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Pediatric Hypersensitivity Pneumonitis Workup

  • Author: Harold J Farber, MD, MSPH; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
 
Updated: May 20, 2016
 

Laboratory Studies

See the list below:

  • Precipitating antibodies to the offending antigen are commonly present in hypersensitivity pneumonitis (HP); however it is not a specific finding as exposed persons without disease may have precipitating antibodies to the antigen. [73, 74] Reports have attributed missed diagnoses to false-negative results of precipitin studies, although repeat testing showed true-positive findings of precipitin in many cases. [75] The offending antigen may not be present on commonly used commercial hypersensitivity pneumonitis panels; sometimes a home inspection may be needed with immunodiffusion testing for the specific antigens found in the home.{ref98) See the image below.
    Photograph reveals precipitin lines produced by me 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.
  • The erythrocyte sedimentation rate and C-reactive protein levels may be elevated, a rheumatoid factor may be present, and circulating immune complexes may be observed. However, these findings are not considered sufficiently specific to be useful for diagnosis. [42]
  • Hypergammaglobulinemia is a common finding but is neither sensitive nor specific.
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Imaging Studies

Chest radiography is a useful first step because it is widely available, inexpensive, and can be used to screen for other cardiopulmonary disorders. However, chest radiography cannot be used to exclude hypersensitivity pneumonitis because normal chest radiography findings can be observed in subjects who meet other diagnostic criteria for hypersensitivity pneumonitis.

Chest CT scanning is more sensitive than chest radiography, and about 40% of cases of hypersensitivity pneumonitis with normal chest radiography findings show pulmonary abnormalities on chest CT scanning. The imaging findings depend on the phase of the disease, and findings of more than one phase may be observed if exposure to the causative antigen is ongoing.[76, 77]

  • Acute hypersensitivity pneumonitis: Nodular, ground glass, or consolidative airspace opacities resembling edema or infectious pneumonia can be seen on chest radiography or chest CT scanning in the acute setting, especially after heavy exposure to causative antigens. These opacities can be fleeting, and relative sparing of the upper lung zones may be observed.
  • Subacute hypersensitivity pneumonitis: Imaging findings are similar to those observed in acute disease, with the additional chest CT scan findings of ill-defined centrilobular nodules corresponding to poorly formed granulomas on lung biopsy, and foci of air trapping. See the images below.
    14-year-old girl with subacute hypersensitivity pn 14-year-old girl with subacute hypersensitivity pneumonitis from avian antigen exposure. Chest radiograph demonstrates numerous tiny pulmonary nodules bilaterally.
    Chest CT from same patient as previous image revea Chest CT from same patient as previous image reveals widespread bilateral ill-defined centrilobular nodular opacities representing poorly formed granulomas.
  • Chronic hypersensitivity pneumonitis: Chest CT scanning reveals ill-defined centrilobular nodules, as well as irregular linear opacities, architectural distortion, and honeycombing related to pulmonary fibrosis. See the image below.
    10-year-old girl with chronic hypersensitivity pne 10-year-old girl with chronic hypersensitivity pneumonitis from avian antigen exposure. Chest CT image shows irregular linear opacities and architectural distortion at the lung bases indicative of pulmonary fibrosis.

The imaging findings of acute and subacute hypersensitivity pneumonitis may take several weeks to resolve with treatment. The chest CT findings of pulmonary fibrosis persist despite elimination of exposure to the causative antigen.

Pulmonary hypertension has been reported in older adults with advanced chronic hypersensitivity pneumonitis complicated by moderate to severe pulmonary restriction and hypoxemia on room air.[78] Given this finding, screening children with severe chronic hypersensitivity pneumonitis for pulmonary hypertension using Doppler echocardiography is reasonable.

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Other Tests

See the list below:

