Hypersensitivity pneumonitis and bronchial asthma attacks caused by environmental fungi.

We report a case of hypersensitivity pneumonitis and asthma attacks caused by environmental fungi in a 75-year-old man. The diagnosis was established by inhalation challenge with Bjerkandera adusta and Aspergillus fumigatus. The patient was admitted for treatment of fever, wheezing, and dyspnea. Chest computed tomography showed small nodular shadows with diffuse, partially patchy, ground-glass opacities. The findings of bronchoalveolar lavage fluid were compatible with hypersensitivity pneumonitis. His symptoms and objective findings, including chest radiographs, worsened after returning home, suggesting the existence of causative antigens in his house. B. adusta and A. fumigatus were isolated from the living room and bedroom. Based on the results of antigen inhalation bronchoprovocation test, he was given a diagnosis of hypersensitivity pneumonitis caused by B. adusta and bronchial asthma attacks caused by B. adusta and A. fumigatus. After cleaning the entire house, the patient has had no recurrence of the symptoms on returning home.     

Isolated chronic cough with sputum eosinophilia caused by Humicola fuscoatra antigen: the importance of environmental survey for fungus as an etiologic agent.

We report here a 35-year-old man with isolated chronic cough associated with sputum eosinophilia in which Humicola fuscoatra (H. fuscoatra) antigen was an etiologic agent. He was admitted for the diagnosis and the treatment of his severe nonproductive cough. Although 80% of the nucleated cells in his induced sputum were eosinophils, he did not have bronchial hyperresponsiveness to methacholine or heightened bronchomotor tone. Bronchodilator therapy was not effective against his coughing. His cough worsened on his return home, suggesting the existence of some etiologic agent in his house. H. fuscoatra was isolated from his house, and the bronchoprovocation test with H. fuscoatra antigen was positive: i.e., development of coughing and decrease in capsaicin cough threshold (capsaicin concentration causing five or more coughs) from the prechallenge value of 31.3 microM to 1.95 microM at 6 and 48 hr, respectively, after the challenge. In addition, repeated environmental survey for fungi was suggestive of the importance of H. fuscoatra in the sputum eosinophilia. This is the first report concerning chronic cough with sputum eosinophilia caused by allergic reaction to H. fuscoatra antigen.     

A case of hypersensitivity pneumonitis caused by Gyrodontium versicolor]

A 36-year-old woman was admitted to our hospital because of fever, dry cough, dyspnea on exertion and body weight loss in August 2000. Chest radiography and CT scanning showed diffuse ground glass opacity and small centrilobular nodules in the middle and lower lung fields of both lungs. Serum antibody against Trichosporon cutaneum was positive; and summer-type hypersensitivity pneumonitis was therefore initially diagnosed. Treatment with methylprednisolone and prednisolone decreased the symptoms, but the dyspnea reappeared when the patient was at home. Inspection of her house revealed the presence of fungi under the floor. After these were removed, her symptoms disappeared completely. The lymphocytic stimulation test of the peripheral blood was positive for the fungi, and it was therefore suggested that they were the cause of her hypersensitivity pneumonitis. The fungi were identified as Gyrodontium versicolor. This is the first report of hypersensitivity pneumonitis caused by Gyrodontium versicolor.     

Eosinophilic tracheobronchitis with cough hypersensitivity caused by Streptomyces albus antigen

A 52-year-old woman is reported with atopic cough, in whom bronchoprovocation with Streptomyces albus antigen induced cough and bronchoscopic biopsy revealed eosinophilic tracheobronchitis. She was admitted for the diagnosis and treatment of severe non-productive cough. Although her induced sputum contained 8% eosinophils of nucleated cells and bronchoscopic biopsy specimens revealed eosinophil infiltration in both tracheal and bronchial wall, she did not have bronchial hyperresponsiveness to methacholine or heightened bronchomotor tone. Bronchodilator therapy was not effective for her coughing. Her symptoms worsened on returning home, suggesting the existence of some etiologic agents in her house. Streptomyces albus was isolated from her house. A high titer of anti-S. albus antibody was detected in her serum and the bronchoprovocation test with S. albus antigen was positive: development of coughing 15 min later and decrease in cough threshold to inhaled capsaicin 24 h later (3.9 μmol/L from 31.3 μmol/L prechallenge). This is the first report on eosinophilic tracheobronchitis with cough hypersensitivity caused by allergic reaction to S. albus antigen.     

Summer-type hypersensitivity pneumonitis outside Japan: A case report and the state of the art

Abstract A 61-year-old Korean housewife developed dyspnoea, cough and weight loss in the summer of 1994. The case was diagnosed as definite summer-type hypersensitivity pneumonitis (SHP) according to the criteria proposed for hypersensitivity pneumonitis and for SHP. Her serum antibodies to Trichosporon were positive. Her symptoms were exacerbated after she returned home and Trichosporon was isolated from the patient's home, indicating Trichosporon as the causative antigen. This is the first confirmed case of SHP outside Japan. On the basis of our research in SHP to date, we propose that SHP occurs in other Asian countries and that the assay of anti-Trichosporon antibodies is useful for the diagnosis of the disease.     

