitivity pneumonitis in peat moss processing plant workers. Am J Respir Crit Care Med. Aug 1998;158(2):412-7. [Medline].

  19. Blanchet MR, Israël-Assayag E, Cormier Y. Inhibitory effect of nicotine on experimental hypersensitivity pneumonitis in vivo and in vitro. Am J Respir Crit Care Med. Apr 15 2004;169(8):903-9. [Medline].

  20. Dangman KH, Storey E, Schenck P, Hodgson MJ. Effects of cigarette smoking on diagnostic tests for work-related hypersensitivity pneumonitis: data from an outbreak of lung disease in metalworkers. Am J Ind Med. May 2004;45(5):455-67. [Medline].

  21. Ohtsuka Y, Munakata M, Tanimura K, Ukita H, Kusaka H, Masaki Y. Smoking promotes insidious and chronic farmer's lung disease, and deteriorates the clinical outcome. Intern Med. Oct 1995;34(10):966-71. [Medline].

  22. Diaz de la Vega V, Bialostosky D, Lupi E, Castro G, Barrios R, Reyes PA. Familial pigeon breeder's disease. Possible association to HLA-Bw40 antigen. Rev Invest Clin. Oct-Dec 1980;32(4):401-7. [Medline].

  23. Muers MF, Faux JA, Ting A, Morris PJ. HLA-A, B, C and HLA-DR antigens in extrinsic allergic alveolitis (budgerigar fancier's lung disease). Clin Allergy. Jan 1982;12(1):47-53. [Medline].

  24. Rittner C, Sennekamp J, Mollenhauer E, et al. Pigeon breeder's lung: association with HLA-DR 3. Tissue Antigens. May 1983;21(5):374-9. [Medline].

  25. Gudmundsson G, Hunninghake GW. Respiratory epithelial cells release interleukin-8 in response to a thermophilic bacteria that causes hypersensitivity pneumonitis. Exp Lung Res. Apr-May 1999;25(3):217-28. [Medline].

  26. Perez-Padilla R, Salas J, Chapela R, et al. Mortality in Mexican patients with chronic pigeon breeder's lung compared with those with usual interstitial pneumonia. Am Rev Respir Dis. Jul 1993;148(1):49-53. [Medline].

  27. [Guideline] Lacasse Y, Selman M, Costabel U, et al. HP Study Group. Clinical diagnosis of hypersensitivity pneumonitis. Am J Respir Crit Care Med. Oct 15 2003;168(8):952-8.

  28. King TE. Classification and clinical manifestations of hypersensitivity pneumonitis. in UpToDate, Waltham MA. Available at http://www.uptodate.com/. Accessed August 9, 2009.

  29. Earis JE, Marsh K, Pearson MG, Ogilvie CM. The inspiratory "squawk" in extrinsic allergic alveolitis and other pulmonary fibroses. Thorax. Dec 1982;37(12):923-6. [Medline].

  30. Reich JM. Chirping rales in bird-fancier's lung. Chest. Jul 1993;104(1):326-7. [Medline].

  31. Ando M, Suga M, Nishiura Y, Miyajima M. Summer-type hypersensitivity pneumonitis. Intern Med. Aug 1995;34(8):707-12. [Medline].

  32. Wild LG, Lopez M. Hypersensitivity pneumonitis: a comprehensive review. J Investig Allergol Clin Immunol. 2001;11(1):3-15. [Medline].

  33. Yee WF, Castile RG, Cooper A, Roberts M, Patterson R. Diagnosing bird fancier's disease in children. Pediatrics. May 1990;85(5):848-52. [Medline].

  34. Levenson T, Patterson R. Chronic cough in a child. Ann Allergy Asthma Immunol. Apr 1996;76(4):311-6. [Medline].

  35. Boyer RS, Klock LE, Schmidt CD, Hyland L, Maxwell K, Gardner RM. Hypersensitivity lung disease in the turkey raising industry. Am Rev Respir Dis. Jun 1974;109(6):630-5. [Medline].

  36. Saltoun CA, Harris KE, Mathisen TL, Patterson R. Hypersensitivity pneumonitis resulting from community exposure to Canada goose droppings: when an external environmental antigen becomes an indoor environmental antigen. Ann Allergy Asthma Immunol. Jan 2000;84(1):84-6. [Medline].

  37. du Marchie Sarvaas GJ, Merkus PJ, de Jongste JC. A family with extrinsic allergic alveolitis caused by wild city pigeons: A case report. Pediatrics. May 2000;105(5):E62. [Medline].