  • Pulmonary function studies
    • Acute hypersensitivity pneumonitis: Pulmonary function may be normal between acute episodes of hypersensitivity pneumonitis. Normal diffusing capacity observed between exacerbations of acute or subacute hypersensitivity pneumonitis does not exclude the diagnosis. Testing during acute episodes of hypersensitivity pneumonitis reveals predominately restrictive changes; however, obstruction and bronchial hyperreactivity can also be seen. Obstruction alone does not preclude a diagnosis of hypersensitivity pneumonitis. Hypoxemia can be seen in patients with active pneumonitis whether the affected patient is at rest or exercising.[46]
    • Subacute hypersensitivity pneumonitis: Pulmonary function testing may demonstrate mild hypoxemia, restriction and/or obstruction, and a reduced capacity for diffusing carbon monoxide.
    • Chronic hypersensitivity pneumonitis: A reduced diffusing capacity of the lung for carbon monoxide may be the earliest abnormality observed. Pulmonary restriction, hypoxemia at rest, and/or desaturation during the 6-minute walk test indicates the presence of more advanced disease.
  • Provocation challenge: The role of inhalation challenge is controversial because it can provoke clinically significant disease and standardized antigen preparations are not yet available. Because of the risk for the late-phase severe reactions, patients should be closely observed for at least 24 hours after the inhalation challenge is administered. [79]
  • Natural challenge: The development of signs and symptoms after the patient is re-exposed to the antigenic environment supports a diagnosis of acute or subacute hypersensitivity pneumonitis.
  • Skin testing: Skin testing is not helpful in assessing hypersensitivity pneumonitis. [80]
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Procedures

See the list below:

  • Analysis of bronchoalveolar lavage (BAL) fluid (BALF) is the most sensitive tool for alveolitis detection in patients with suspected hypersensitivity pneumonitis. Analysis of BALF in hypersensitivity pneumonitis typically reveals the following: [79, 15]
    • Lymphocytosis (>20% of WBCs recovered)
    • Elevated proportion of neutrophils (may be elevated to >5%), especially after recent antigenic exposure or in advanced disease
    • Elevated proportion of eosinophils (may be >5%), particularly in advanced disease
  • Analysis of bronchoalveolar lavage fluid in adults with hypersensitivity pneumonitis frequently reveals a CD4/CD8 ratio of less than 1. As stated above (see Pathophysiology), children naturally have a low CD4/CD8 ratio due to an elevated number of CD8 cells. Thus, this finding is neither sensitive nor specific for hypersensitivity pneumonitis in children. [81, 82]
  • One study of BALF cytology reported that adults with hypersensitivity pneumonitis have a greater percentage of natural killer T cells than adults with sarcoidosis. [13] The natural killer T cells observed in patients with hypersensitivity pneumonitis were predominantly of the CD8+CD56+ population. The clinical use of this observation has yet to be determined.
  • Induced sputum has been proposed as a noninvasive alternative to BAL. In adults with hypersensitivity pneumonitis, the distribution of T-cell subpopulations is similar in induced sputum and BALF; however the percentage of lymphocytes was substantially lower in the induced sputum. [83] Although lymphocytosis and elevated proportion of CD8+ cells on induced sputum is consistent with hypersensitivity pneumonitis, induced sputum should not be relied on to exclude the diagnosis.
  • Lung biopsy can be considered if the diagnosis cannot be established by other less-invasive methods. The role of transbronchial biopsy is controversial, with some authors advocating it as a less invasive test; [79] others are much less enthusiastic because the diagnostic yield is poor and interpretation is not consistent. [84] The extent to which invasive testing should be performed should be based on the probability of the diagnosis, the impact on patient and family of making the diagnosis, and the need to rule out alternative diagnoses. [12] Examples of lung biopsy findings are shown in the images below.
    Photomicrograph of a lung biopsy specimen reveals 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 in 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.
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Histologic Findings

See the list below:

  • Hypersensitivity pneumonitis is a diffuse, predominantly mononuclear cell inflammation of the small airways and pulmonary parenchyma. The inflammation is often associated with poorly formed, nonnecrotizing granulomas. [85] A bronchiolocentric distribution of the interstitial inflammation is believed to result from the airway being the portal of entry for the offending agent. Histologic findings may include the following: [86, 87]
    • Bronchiolocentric, chronic interstitial inflammation in which lymphocytes predominate
    • Poorly formed, noncaseating necrotizing interstitial granulomas
    • Foamy macrophages within airspaces
    • Intra-alveolar foci of organizing pneumonia
    • Dense fibrosis, honeycombing, and fibroblastic foci in advanced, chronic disease with potential upper lobe contraction.
  • Nonclassic and nonspecific pathology has been described in patients who otherwise met criteria for hypersensitivity pneumonitis. Cases of clinical hypersensitivity pneumonitis have been documented with biopsy results showing only nonspecific interstitial pneumonitis (NSIP) or a bronchiolitis obliterans organizing pneumonia (BOOP)–like picture. [15, 88]
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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Coauthor(s)

R Paul Guillerman, MD Associate Professor of Radiology, Baylor College of Medicine

R Paul Guillerman, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Society for Pediatric Radiology, Children's Oncology Group

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler 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, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Chief Editor

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Bettina Hilman, MD, Nidhy Paulose Varghese, MD, Lori R Johnson, MD, and Laurianne Wild, MD. Leland Fan, MD, reviewed previous versions and provided helpful suggestions.

