Sections

Sections Pediatric Hypersensitivity Pneumonitis
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
Media Gallery
Tables
References

Treatment

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).^[93]

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, latent tuberculosis infection should be excluded prior to starting corticosteroid therapy.

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.

A few case reports have described clinical improvement with rituximab when used as salvage therapy in adults with severe progressive chronic hypersensitivity pneumonitis.^{[94, 95]}Rituximab is an anti-CD20 monoclonal antibody that depletes B cells from the peripheral circulation. One of the reports of clinical experience with rituximab in 6 adults with severe progressive hypersensitivity pneumonitis found that lung function stabilized or improved in 3 and continued to deteriorate in the other 3, all of whom died within 4 months of treatment.^[95]There are no reports of pediatric experience with this medication in hypersensitivity pneumonitis.

In this author’s opinion, rituximab should not be considered standard therapy for chronic hypersensitivity pneumonitis. Rituximab may be considered as salvage therapy in a patient with severe, progressive, and life-threatening chronic hypersensitivity pneumonitis in whom standard therapies (including aggressive attempts to identify and eliminate exposure to the offending antigen) have clearly failed. This would be very unusual for a child.

A recent clinical trial showed that antifibrotic drugs could reduce disease progression in patients with progressive ILD, including hypersensitivity pneumonitis.^[96]

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.

Diet

No dietary restrictions are needed.

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.

Guidelines

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. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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.
Cormier Y. Wind-instruments lung: a foul note. Chest. 2010 Sep. 138(3):467-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Jordan LE, Guy E. Paediatric feather duvet hypersensitivity pneumonitis. BMJ Case Rep. 2015 Jun 25. 2015:[QxMD MEDLINE Link].
Selman M. Hypersensitivity pneumonitis: a multifaceted deceiving disorder. Clin Chest Med. 2004 Sep. 25(3):531-47, vi. [QxMD MEDLINE Link].
Lacasse Y, Assayag E, Cormier Y. Myths and controversies in hypersensitivity pneumonitis. Semin Respir Crit Care Med. 2008 Dec. 29(6):631-42. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kronenberg M, Gapin L. The unconventional lifestyle of NKT cells. Nat Rev Immunol. 2002 Aug. 2(8):557-68. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gudmundsson G, Monick MM, Hunninghake GW. Viral infection modulates expression of hypersensitivity pneumonitis. J Immunol. 1999 Jun 15. 162(12):7397-401. [QxMD MEDLINE Link].
Denis M. Proinflammatory cytokines in hypersensitivity pneumonitis. Am J Respir Crit Care Med. 1995 Jan. 151(1):164-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gudmundsson G, Hunninghake GW. Interferon-gamma is necessary for the expression of hypersensitivity pneumonitis. J Clin Invest. 1997 May 15. 99(10):2386-90. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ando M, Suga M, Nishiura Y, Miyajima M. Summer-type hypersensitivity pneumonitis. Intern Med. 1995 Aug. 34(8):707-12. [QxMD MEDLINE Link].
Wild LG, Lopez M. Hypersensitivity pneumonitis: a comprehensive review. J Investig Allergol Clin Immunol. 2001. 11(1):3-15. [QxMD MEDLINE Link].
Yee WF, Castile RG, Cooper A, Roberts M, Patterson R. Diagnosing bird fancier's disease in children. Pediatrics. 1990 May. 85(5):848-52. [QxMD MEDLINE Link].
Levenson T, Patterson R. Chronic cough in a child. Ann Allergy Asthma Immunol. 1996 Apr. 76(4):311-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Bahna SL. A custodian cured the doctor!. Pediatrics. 2000 May. 105(5):E71. [QxMD MEDLINE Link].
Karakurum M, Doraswamy B, Bennuri SS. Index of suspicion. Case 1. Hypersensitivity pneumonitis. Pediatr Rev. 1999 Feb. 20(2):53-4. [QxMD MEDLINE Link].
Inase N, Ohtani Y, Endo J, Miyake S, Yoshizawa Y. Feather duvet lung. Med Sci Monit. May 2003. 9(5):CS37-40.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Thorshauge H, Fallesen I, Ostergaard PA. Farmer's lung in infants and small children. Allergy. 1989 Feb. 44(2):152-5. [QxMD MEDLINE Link].
Iyori H, Kawamura K, Seo K. Summer-type hypersensitivity pneumonitis in a child. Acta Paediatr Jpn. 1991 Aug. 33(4):488-91. [QxMD MEDLINE Link].
Apostolakos MJ, Rossmoore H, Beckett WS. Hypersensitivity pneumonitis from ordinary residential exposures. Environ Health Perspect. 2001 Sep. 109(9):979-81. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kristiansen JD, Lahoz AX. Riding-school lung? Allergic alveolitis in an 11-year-old girl. Acta Paediatr Scand. 1991 Mar. 80(3):386-8. [QxMD MEDLINE Link].
Saltos N, Saunders NA, Bhagwandeen SB, Jarvie B. Hypersensitivity pneumonitis in a mouldy house. Med J Aust. 1982 Sep 4. 2(5):244-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Glazer CS, Rose CS, Lynch DA. Clinical and radiologic manifestations of hypersensitivity pneumonitis. J Thorac Imaging. 2002 Oct. 17(4):261-72. [QxMD MEDLINE Link].
Kawai T, Tamura M, Murao M. Summer-type hypersensitivity pneumonitis. A unique disease in Japan. Chest. 1984 Mar. 85(3):311-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ando M, Suga M, Nishiura Y, Miyajima M. Summer-type hypersensitivity pneumonitis. Intern Med. 1995 Aug. 34(8):707-12. [QxMD MEDLINE Link].
Iyori H, Kawamura K, Seo K. Summer-type hypersensitivity pneumonitis in a child. Acta Paediatr Jpn. 1991 Aug. 33(4):488-91. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Macaluso C, Boccabella C, Kokosi M, Sivarasan N, Kouranos V, George PM, et al. Short-term lung function changes predict mortality in patients with fibrotic hypersensitivity pneumonitis. Respirology. 2022 Jan 12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[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.
King TE. Classification and clinical manifestations of hypersensitivity pneumonitis. in UpToDate, Waltham MA. Available at http://www.uptodate.com/. Accessed: August 9, 2009.
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. [QxMD MEDLINE Link]. [Full Text].
Reich JM. Chirping rales in bird-fancier's lung. Chest. 1993 Jul. 104(1):326-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Morgan WK. Zamboni disease'. Pulmonary edema in an ice hockey player. Arch Intern Med. 1995 Dec 11-25. 155(22):2479-80. [QxMD MEDLINE Link].
Raghu G, Remy-Jardin M, Ryerson CJ, Myers JL, Kreuter M, et al. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Aug 1. 202 (3):e36-e69. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hartman TE. The HRCT features of extrinsic allergic alveolitis. Semin Respir Crit Care Med. 2003 Aug. 24(4):419-26. [QxMD MEDLINE Link].
Guillerman RP. Imaging of Childhood Interstitial Lung Disease. Pediatr Allergy Immunol Pulmonol. 2010 Mar. 23(1):43-68. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Fernández Pérez ER, Travis WD, Lynch DA, et al. Diagnosis and evaluation of hypersensitivity pneumonitis: CHEST guideline and expert panel report. Chest. 2021 Aug. 160 (2):e97-e156. [QxMD MEDLINE Link]. [Full Text].
Koschel DS, Cardoso C, Wiedemann B, Höffken G, Halank M. Pulmonary hypertension in chronic hypersensitivity pneumonitis. Lung. 2012 Jun. 190(3):295-302. [QxMD MEDLINE Link].
King TE. Diagnosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis). UpToDate, Waltham MA. 2009. Available at http://www.uptodate.com/. Accessed: August 9, 2009.
Salvaggio JE. Robert A. Cooke memorial lecture. Hypersensitivity pneumonitis. J Allergy Clin Immunol. 1987 Apr. 79(4):558-71. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
Fan LL. Hypersensitivity pneumonitis in children. Curr Opin Pediatr. 2002 Jun. 14(3):323-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Barrios RJ. Hypersensitivity pneumonitis: histopathology. Arch Pathol Lab Med. 2008 Feb. 132(2):199-203. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SLF, Inoue Y, et al. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. N Engl J Med. 2019 Oct 31. 381 (18):1718-1727. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Takemura T, Akashi T, Ohtani Y, Inase N, Yoshizawa Y. Pathology of hypersensitivity pneumonitis. Curr Opin Pulm Med. 2008 Sep. 14(5):440-54. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