  38. Bahna SL. A custodian cured the doctor!. Pediatrics. May 2000;105(5):E71. [Medline].

  39. Karakurum M, Doraswamy B, Bennuri SS. Index of suspicion. Case 1. Hypersensitivity pneumonitis. Pediatr Rev. Feb 1999;20(2):53-4. [Medline].

  40. Inase N, Ohtani Y, Endo J, Miyake S, Yoshizawa Y. Feather duvet lung. Med Sci Monit. May 2003;9(5):CS37-40.

  41. Inase N, Ohtani Y, Sumi Y, Umino T, Usui Y, Miyake S. A clinical study of hypersensitivity pneumonitis presumably caused by feather duvets. Ann Allergy Asthma Immunol. Jan 2006;96(1):98-104. [Medline].

  42. Bureau MA, Fecteau C, Patriquin H, Rola-Pleszczynski M, Masse S, Begin R. Farmer's lung in early childhood. Am Rev Respir Dis. Apr 1979;119(4):671-5. [Medline].

  43. Thorshauge H, Fallesen I, Ostergaard PA. Farmer's lung in infants and small children. Allergy. Feb 1989;44(2):152-5. [Medline].

  44. Iyori H, Kawamura K, Seo K. Summer-type hypersensitivity pneumonitis in a child. Acta Paediatr Jpn. Aug 1991;33(4):488-91. [Medline].

  45. Apostolakos MJ, Rossmoore H, Beckett WS. Hypersensitivity pneumonitis from ordinary residential exposures. Environ Health Perspect. Sep 2001;109(9):979-81. [Medline].

  46. Aebischer CC, Frey U, Schöni MH. Hypersensitivity pneumonitis in a five-year-old boy: an unusual antigen source. Pediatr Pulmonol. Jan 2002;33(1):77-8. [Medline].

  47. Kristiansen JD, Lahoz AX. Riding-school lung? Allergic alveolitis in an 11-year-old girl. Acta Paediatr Scand. Mar 1991;80(3):386-8. [Medline].

  48. Saltos N, Saunders NA, Bhagwandeen SB, Jarvie B. Hypersensitivity pneumonitis in a mouldy house. Med J Aust. Sep 4 1982;2(5):244-6. [Medline].

  49. Hogan MB, Patterson R, Pore RS, Corder WT, Wilson NW. Basement shower hypersensitivity pneumonitis secondary to Epicoccum nigrum. Chest. Sep 1996;110(3):854-6. [Medline].

  50. Miller MM, Patterson R, Fink JN, Roberts M. Chronic hypersensitivity lung disease with recurrent episodes of hypersensitivity pneumonitis due to a contaminated central humidifer. Clin Allergy. Sep 1976;6(5):451-62. [Medline].

  51. Banaszak EF, Thiede WH, Fink JN. Hypersensitivity pneumonitis due to contamination of an air conditioner. N Engl J Med. Aug 6 1970;283(6):271-6. [Medline].

  52. Rose CS, Martyny JW, Newman LS, Milton DK, King TE Jr, Beebe JL. "Lifeguard lung": endemic granulomatous pneumonitis in an indoor swimming pool. Am J Public Health. Dec 1998;88(12):1795-800. [Medline].

  53. Embil J, Warren P, Yakrus M, Stark R, Corne S, Forrest D. Pulmonary illness associated with exposure to Mycobacterium-avium complex in hot tub water. Hypersensitivity pneumonitis or infection?. Chest. Mar 1997;111(3):813-6. [Medline].

  54. Hanak V, Kalra S, Aksamit TR, Hartman TE, Tazelaar HD, Ryu JH. Hot tub lung: presenting features and clinical course of 21 patients. Respir Med. Apr 2006;100(4):610-5. [Medline].

  55. Engelhart S, Rietschel E, Exner M, Lange L. Childhood hypersensitivity pneumonitis associated with fungal contamination of indoor hydroponics. Int J Hygiene Environ Health. Jan 2009;212(1):18-20.

  56. Glazer CS, Rose CS, Lynch DA. Clinical and radiologic manifestations of hypersensitivity pneumonitis. J Thorac Imaging. Oct 2002;17(4):261-72. [Medline].

  57. Seifert SA, Von Essen S, Jacobitz K, Crouch R, Lintner CP. Organic dust toxic syndrome: a review. J Toxicol Clin Toxicol. 2003;41(2):185-93. [Medline].