A case of loxoprofen-induced pneumonitis pathologically resembling hypersensitivity pneumonitis]

A 66-year-old woman was admitted to our hospital because of high fever, general fatigue, hypoxemia and liver dysfunction. Chest radiographs showed diffuse interstitial shadows in both lungs. We suspected drug-induced pneumonitis because of her history of drug administration for upper respiratory infection. Her symptoms and findings were markedly decreased by discontinuation of the drugs. Transbronchial lung biopsy specimens showed infiltration of eosinophils and lymphocytes to the alveolar septa, granuloma with Langhans' giant cells, and Masson bodies in a manner suggestive of hypersensitivity pneumonitis. Drug lymphocyte stimulation tests were negative except for loxoprofen. There was no recurrence of systemic or respiratory symptoms during overnight stays at home. On the basis of these findings, we arrived at a diagnosis of drug-induced pneumonitis caused by loxoprofen.     

A case of Japanese summer-type hypersensitivity pneumonitis: monitoring with serum KL-6 and examination of the phenotype of HLA]

A 55-year-old woman was admitted with a cough and fever in August. A diagnosis of Japanese summer-type hypersensitivity pneumonitis was made on the basis of radiological, serological and pathological findings, in addition to positive returning home provocation. Serum KL-6 was monitored during the clinical course. Although KL-6 fluctuated slowly in comparison with the clinical symptoms and HRCT findings, it was considered useful for confirming the effects of treatment. Serum anti-Trichosporon antibody and the phenotype of HLA were studied in both the patient and her asymptomatic roommate, with whom she had no blood relationship. Though both were sensitized immunologically, HLA-DQ 3, which was reported to be associated with Japanese summer-type hypersensitivity pneumonitis, was detected in the patient but not in her roommate. It was suggested that HLA plays a role in the development of this disease.     

Pigeon hypersensitivity pneumonitis: immunohistochemical demonstration of the causative antigen in the lung.

A number of clinicopathological manifestations may define the presence of hypersensitivity pneumonitis. Histological study is used to establish the diagnosis and to differentiate the disease from other respiratory disorders. This case report suggests that immunohistological demonstration of the causative antigen in the lung may be a useful diagnostic approach in cases of pigeon hypersensitivity pneumonitis. A 52 year-old woman was studied. She had a prior history of pigeon exposure, and lived in an area with a high prevalence of tuberculosis. Her clinical presentation, respiratory function tests and imaging studies revealed a predominant interstitial lung disease. The results of antiavian antibodies, bronchoalveolar analysis, and other laboratory parameters were non-diagnostic. A lung biopsy showed a prominent granulomatous reaction with a sarcoid-like appearance in some areas, and an interstitial infiltration constituted by lymphocytes, plasma cells and foamy macrophages. Although the disease manifestations were compatible with hypersensitivity pneumonitis, we decided to study the causal antigen by immunohistochemistry. The use of a polyclonal antibody raised against pigeon serum showed a predominant cytoplasmic immunostaining in multinucleated giant cells and histiocytes from lung granulomas. Other respiratory disorders were reasonably excluded. Previous exposure to a known antigen may support the diagnosis of hypersensitivity pneumonitis. Although the inhalation of organic dusts may be clinically evident, the aetiology is commonly evaluated by different challenge tests or immunological methods. We propose that the study of pigeon antigen by immunohistochemistry may be used as part of the diagnostic approach for hypersensitivity pneumonitis.     

A case of hypersensitivity pneumonitis presenting with copious sputum and marked obstructive impairment of lung function]

A 44-year-old male was hospitalized due to dyspnea and persistent cough with copious sputum (about 100 ml/day). Chest radiograph on admission showed hyperinflation and fine nodular shadows throughout both lungs, as well as a tram line appearance in the right lower lung field which suggested thickening of bronchial walls. Pulmonary function tests demonstrated moderate to severe reduction of %VC, FEV1.0 and PaO2. Fiberoptic bronchoscopy revealed inflammatory change in the walls of proximal bronchi. Although his dyspnea resolved rapidly, productive cough and impaired lung function were persistent and improved very slowly over the one-month-period following admission. After resolution, similar symptoms were provoked again 5 to 6 hours after returning to his home, suggesting the recurrence of hypersensitivity pneumonitis. Open lung biopsy was performed for the differential diagnosis of hypersensitivity, diffuse panbronchiolitis, and bronchial asthma, because neither transbronchial lung biopsy nor broncho-alveolar lavage was diagnostic. Histopathology of the open lung biopsy specimens revealed marked desquamation of bronchiolar epithelium in addition to bronchiolo-alveolitis with epithelial granulomas, consistent with hypersensitivity pneumonitis. Copious sputum is a very uncommon clinical feature in hypersensitivity pneumonitis. We consider that the large volume of airway fluid was caused by epithelial ulceration of bronchioles and catarrhal bronchitis associated with hypersensitivity pneumonitis.     

