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

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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.
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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].
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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].
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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].
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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].
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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].
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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].
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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].
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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 Professor, Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center

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

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, The Society of Federal Health Professionals (AMSUS), 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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