I have no conflict of interest

A case of hypersensitivity pneumonitis

Dr Hilal Altınözİstanbul Occupational Diseases Hospital

14.04.2012Turkish Thoracic Society 15th Annual Congress

• HA• 40 year old female• Cough, dyspnea and weight loss in march

2011• Compliants for one month• Never smoked

• Began to work in an mushroom cultivating farm in January 2010

• She bedded the compost and pounded it. Then spawned .

• She specifies that a few months before she attended the hospital, a new composit is brought from Antalya and it irritated her eyes as she opened the package first.

• She also says that bleach is used for fly prevention.

• March 2011

• Routine blood specimens: Normal• PFT: Restrictive ,• DLCO:%80 • O2 sat:%96,9, Arterial blood gase:Normal• BAL and TBB by FOB• BAL: Lymphocytic character, CD4/CD8: 1,44• FOB: (The capillarity on the left bronchial

system mucosa)

• Two months of sick leave.• No medication.• Completely recovered in May 2011.

• 24.05.2011

• 24.08.2011

Five months later. No medication

Five months later. No medication

What’s hypersensitivity pneumonitis?

• Extrinsic allergic alveolitis• Occurs because of recurrent inhalation of dusts

with organic antigene.• These dusts may originate from milk products,

dairy and grain products, animal products, water sprinklers or wood bark.

• The most common antigenes are thermophilic Actinomycetes species and avian proteins.

• “Farmer’s lung”, “Bird fancier’s lung” are common.

• Characterized as diffuse inflammation on pulmonary parenchyma.

• According to exposure time and density– Acute, subacute or chronic

• Acute: Characterized as peribronchial mononuclear cell infiltration . Rarely noncaseafing granulome is seen.

• Subacute, intermittan forms have noncaseifing granüloms, organised pneumonia is nearby

• Chronic forms have honeycomb fibrosis.

• MDI is used for polyurethane production. Polyurethane applications– Adhesive/sealant (7%)– Ttool production(7%)– Automotive (16%) – Files (2%)– Construction (22%)– Base (9%)– Elastomers (7%)– Shoe (8%)– Furniture/bed production (23%)

• Mostly Ig G antibody is produced agaisnt the causative antigen.Even %50 of the patients without any symptoms have these antibodies.

• Although immuncomplex formation is thougt to be the reason, nowadays cellular immunity is the accepted theory.

• Neutrophili in the alveol and small airways, is the earliest response. Then comes the mononuclear cells, secreting proteolitic enzyme, prostaglandins and leukotriens.

Kayın mushroom production

• Incidence is variable• American farmers 8-540 /100.000, while in

American pigeon breeders 6000-21000/100.000

• In English farmers 420-3000/100.000, French farmers 4370/100.000, Finnish farmers 1400-1700/100.000

• Mostly complete recover is seen after the exposure lasts.

• The bird breeders’ prognosis is a little bit worse than the farmers’.

• Generally seen between 4.-6. decade.• Generally male:female ratio is 1,2:1.

• Auscultation: Bibasiler fine crackles in the begining.

• Hypersensitivity pneumonia-like situations– Inhalational fever without any radiological

findings.– Organic dust toxic syndrome, occuring after the

exposure of bioaerosols contaminated with toxin forming fungi (mycotoxin). (Difference is, in this case there’s no exposure before)

– Chronic bronchitis of agriculture workers.

Laboratory

• Leucocytosis, neutrophily, high ESR and CRP • PFT: Restriction• DLCO decreases.• Spesific provocation test in workplace: There’s

no standardisation .• Rarely at rest, commonly at effort hypoxemia.• BAL: The lymphocyt count more than 20 % is

not specific but supportive. CD4/CD8 is commonly less than 1.

Radiology

Therapy

• Stop the exposure• Streoid therapy: Optimum dose and duration

is not certain. 0,5-1 mg/kg /day is suggested, after 6-8 weeks can be stopped by tapering(Generally needed in the chronic forms).

Protection

• Worker education• Protection against dampness.• Antibiotics against fungi.• Prohibition of wet or damp carpet,

furniture,etc.• Change in agricultural technics and better

environmental hygene.