Extrinsic allergic Extrinsic allergicalveolitisalveolitis

Hypersensitvity p Hypersensitvity pneumonitisneumonitis

ปอดอ�กเสบภู�มิ ไวเก นปอดอ�กเสบภู�มิ ไวเก นศ.น.พ. อรรถ นานาคณะแพทยศาสตร�ศ ร ราชคณะแพทยศาสตร�ศ ร ราช

พยาบาลพยาบาลมิหาว ทยาล�ยมิห ดลมิหาว ทยาล�ยมิห ดล

HP: IntroductionHP: Introduction• immunologically induced lung disea immunologically induced lung diseasese

• diffuse inflammation of lung parenc diffuse inflammation of lung parenc hyma & airways in previously sensit hyma & airways in previously sensit

ized patients ized patients• sensitized to repeated inhalation of sensitized to repeated inhalation of

dusts containing organic dusts containing organic & low & low molecular weight chemical molecular weight chemical antigenantigenss

HP: IntroductionHP: Introduction• dusts derived from dusts derived from

– dairy & grain products dairy & grain products– animal dander & proteins animal dander & proteins– wood bark wood bark– water reservoir water reservoir

vaporizers vaporizers• not atopic disease not atopic disease• not associated with not associated with

increase IgE or eosinop increase IgE or eosinophilshils

HP: Selected etiological HP: Selected etiological agentsagents

Disease Farmer’s lung

ปอดชาวไร่Bagassosisโร่คชานอ�อยBird-breeder’s lungBird-fancier’s lungPigeon-breeder’s lung

-Mushroom worker’s lung

คนเพาะเห็�ดHumidifier/air conditionerlungปอดเคร่��องทำ�าความช��นปอดอ�กเสบการ่ร่ะบายอากาศ

Sourceห็ญ้�าแห็�งทำ$�ขึ้&�น

ร่า

ชานอ�อยทำ$�ขึ้&�นร่า

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แก�ว)

ป*+ยทำ$�ขึ้&�นร่า,ห็ญ้�าแห็�ง

เคร่��องทำ�าความช��น

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Antigen Micropolyspora

faeni

Thermoactino myces

sacchari

Avian proteins

Thermoactino myces

vulgaris

Micropolyspora faeni

Thermoactino myces

vulgaris

HP: Epidemiology HP: Epidemiology• Varies• 0.5-5% of farmers (Farmer’s lung disease)• 8-30% of members of pigeon breeding clubs (pigeon breeder’s disease)• Prevalence Farmer’s lung

UK

France

Finland

U.S.A.

420-3000

4370

1400-1700

540

cases/100,000 /

“

“

“

persons at

“

“

“

risk

“

“

“

Bagassosis : A Report of 8 Bagassosis : A Report of 8 CasesCases

Pee Kamtorn, M.D.*Pee Kamtorn, M.D.*

Poonkasem Charoenpan, M.D.**Poonkasem Charoenpan, M.D.**

Yosvi Sukumalchantra, M.D. , F.A.C.P. , F.R.C.P. (C) ,F.A.C.C.**Yosvi Sukumalchantra, M.D. , F.A.C.P. , F.R.C.P. (C) ,F.A.C.C.**

Vijitr Boonpucknavig, M.D.***Vijitr Boonpucknavig, M.D.***

Kalyanakit Kitiyakara, M.B. , B.S. , M.R.C.S. , L.R.C.P.****Kalyanakit Kitiyakara, M.B. , B.S. , M.R.C.S. , L.R.C.P.****

Chirotchana Suchato, M.D.*****Chirotchana Suchato, M.D.*****

Chaivej Nuchprayoon, M.D.******Chaivej Nuchprayoon, M.D.******

Bagassosis is classified as an extrinsic allergicBagassosis is classified as an extrinsic allergic

pneumonia. It is considered to be the result ofpneumonia. It is considered to be the result of

allergic reaction to moldy sugar cane inhalationallergic reaction to moldy sugar cane inhalation(1)(1) . .

Case ReportCase Report

All of the patients worked at a All of the patients worked at a

paper produc-paper produc-

tion factory in Karnchanaburi tion factory in Karnchanaburi

province and wereprovince and were

จดหมิายเหต"ทางแพทย� 2517:57;468-74.

