Pediatric Hypersensitivity Pneumonitis Treatment & Management

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

Medical Care

The key to effective treatment of hypersensitivity pneumonitis (HP) is identifying the offending antigen and eliminating further exposure. These goals can be hard to achieve because the offending antigen may not be obvious and may endure long after the antigenic source is removed (ie, avian antigens).[75]

Removal from exposure usually results in complete resolution of symptoms, although substantially more time is required in subacute than in acute disease. In many patients, complete resolution requires weeks to months. Permanent lung damage, continued progression, or both may be seen in advanced cases of chronic hypersensitivity pneumonitis.

Corticosteroids can speed resolution of hypersensitivity pneumonitis; however, corticosteroid therapy does not eliminate or reduce the need to identify the causative antigen and elimination of exposure to it, nor does it change the long-term prognosis. If systemic corticosteroid therapy is used, the same dosage regimen should be continued until clinical improvement of pulmonary function is observed. The dosage should then be gradually tapered downward. In advanced chronic disease, progression of pulmonary fibrosis and death can occur despite aggressive corticosteroid therapy. If the patient has risk factors for tuberculosis, tuberculin skin testing should be considered before corticosteroid therapy is started.

Antibiotic therapy is not indicated for treatment of hypersensitivity pneumonitis. However, in many cases, antibiotic drugs are administered until a diagnosis of infectious pneumonia is ruled out.

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Consultations

Consulting a pediatric pulmonologist, an allergist, or both who have experience in treating hypersensitivity pneumonitis can be helpful for confirming the diagnosis, assessing complications, educating the patient and family, and providing long-term follow-up care for the patient.

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Diet

No dietary restrictions are needed.

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Activity

If the patient has pulmonary fibrosis, subpleural blebs, or airway obstruction, activities that may increase intrathoracic pressure (eg, scuba diving, playing horn instruments) are contraindicated because of the risk of pneumothorax. Otherwise, activity levels should be adjusted according to the patient's comfort; dyspnea causes most patients to spontaneously reduce their physical activity. If needed, tolerance of physical activity can be objectively assessed with 6-minute walk testing.

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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.

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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
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