  58. Morgan WK. 'Zamboni disease'. Pulmonary edema in an ice hockey player. Arch Intern Med. Dec 11-25 1995;155(22):2479-80. [Medline].

  59. doPico GA, Reddan WG, Chmelik F, Peters ME, Reed CE, Rankin J. The value of precipitating antibodies in screening for hypersensitivity pneumonitis. Am Rev Respir Dis. Apr 1976;113(4):451-5. [Medline].

  60. Dodge RR, Reed CE, Barbee RA. The absence of a relationship between serum precipitins and pulmonary disease in a community. Chest. May 1978;73(5):608-12. [Medline].

  61. Patterson R, Greenberger PA, Castile RG, Yee WF, Roberts M. Diagnostic problems in hypersensitivity lung disease. Allergy Proc. Mar-Apr 1989;10(2):141-7. [Medline].

  62. McSharry C, Dye GM, Ismail T, Anderson K, Spiers EM, Boyd G. Quantifying serum antibody in bird fanciers' hypersensitivity pneumonitis. BMC Pulm Med. 2006;6:16. [Medline].

  63. Lynch DA, Rose CS, Way D, King TE Jr. Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study. AJR Am J Roentgenol. Sep 1992;159(3):469-72. [Medline].

  64. Nasser-Sharif FJ, Balter MS. Hypersensitivity pneumonitis with normal high resolution computed tomography scans. Can Respir J. Mar-Apr 2001;8(2):98-101. [Medline].

  65. King TE. Diagnosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis). UpToDate, Waltham MA. 2009. Available at http://www.uptodate.com/. Accessed August 9, 2009..

  66. Salvaggio JE. Robert A. Cooke memorial lecture. Hypersensitivity pneumonitis. J Allergy Clin Immunol. Apr 1987;79(4):558-71. [Medline].

  67. Ratjen F, Costabel U, Griese M, Paul K. Bronchoalveolar lavage fluid findings in children with hypersensitivity pneumonitis. Eur Respir J. Jan 2003;21(1):144-8. [Medline].

  68. Riedler J, Grigg J, Stone C, Tauro G, Robertson CF. Bronchoalveolar lavage cellularity in healthy children. Am J Respir Crit Care Med. Jul 1995;152(1):163-8. [Medline].

  69. Sobiecka M, Kus J, Demkow U et al. Induced sputum in patients with interstitial lung disease; a non-invasive surrogate for certain parameters in bronchoalveolar lavage fluid. J Physiolo Pharmacol. Dec 2008;59 Suppl 6:645-657.

  70. Lacasse Y, Fraser RS, Fournier M, Cormier Y. Diagnostic accuracy of transbronchial biopsy in acute farmer's lung disease. Chest. Dec 1997;112(6):1459-65. [Medline].

  71. Fan LL. Hypersensitivity pneumonitis in children. Curr Opin Pediatr. Jun 2002;14(3):323-6. [Medline].

  72. Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ. Needs and opportunities for research in hypersensitivity pneumonitis. Am J Respir Crit Care Med. Apr 1 2005;171(7):792-8. [Medline].

  73. Barrios RJ. Hypersensitivity pneumonitis: histopathology. Arch Pathol Lab Med. Feb 2008;132(2):199-203. [Medline].

  74. Ohtani Y, Saiki S, Kitaichi M, et al. Chronic bird fancier's lung: histopathological and clinical correlation. An application of the 2002 ATS/ERS consensus classification of the idiopathic insterstitial pneumonias. Thorax. 2005;60(8):665-671.

  75. Craig TJ, Hershey J, Engler RJ, Davis W, Carpenter GB, Salata K. Bird antigen persistence in the home environment after removal of the bird. Ann Allergy. Dec 1992;69(6):510-2. [Medline].

  76. Akashi T, Takemura T, Ando N, Eishi Y, Kitagawa M, Takizawa T. Histopathologic analysis of sixteen autopsy cases of chronic hypersensitivity pneumonitis and comparison with idiopathic pulmonary fibrosis/usual interstitial pneumonia. Am J Clin Pathol. Mar 2009;131(3):405-15. [Medline].

  77. Dakhama A, Hegele RG, Laflamme G, Israel-Assayag E, Cormier Y. Common respiratory viruses in lower airways of patients with acute hypersensitivity pneumonitis. Am J Respir Crit Care Med. Apr 1999;159(4 Pt 1):1316-22. [Medline].