HP : PathogenesisHP : Pathogenesis

• - immune complex m - immune complex m ediated process ediated process

– precipitating Ab precipitating Ab against specific Ag against specific Ag

– 50% o 50% o f asymptomatic persons f asymptomatic persons

exposed also have Ab exposed also have Ab

HP: PathogenesisHP: Pathogenesis

• - cell mediated immunity m - cell mediated immunity m ore important ore important

•responseresponse– increase PMN in alveoli increase PMN in alveoli && sm sm

all airways all airways– influx of mononuclear cells influx of mononuclear cells– formation of granulomas formation of granulomas

• - cytokine from T - cytokine from T lymphocytes & macrophag lymphocytes & macrophag

eses

HP : Histologic HP : Histologicfindingsfindings

• diffuse interstitial infiltrate : lympho diffuse interstitial infiltrate : lympho cytes, cytes,

macrophages, mast cells, plasma cell macrophages, mast cells, plasma cell s s

• scattered noncaseating granulomas scattered noncaseating granulomas• cellular inflammation of bronchioles, cellular inflammation of bronchioles,

+ bronchiolar obstruction + bronchiolar obstruction• absentabsent generalized vasculitis, necrot generalized vasculitis, necrot

izing granulomata izing granulomata

~ duration or stage of disease, adequ ~ duration or stage of disease, adequ acy of biopsy acy of biopsy samplesample

HP : Diagnostic HP : Diagnostic criteriacriteria

Major criteriaMajor criteria1. Symptoms c/w HP , appear or 1. Symptoms c/w HP , appear or worsens within hours after Ag worsens within hours after Ag exposureexposure

2. Confirmation of exposure to the 2. Confirmation of exposure to the offending agent byoffending agent by

- Hx- Hx

-investigation of the environment-investigation of the environment

-serum precipitin test-serum precipitin test

-BAL Ab -BAL Ab

HP : Diagnostic HP : Diagnostic criteriacriteria

3. Compatible CXR or HRCT3. Compatible CXR or HRCT

4. Lymphocytosis in BAL4. Lymphocytosis in BAL

5. Compatible histologic changes 5. Compatible histologic changes

6. “ ”Positive natural challenge or b 6. “ ”Positive natural challenge or b y y

cccccccccc cccccccccccc ccccccccccccccc cccccccccccc ccccccccccccc

HP : Diagnostic HP : Diagnostic criteriacriteria

Minor criteria Minor criteria

1. Basilar crackles 1. Basilar crackles

2. Decreased diffusion cap 2. Decreased diffusion capaci tyaci ty

3 . ,Arterial hypoxemia at res 3 . ,Arterial hypoxemia at res t or wi thexerci se t or wi thexerci se

HP : Diagnostic HP : Diagnostic criteriacriteria

Four major criteria Four major criteria

Two minor criteria Two minor criteria

Other diseases have been ex Other diseases have been excludedcluded

Adapted from Schuyler + Cormier Adapted from Schuyler + Cormier -Chest 1997; 111: 534 6. -Chest 1997; 111: 534 6.

HP : DiagnosisHP : Diagnosis

• often unrecognized & misdiagnosed often unrecognized & misdiagnosed

• respiratory symptoms with Hx. of respiratory symptoms with Hx. of

– environmental environmental

– occupational exposure occupational exposure

• respiratory symptoms with episodic respiratory symptoms with episodic radiographic infiltrates radiographic infiltrates “Recurre“Recurre

nt pneumonia” nt pneumonia”

HP : Radiographic HP : Radiographic findingsfindings

•vary to the stage of diseasevary to the stage of disease•acute HPacute HP

– bilateral micronodular (1-4 bilateral micronodular (1-4 mm.) infiltratesmm.) infiltrates

– patchy ground-glass patchy ground-glass opacitiesopacities

– decreased attenuation (air decreased attenuation (air trapping from bronchiolitis) and trapping from bronchiolitis) and mosaic pattern (expiratory mosaic pattern (expiratory view)view)

HP : Radiographic HP : Radiographic findingsfindings

• Subacute HP Subacute HP– fine linear shadows, small nodules fine linear shadows, small nodules

= reticulonodular appearance = reticulonodular appearance

• Chroni c HP Chroni c HP– volume loss volume loss– reticulonodular infiltrates reticulonodular infiltrates– honeycombing honeycombing– predominantly upper & mid lung z predominantly upper & mid lung z

onesones

HP : Pulmonary HP : Pulmonary function testsfunction tests

• restrictive changesrestrictive changes

• (superimposed obstruction in chronic (superimposed obstruction in chronic HP)HP)

