Spotlight on the diagnosis of extrinsic allergic alveolitis (hypersensitivity pneumonitis)
© Baur et al.; licensee BioMed Central. 2015
Received: 25 November 2014
Accepted: 2 April 2015
Published: 20 April 2015
Repeated inhalative exposures to antigenic material from a variety of sources, mainly from moulds, thermophilic Actinomycetes, and avians, respectively, can induce immune responses with the clinical picture of extrinsic allergic alveolitis (EAA) or hypersensitivity pneumonitis. Delays of years or even decades till the diagnosis is made are not uncommon; frequent misdiagnoses include allergic asthma, COPD, recurrent flue and other infections. We provide here the state of the art references, a detailed case description and recommend a current diagnostics schema.
Sources and major antigens of extrinsic allergic alveolitis (hypersensitivity pneumonitis)
Saccharopolyspora rectivirgula (Micropolyspora faeni), Thermoactinomyces vulgaris, Aspergilli
Mouldy sugar cane fiber
Contaminated forced-air systems, heated water reservoirs
S. rectivirgula, T. vulgaris, various fungi
Bird breeder's lung
Pigeons, parakeets, fowl
Avian proteins (of bloom or faeces)
Metal working hypersensitivity pneumonitis
Microbially contaminated metal working fluid
Various moulds and bacteria
Cheese worker's lung
Malt worker‘s lung
Paprika splitter‘s lung
Mollusk shell hypersensitivity
Proteins in dust from sea snail shells or mother-of-pearl shells
Chemical worker’s lung, isocyanate alveolitis
Manufacture of plastics, polyurethane foam, rubber
Trimellitic anhydride, diisocyanates
EAA is associated with diffuse inflammation of lung parenchyma and airways in sensitized subjects including non-caseating interstitial granulomas and peribronchial mononuclear cell infiltration with giant cells. Although most affected subjects typically have high serum concentrations of circulating immunoglobulin G antibodies specific for the causative antigen(s), the diagnosis may be difficult as the symptoms are often non-specific, have typically a latency period of several hours, or may appear constitutional with malaise and weight loss; frequently they are gradually progressive over years, finally with persisting respiratory distress independent of the inducing exposure (Figures 1, 2, 3 and 4). Delays of years or even decades till the diagnosis is made are not uncommon, misdiagnoses include allergic asthma, COPD, recurrent flue and other infections. We recommend the following diagnostics schema for the disease pattern.
Diagnostic parameters of extrinsic allergic alveolitis
Exposure (work)-related cough, chest tightness, dyspnea, fever, with latency period of several hrs
Progressive flu-like symptoms during the exposure periods (e.g. working week) with solution at days off
Dyspnea on exertion
Weight loss in the absence of any other reason
Fine bibasilar end-inspiratory crackles in advanced chronic forms clubbing and respiratory distress
Presence of high serum concentrations of antigen-specific IgG antibodies
Lung function testing:
FVC < 80% predicted (below lower limit of normal) or
FVC < 70% pred. and/or TL,CO < 80% pred. or
TL,CO < 60% pred. or hypoxemia during exercise
Abnormal chest x-ray (nodular, patchy and/or diffuse ground glass pattern)
Abnormal HRCT (ground glass, nodular and/ or patchy opacities, mosaic or UIP pattern
Serial lung function testing and clinical investigations during antigen exposure periods and days off (for minimal diagnostic changes see SIC below):
Specific inhalation challenge (minimal changes after 5-12 hrs):
FVC and TLC -15%
TL,CO -15% or Pa,O2 – 7 mmHg
New fine bibasilar end-inspiratory crackles
Systemic symptoms (temperature + 1°C and leukocytosis + 2.5 × 109/L)
Case history: 4-8 hours following heavy exposure to an inciting agent patients develop fever, chills, malaise, cough, dyspnea, headache (acute course). Some cases don’t develop acute symptoms, rather, they have an insidious onset of these symptoms. Especially at lower exposures, patients gradually develop productive chronic cough, dyspnea on exertion, fatigue, anorexia, weight loss (subacute or intermittent course) (Table 2). These findings may be also present in patients who experience repeated acute attacks.
Physical examination: During the acute attack there are fever, tachypnea, and diffuse fine bibasilar end-inspiratory crackles upon auscultation. Further frequent findings include muscle wasting, weight loss, in the chronic pronounced form also clubbing, tachypnea, respiratory distress.
Lung function testing: A restrictive ventilatory pattern (i.e. reduced total lung capacity, vital capacity, and lung compliance) and impaired gas exchange parameters (reduced diffusing capacity, hypoxemia during exercise or even at rest) are typical features of the advanced chronic course. Also a mixed obstructive and restrictive ventilation pattern can develop.
IgG antibodies and other laboratory findings: High serum concentrations of IgG antibodies specific for causative antigens are found in c. 70% of affected patients (Figure 2). More problematic from the diagnostic view is that more than 50% of the prevailing exposed healthy subjects may show such antibodies, depending on the causative antigen(s) and sensitivity and specificity of the laboratory test used. So far, for most causative antigens validated laboratory tests are not available on the market. In addition to an immunocomplex-mediated process, cell-mediated immunity obviously plays an important pathophysiological role. However, no routine diagnostic test for displaying this cellular response is available yet. Other abnormal laboratory findings during acute and subacute courses include leukocytosis, neutrophilia, elevated erythrocyte sedimentation rate, and increased levels of quantitative immunoglobulins and C-reactive protein.