References
  1. Krasnick J, Patterson R, Stillwell PC, Basaran MG, Walker LH, Kishore R. Potentially fatal hypersensitivity pneumonitis in a child. Clin Pediatr (Phila). 1995 Jul. 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. 1983 Aug 19. 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. Cormier Y. Wind-instruments lung: a foul note. Chest. 2010 Sep. 138(3):467-8. [Medline].

  6. Metzger F, Haccuria A, Reboux G, Nolard N, Dalphin JC, De Vuyst P. Hypersensitivity pneumonitis due to molds in a saxophone player. Chest. 2010 Sep. 138(3):724-6. [Medline].

  7. Metersky ML, Bean SB, Meyer JD, Mutambudzi M, Brown-Elliott BA, Wechsler ME, et al. Trombone player's lung: a probable new cause of hypersensitivity pneumonitis. Chest. 2010 Sep. 138(3):754-6. [Medline].

  8. Koschel D, Wittstruck H, Renck T, Müller-Wening D, Höffken G. Presenting features of feather duvet lung. Int Arch Allergy Immunol. 2010. 152(3):264-70. [Medline].

  9. Haitjema T, van Velzen-Blad H, van den Bosch JM. Extrinsic allergic alveolitis caused by goose feathers in a duvet. Thorax. 1992 Nov. 47(11):990-1. [Medline]. [Full Text].

  10. Jordan LE, Guy E. Paediatric feather duvet hypersensitivity pneumonitis. BMJ Case Rep. 2015 Jun 25. 2015:[Medline].

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

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

  13. 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. 2007 Oct. 132(4):1291-7. [Medline].

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

  15. 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. 2002 Apr 15. 112(6):490-3. [Medline].

  16. 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. 2008 Dec. 59 Suppl 6:499-505. [Medline].

  17. 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. 2009 Feb. 102(2):149-54. [Medline].

  18. 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. 2001 Feb. 163(2):379-82. [Medline].

  19. Barrera L, Mendoza F, Zuñiga J, Estrada A, Zamora AC, Melendro EI, et al. Functional diversity of T-cell subpopulations in subacute and chronic hypersensitivity pneumonitis. Am J Respir Crit Care Med. 2008 Jan 1. 177(1):44-55. [Medline].

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

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

  22. Fournier E, Tonnel AB, Gosset P, Wallaert B, Ameisen JC, Voisin C. Early neutrophil alveolitis after antigen inhalation in hypersensitivity pneumonitis. Chest. 1985 Oct. 88(4):563-6. [Medline].

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

  24. 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. 1992 Jul-Aug. 47(4):274-8. [Medline].

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

  26. 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. 2004 Apr 15. 169(8):903-9. [Medline].

  27. 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. 2004 May. 45(5):455-67. [Medline].

  28. 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. 1995 Oct. 34(10):966-71. [Medline].

  29. 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. 1980 Oct-Dec. 32(4):401-7. [Medline].

  30. 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. 1982 Jan. 12(1):47-53. [Medline].

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

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

  33. Kawai T, Tamura M, Murao M. Summer-type hypersensitivity pneumonitis. A unique disease in Japan. Chest. 1984 Mar. 85(3):311-7. [Medline].

  34. Ando M, Arima K, Yoneda R, Tamura M. Japanese summer-type hypersensitivity pneumonitis. Geographic distribution, home environment, and clinical characteristics of 621 cases. Am Rev Respir Dis. 1991 Oct. 144(4):765-9. [Medline].

  35. Yoshida K, Ando M, Sakata T, Araki S. Prevention of summer-type hypersensitivity pneumonitis: effect of elimination of Trichosporon cutaneum from the patients' homes. Arch Environ Health. 1989 Sep-Oct. 44(5):317-22. [Medline].

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

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

  38. Kawayama T, Shigematsu H, Kawaguchi S, Kawahara M, Oizumi K. [Summer-type hypersensitivity pneumonitis in a family]. Nihon Kyobu Shikkan Gakkai Zasshi. 1996 Dec. 34(12):1401-5. [Medline].