A case of acute hypersensitivity pneumonitis associated with an oil fan heater

We report here a case of acute hypersensitivity pneumonitis induced by an oil fan heater. A 57-year-old man was admitted to our hospital because of fever, nonproductive cough, and dyspnea. Paeccilomyces variotii and Paeccilomyces nivea were identified from an oil fan heater in his house. The result of an environmental challenge test was positive. Intradermal reaction and precipitin results to sugar antigen of those fungi were positive only in the patient. This is the first described case of acute hypersensitivity pneumonitis caused by an oil fan heater.     

Neumonitis por hipersensibilidad a Mucor sp. en un trabajador de la industria del corcho

Suberosis is a type of hypersensitivity pneumonitis caused by exposure to cork proteins and molds such as Aspergillus fumigatus and Penicillium frequentans. We present the case of a man with suberosis caused by Mucor species, a mold that has been rarely reported to cause hypersensitivity pneumonitis. Furthermore, the patient had symptoms and lung function tests indicating bronchial obstruction—an atypical presentation of hypersensitivity pneumonitis. No imaging abnormalities were observed. A diagnosis was made on the basis of bronchoalveolar lavage and transbronchial biopsy findings. Mucor species was identified as the causative agent using a specific bronchial challenge test.     

A case of summer type hypersensitivity pneumonitis resulting in chronic respiratory failure and cor pulmonale

A female case of Japanese summer-type hypersensitivity pneumonitis who was a smoker developed in chronic respiratory failure several years later. Biopsy specimen on first admission showed findings of granulomatous bronchioloalveolitis distributed in the center of secondary lobules. Pulmonary function studies demonstrated restrictive disease with high RV% and low airway conductance. In spite of steroid therapy, dyspnea persisted and the same symptoms were found on next summer. Six years later symptoms of chronic respiratory failure and cor pulmonale developed. Chest X-Ray showed dilated pulmonary artery, cardiomegaly and overinflation without apparent fibrosis. Hypoxemia and hypercapnia were also seen on blood gas analysis. Pulmonary function was unchanged compared to the findings on first admission. Since then long term oxygen therapy was started. It was thought that irreversible small airway disease caused by hypersensitivity pneumonitis was attributable to cor pulmonale and chronic respiratory failure because of her smoking habit and long period of exposure to antigen. As a patient with summer type hypersensitivity pneumonitis always has a possibility of chronic disease developing after long term exposure to antigen, such as a farmer's lung, the cessation of exposure to antigen by complete cleaning up of the patient's environment or moving out were considered to be important.     

Familial summer-type hypersensitivity pneumonitis--case report and review of literature]

A 37-year-old-woman was admitted to our hospital because of chest bilateral reticular shadow with fever, cough, general malaise and exertional dyspnea in the summer. A diagnosis of summer-type hypersensitivity pneumonitis (SHP) was made by radiological, serological and histological examinations. Her 10-year-old daughter had chest reticular shadows and similar symptoms. These two patients were positive for serum anti-Trichosporon cutaneum (T. asahii, T. mucoides) antibodies and T. asahii was identified from cultured samples obtained from their house. They recovered spontaneously after hospitalization or isolation from the antigen. We reviewed the clinical features in sixteen families with familial SHP reported in Japan. Children aged under 15 years old accounted for 34% and there was no gender difference among patients. This finding differs from the conventionally defined features of patients with SHP. Measurements of serum KL-6, SP-D and SP-A seem to be useful for auxiliary diagnosis and monitoring the disease activity of SHP, especially in pediatric cases who cannot undergo invasive evaluation.     

Successful treatment of hypersensitivity pneumonitis caused by Grifola frondosa (Maitake) mushroom using a HFA-BDP extra-fine aerosol

We successfully treated a patient with occupational hypersensitivity pneumonitis (HP) caused by Grifola frondosa (Maitake) mushroom spore with an extra-fine aerosol corticosteroid; beclomethasone dipropionate (BDP) dissolved in hydrofluoroalkane-134a (HFA). A 49-year-old woman developed respiratory symptoms 3 months after beginning work on a mushroom farm. She was diagnosed as HP based on radiological and serological findings. Oral prednisolone therapy improved her HP and she returned to the same farm. Her HP relapsed after 5 months, and daily 400 microg of HFA-BDP was administered with gradual improvement. An extra-fine particle inhaled corticosteroid might reach appropriate alveoli to be effective therapy for mild HP.     