  78. Patel AM, Ryu JH, Reed CE. Hypersensitivity pneumonitis: current concepts and future questions. J Allergy Clin Immunol. Nov 2001;108(5):661-70. [Medline].

  79. Patterson R, Mazur N, Roberts M, Scarpelli D, Semerdjian R, Harris KE. Hypersensitivity pneumonitis due to humidifier disease: seek and ye shall find. Chest. Sep 1998;114(3):931-3. [Medline].

  80. Ratjen F, Bredendiek M, Zheng L, Brendel M, Costabel U. Lymphocyte subsets in bronchoalveolar lavage fluid of children without bronchopulmonary disease. Am J Respir Crit Care Med. Jul 1995;152(1):174-8. [Medline].

  81. Suda T, Sato A, Ida M, Gemma H, Hayakawa H, Chida K. Hypersensitivity pneumonitis associated with home ultrasonic humidifiers. Chest. Mar 1995;107(3):711-7. [Medline].

  82. Swingler GH. Summer-type hypersensitivity pneumonitis in southern Africa. A report of 5 cases in one family. S Afr Med J. Jan 20 1990;77(2):104-7. [Medline].

  83. Takemura T, Akashi T, Ohtani Y, Inase N, Yoshizawa Y. Pathology of hypersensitivity pneumonitis. Curr Opin Pulm Med. Sep 2008;14(5):440-54. [Medline].

 
Previous
Next
 
Anteroposterior chest radiograph reveals a right-sided tension pneumothorax with mediastinal shift to the left in a female adolescent with severe chronic hypersensitivity pneumonitis (HP) resulting from bird exposure. Radiograph reveals diffuse haziness and increased interstitial markings of the underlying lung. Reprinted with permission from Farber and Budson, 2000.
High-resolution chest CT scan in the same patient as in the previous image reveals ground-glass attenuation, areas of nodular attenuation, and a thickened interstitium. A chest tube is evacuating the pneumothorax. Reprinted with permission from Farber and Budson, 2000.
Axial high-resolution chest CT scan (1-mm section) obtained at the level of the third thoracic vertebra reveals a persistent right pneumothorax and diffuse ground-glass attenuation through both lung fields. Areas of nodular attenuation, a thickened interstitium, and small subpleural cysts are most prominent on the superior section. Reprinted with permission from Farber and Budson, 2000.
Photomicrograph of a lung biopsy specimen reveals marked interstitial inflammation with lymphocytic predominance and a multinucleated giant cell (hematoxylin-eosin stain, original magnification 40X). Reprinted with permission from Farber and Budson, 2000.
Photomicrograph of a lung biopsy sample reveals interstitial fibrosis with active interstitial inflammation (hematoxylin-eosin stain, original magnification 10X). Reprinted with permission from Farber and Budson, 2000.
Photograph reveals precipitin lines produced by means of Ouchterlony immunodiffusion assay. Central wells contain the patient's serum. Peripheral wells contain serum or droppings from various birds. Reprinted with permission from Farber and Budson, 2000.
Table 1. Commonly Described Causes of Hypersensitivity Pneumonitis[32]
Exposure Disease Source of Antigen
AvianBird fancier's lung, pigeon breeder's lung, poultry worker's lungFeathers, droppings, serum proteins, intestinal mucins, avian immunoglobulin A
AgricultureFarmer's lung, Bagasse (sugar cane) lung, mushroom worker's lung, potato riddler's lung, paprika slicer's lung, wine maker's lung Thermophilic actinomycetes, Aspergillus species, and other fungi in moldy hay or grains; moldy sugar cane; mushroom spores and thermophilic actinomycetes; moldy hay around potatoes, thermophilic actinomycetes, and others; Mucor stolonifer (on moldy paprika pods); B cinerea (noble rot on grapes)
Water-based systemsHumidifier lung, hot-tub lung, sauna taker's lung, lifeguard's lung, sewage pneumonitisAerosolized molds, endotoxins, mycobacteria, thermophilic actinomycetes, Penicillium species, others
Home environmentSummer-type pneumonitis, mold-contaminated walls, humidifiers, wallpaperTrichosporon species, mold contamination in older and/or water-damaged homes
ChemicalsChemical worker's lung, epoxy-resin lung, pyrethrum pneumonitisExposure to chemicals in manufacturing, laboratories, spray paints, heated epoxy resins, insecticides
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.