  39. Ubukata M, Takayanagi N, Matsushima H, Sakamoto T, Motegi M, Yanagisawa T, et al. [Familial summer-type hypersensitivity pneumonitis in a grandfather and his two-and-a-half-year-old grandson]. Nihon Kokyuki Gakkai Zasshi. 2000 Dec. 38(12):923-7. [Medline].

  40. 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. 1993 Jul. 148(1):49-53. [Medline].

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

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

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

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

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

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

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

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

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

  50. 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. 2000 Jan. 84(1):84-6. [Medline].

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

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

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

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

  55. 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. 2006 Jan. 96(1):98-104. [Medline].

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

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

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

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

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

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

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

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

  64. 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. 1976 Sep. 6(5):451-62. [Medline].

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

  66. 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. 1998 Dec. 88(12):1795-800. [Medline].

  67. 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. 1997 Mar. 111(3):813-6. [Medline].

  68. 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. 2006 Apr. 100(4):610-5. [Medline].

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

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

  71. 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].

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

  73. 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. 1976 Apr. 113(4):451-5. [Medline].

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

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

  76. Hartman TE. The HRCT features of extrinsic allergic alveolitis. Semin Respir Crit Care Med. 2003 Aug. 24(4):419-26. [Medline].

  77. Guillerman RP. Imaging of Childhood Interstitial Lung Disease. Pediatr Allergy Immunol Pulmonol. 2010 Mar. 23(1):43-68. [Medline]. [Full Text].

  78. Koschel DS, Cardoso C, Wiedemann B, Höffken G, Halank M. Pulmonary hypertension in chronic hypersensitivity pneumonitis. Lung. 2012 Jun. 190(3):295-302. [Medline].

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

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

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

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

  83. 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. 2008 Dec. 59 Suppl 6:645-657.

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

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

  86. 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. 2005 Apr 1. 171(7):792-8. [Medline].

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

  88. 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.

  89. 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. 1992 Dec. 69(6):510-2. [Medline].

  90. Lota HK, Keir GJ, Hansell DM, Nicholson AG, Maher TM, Wells AU. Novel use of rituximab in hypersensitivity pneumonitis refractory to conventional treatment. Thorax. 2013 Aug. 68(8):780-1. [Medline].

  91. Keir GJ, Maher TM, Ming D, Abdullah R, de Lauretis A, Wickremasinghe M. Rituximab in severe, treatment-refractory interstitial lung disease. Respirology. 2013 Nov 29. [Medline].

  92. 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. 1992 Sep. 159(3):469-72. [Medline].

  93. 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. 2009 Mar. 131(3):405-15. [Medline].

  94. 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. 2007 Oct. 132(4):1291-7. [Medline].

  95. 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].

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

  97. Millerick-May ML, Mulks MH, Gerlach J, Flaherty KR, Schmidt SL, Martinez FJ, et al. Hypersensitivity pneumonitis and antigen identification - An alternate approach. Respir Med. 2016 Mar. 112:97-105. [Medline].

 
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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.
14-year-old girl with subacute hypersensitivity pneumonitis from avian antigen exposure. Chest radiograph demonstrates numerous tiny pulmonary nodules bilaterally.
Chest CT from same patient as previous image reveals widespread bilateral ill-defined centrilobular nodular opacities representing poorly formed granulomas.
10-year-old girl with chronic hypersensitivity pneumonitis from avian antigen exposure. Chest CT image shows irregular linear opacities and architectural distortion at the lung bases indicative of pulmonary fibrosis.
Table 1. Commonly Described Causes of Hypersensitivity Pneumonitis [46]
Exposure Disease Source of Antigen
Avian Bird fancier's lung, pigeon breeder's lung, poultry worker's lung, feather duvet lung Feathers, droppings, serum proteins, intestinal mucins, avian immunoglobulin A
Agriculture Farmer'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 systems Humidifier lung, hot-tub lung, sauna taker's lung, lifeguard's lung, sewage pneumonitis, wind instrument lung Aerosolized molds, endotoxins, mycobacteria, thermophilic actinomycetes, Penicillium species, others
Home environment Summer-type pneumonitis, mold-contaminated walls, humidifiers, wallpaper Trichosporon species, mold contamination in older and/or water-damaged homes



 



Chemicals Chemical worker's lung, epoxy-resin lung, pyrethrum pneumonitis Exposure to chemicals in manufacturing, laboratories, spray paints, heated epoxy resins, insecticides
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