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 poorly-defined centrilobular ground-glass nodules related to bronchiolocentric cellular interstitial pneumonia with poorly-formed granulomas.
A 10-year-old girl with chronic hypersensitivity pneumonitis from avian antigen exposure. Chest CT image shows reticular pulmonary opacities and architectural distortion at the lung bases indicative of pulmonary fibrosis.

of 6

Author

Naga Jaya Smitha Yenduri, MD Assistant Professor, Division of Pediatrics, Pulmonary Section, Texas Children's Hospital, Baylor College of Medicine

Naga Jaya Smitha Yenduri, MD is a member of the following medical societies: 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.

Harold J Farber, MD, MSPH Professor of Pediatrics, Section of Pediatric Pulmonology, Baylor College of Medicine, Texas Children's Hospital; Associate Medical Director, Texas Children's Health Plan

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: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Texas Children's Health Plan (a not-for-profit Medicaid Manged Care program owned by Texas Children's Hospital).

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.

Sections Pediatric Hypersensitivity Pneumonitis
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
Media Gallery
Tables
References

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

Pediatric Hypersensitivity Pneumonitis Treatment & Management

Medical Care

Consultations

Diet and Activity

Diet

Activity

Pediatric Hypersensitivity Pneumonitis Treatment & Management

Medical Care

Consultations

Diet and Activity

Diet

Activity

References

Tables

Contributor Information and Disclosures

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