A case of drug-induced pneumonitis due to levofloxacin and kampo medicine]

A 55-year-old woman was admitted to our hospital because of dyspnea on exertion. Hypoxemia and restrictive ventilatory impairment were observed on admission. Chest radiographs showed diffuse patchy infiltration shadows in both lungs. We suspected drug-induced pneumonitis, because her history of fever seemed to be related to drug administration for sinusitis. Her symptoms and findings were gradually decreased by discontinuation of the drugs. Transbronchial lung biopsy specimens showed lymphocyte dominant infiltration in the alveolar septa and Masson bodies. Drug lymphocyte stimulation tests were positive for levofloxacin and shin-i-seihai-to, a kampo medicine. On the basis of these findings, we arrived at a diagnosis of drug-induced pneumonitis caused by these drugs.     

Japanese summer-type hypersensitivity pneumonitis. Geographic distribution, home environment, and clinical characteristics of 621 cases

A survey of hypersensitivity pneumonitis in Japan was carried out by nationwide questionnaire. A total of 835 cases of hypersensitivity pneumonitis was recognized during the last decade from 1980 to 1989. Of the 835 cases, 621 (74.4%) were summer-type hypersensitivity pneumonitis. The number of cases diagnosed doubled in the latter half of the 10-yr period. The residence of the patients was mostly in the western and southern parts of the country; the northernmost incidence was in Akita Prefecture at a latitude of 40 degrees north. Of the patients 86% experienced initial symptoms from June to September with a peak in July. Female patients were 2.0 times as numerous as male patients, probably as a result of more exposure to the offending antigen at home since 39.8% of the patients were female homemakers without an outside occupation. The frequency of family occurrence was 23.8%. The mean age of the patients' houses was 20.5 yr after building, and more than half had unsanitary conditions, such as shady, damp, or poorly ventilated rooms. Serum anti-Trichosporon cutaneum antibody activities were positive in 260 (99.2%) of the 262 cases examined. We conclude that summer-type hypersensitivity pneumonitis occupies the majority of hypersensitivity pneumonitis in the country and that to prevent the disease concentrated attention should be given to the home environment from the viewpoint of environmental medicine.     

A case of severe summer-type hypersensitivity pneumonitis treated with high-dose administration of steroid]

A 40-year-old man who lived in a wooden house built 30 years ago presented with complaints of fever, dry cough and dyspnea. Chest X-ray findings showed interstitial shadows throughout bilateral lung fields. After admission, high-dose administration of 3000 mg of methylprednisolone was performed because of deterioration of chest X-ray shadows and symptoms. In a week, clinical data and symptoms improved. Findings of BAL fluid on admission revealed a relative increase of lymphocytes, neutrophils and mast cells, and pathological findings of transbronchial lung biopsy revealed non-caseous granulation and alveolitis. Precipitating antibodies and indirect fluorescent antibodies against Trichosporon cutaneum and Cryptococcus neoformans had positive reactions and T. cutaneum was isolated and identified from the patient's house. A diagnosis of summer-type hypersensitivity pneumonitis was made according to the criteria advocated by Ando et al. This seemed to be a rare case of summer-type hypersensitivity pneumonitis prolonged after isolation from his normal living environment, successfully treated by high-dose administration of steroid.     

Treatment of Atopic Cough Caused by <Emphasis Type="Italic">Basidiomycetes</Emphasis> Antigen with Low-dose Itraconazol

We report two patients with atopic cough due to Basidiomycetes antigen. One patient was a 27 year-old woman and the other was a 17 year-old boy. Both patients visited our hospital because of severe nonproductive cough. They did not have bronchial hyperresponsiveness to methacholine or heightened bronchomotor tone. Bronchodilator therapy was not effective for their cough. Her symptoms worsened in her office and his in his house, suggesting existence of etiologic agent(s) in their environments. Basidiomycetes was isolated from the womans office and from the boys house, and the bronchoprovocation test with Basidiomycetes antigen was positive. Low dose itraconazol (50 or 100 mg/day) given for two weeks eliminated cough in both patients. This is the first report describing the effectiveness of low dose antifungal therapy for atopic cough caused by Basidiomycetes antigen     

Hypersensitivity pneumonitis.

A case of hypersensitivity pneumonitis (HP) is presented and briefly discussed. The clinical characteristics, diagnosis, pathogenesis, and management of this syndrome are reviewed followed by clinical pearls and pitfalls for the practicing allergist. Most patients with acute HP recover completely with removal from the offending antigen. Treating symptoms only and not avoiding antigen triggers may lead to severe pulmonary fibrosis.     

Neumonitis por hipersensibilidad crónica por estorninos. Exposición antigénica no masiva pero persistente

A 51-year old woman developed hypersensitivity pneumonitis (HP) after inhaling the excrement of starlings that populated a park adjacent to her home.