• decreased diffusing capacitydecreased diffusing capacity

• ABG: increased alveolar-arterial ABG: increased alveolar-arterial oxygen gradientoxygen gradient

– frank hypoxemia (severe cases)frank hypoxemia (severe cases)

– oxygen desat. with exercise (clue oxygen desat. with exercise (clue in suspected case)in suspected case)

HP : BAL fluidHP : BAL fluid

• i ntense l ymphocytosi s i ntense l ymphocytosi s–

8predominantly CD 8predominantly CD ++ c-ccc c-ccc pressor cells pressor cells

~ timingof the l ast anti genexpos ~ timingof the l ast anti genexpos ure, stage of disease ure, stage of disease

HP: key featuresHP: key featuresTime frame

4-48 hr

weeks to 4 M.

4 M. to years

Acute

Subacute

Chronic

Clinicalfeatures

fever, chills,cough

hypoxemi a, aches

dyspnea ,cough,

episodicflares

dyspnea,cough,

fatigue, weight los

s

HRCT

ground glass

infiltrates

microno dules,

airtrapping

fibrosis, honey

combin g,

emphysema

Immunopathology

alveolitis, immune

complex

granulom as,

bronchiolitis

lymphocytic

infiltration ,

fibrosis,air space

destruction

Prognosis

good

good

good

HP : Differential HP : Differential diagnosisdiagnosis

• Acute stage Acute stage– pneumoni apneumoni a– acute tracheobronchi ti s acute tracheobronchi ti s–

organic dust toxic syndrome organic dust toxic syndrome– BOOPBOOP

HP : Differential HP : Differential diagnosisdiagnosis

• Subacute stage Subacute stage– recurrent pneumoni a recurrent pneumoni a–

granulomatous lung diseases granulomatous lung diseases– pneumoconi osi spneumoconi osi s– Wegener’sgranul omatosi s Wegener’sgranul omatosi s

HP : Differential HP : Differential diagnosisdiagnosis

• Chronic stage Chronic stage– IPFIPF– bronchiectasisbronchiectasis– COPD with COPD with

pulmonary fibrosis pulmonary fibrosis– MACMAC

HP: ManagementHP: Management•early diagnosisearly diagnosis•avoidance of further exposure avoidance of further exposure •protective devices :- personal protective devices :- personal

respiratorsrespirators•relocation to a new jobrelocation to a new job•reducing microorganism reducing microorganism

contamination in the environmentcontamination in the environment– altering handling & storagealtering handling & storage– wetting compostwetting compost– using antibiotics to decrease fungal using antibiotics to decrease fungal growthgrowth

– preventive maintenance on all A/C preventive maintenance on all A/C equipmentequipment

HP: key featuresHP: key featuresTime frame

4-48 hr

weeks to 4 M.

4 M. to years

Acute

Subacute

Chronic

Clinicalfeatures

fever, chills, cough

hypoxemi a, aches

dyspnea ,cough,

episodicflares

dyspnea,cough,

fatigue, weight los

s

HRCT

ground glass

infiltrates

microno dules,

airtrapping

fibrosis, honey

combin g,

emphysema

Immunopathology

alveolitis, immune

complex

granulom as,

bronchiolitis

lymphocytic

infiltration ,

fibrosis,air space

destruction

Prognosis

good

good

good

Subacute HP Subacute HP - - 60, a year old dair ffff ff fff f f -ffff fffffff ff fff8

ffffffff fff fffff fffffffff ffffffffff. dulari nt er st i t i al i nfi l t r at i on.

Chronic HP Chronic HP fffffffff fffff, ’ fffffffff fffffffffffffff fffffffff fff .present.

Acute HP Acute HP , ground glass opacification

f fff ff f fffffff f fff Chronic HP Chronic HP fffffffffffff fffffffffffff fff ffffffffff f fff fffffffffffffff ffffffff.

Chronic HP Chronic HP , honeycombing in right upper lung & traction

ffffffffffffff

Acute HP Acute HP , mononuclear infilt ration & noncaseating granulo

mas.

Chronic HP Chronic HP , mostly lymphocytic c ellular infiltrate with epithelioid cell

f fff fffff fff fffffff fffffff & -. ( )

Giant cells are characteristic feature of HP.

Chronic HPChronic HP shows interstitial inflammation associated with fibrosis.