Radiological findings: The typical pictures are centrilobular micronodular (HRCT), patchy or reticular opacities which are mostly prominent in lower lung zones (Figure 3). Ground-glass opacities in the lower and middle lung zones and an interstitial pneumonitis-like pattern may be present during acute attacks. The end stage of the chronic course is characterized by fibrosis and even honeycombing predominant in the lower parts of the lungs. Emphysema may also occur .
Serial lung function testing during antigen exposure periods and days off (exhibiting changes as outlined under SIC and restitution of symptoms and impaired lung function during days off).
Specific inhalative challenge test (SIC): This is a laborious and time consuming diagnostic test by the use of the suspected causative agent. It should only be performed by well-experienced physicians. If done correctly it is a very sensitive and specific diagnostic method. See Table 2 and example in Figures. 1D, methodological methods have been published elsewhere [14,15], with the supplementary material from the European task force on SIC published online asthma additional Handbook of procedures for specific inhalation challenge testing http://erj.ersjournals.com/content/suppl/2014/03/07/09031936.00180313.DC1/Final_Handbook.pdf
Bronchoalveolar lavage: Bronchoalveolar lavage shows leukocytosis (neutrophilia) in the alveoli and small airways in the acute course followed by an influx of mononuclear cells (Figure 1D). In the subacute and chronic courses lymphocytosis with increased CD8 + cells and a CD4+/CD8+ ratio of < 1 are observed 6 hours post challenge.
Lung histology: Invasive diagnostics, i.e. lung biopsy, is usually not needed. In the acute course leukocytic inflammation is dominating. Lymphocyte-dominant interstitial inflammatory cell infiltration, well-formed interstitial epitheliod cell nonnecrotizing granulomas with giant cells are characteristic for the subacute and chronic courses. Cellular bronchiolitis and foci of bronchiolitis obliterans and intra-alveolar fibrosis may also occur. The chronic course includes an interstitial (organizing) pneumonia–like pattern with sub pleural patchy fibrosis, fibroblastic foci with centrilobular fibrosis, finally alveolar destruction (honeycombing) [16,17].
- 10.Integrated diagnostic approach: Above steps 1 through 5 present basic routine diagnostics. If all of them exhibit concordant positive findings diagnosis of extrinic allergic alveolitis is sufficiently likely. If one or more of the respective 6 parameters is/are negative or equivocal at least one additional diagnostic procedure is needed, i.e. serial lung function testing during antigen exposure periods and days off (combined with follow-up of clinical symptoms) or specific inhalation challenge test, bronchoalveolar lavage or lung biopsy (Table 3).Table 3
Summary of diagnostic criteria
Routine, basic diagnostics:
Case history: Exposure to relevant antigen(s)
Exposure-related respiratory and systemic symptoms
Specific IgG antibodies to relevant antigens (i.e. antigen-HSA-conjugates)
Bibasilar end-inspiratory crackles (lower lung)
Lung nodular, patchy and/or ground glass pattern in chest x-ray or HRCT
Restrictive ventilation pattern (FVC, TLC) and reduced gas exchange parameters (TL,CO; Pa,O2)
Facultative diagnostic parameter.
If not all of the before-mentioned parameters are fulfilled at least one additional positive parameter is needed
Serial lung function testing during antigen exposure periods and days off (exhibiting changes as outlined under SIC as well as restitution of symptoms and impaired lung function during days off) or
specific inhalative challenge test (exhibiting changes as outlined in Table 2)
BAL showing lymphocytosis with ratio of CD4/CD8 < 1 or
typical histopathological findings
Case 1 (farmers’ lung)
Case history: The 53 year old farmer has suffered for 5 years from cough, progressive shortness of breath during exertion, chills and fever in late evenings and nights during winter months. He always feed his 40 cows hay which was frequently mouldy.
Physical examination: Inspiratory crackles on basal lung fields.
Lung function testing: A restrictive ventilatory pattern (i.e. reduced total lung capacity, vital capacity, and lung compliance) and impaired gas exchange parameters.
IgG antibodies: High serum concentrations of IgG antibodies for aspergillus species and.
Radiological findings: Patchy opacities on both lower and middle lung fields.
Bronchoalveolar lavage: Bronchoalveolar lavage showed leukocytosis (neutrophilia) in the alveoli and small airways in the acute phase followed by an influx of mononuclear cells.
Case 2 (humidifier lung)
Figure 1C shows humidifier water of a printing plant where several heavily microbially contaminated humidifiers were installed and our 33 year old patient was employed. For chest x-ray findings see Figure 3.
Case history: He had complained of flu-like symptoms and chronic productive cough for more than 6 years without seasonal variation and increasing shortness of breath on exertion.
IgG antibodies: Serum IgG antibody analysis (Figure 2B) showed extremely high concentrations for the extract of the probe shown in Figure 1C, and lower concentrations for a variety of moulds and bacteria.
Specific inhalative challenge test: This was done by means of this humidifier water probe produced after a latency of 4 hours increasing cough, dyspnea, fever, a significant falls of vital capacity and arterial oxygen partial pressure, lasting for 3 hours.
Prevention and Treatment
The best outcome is offered by early recognition and consistent prevention of further exposures. To avoid the causative agent(s) is also the only effective measure to prevent relapses, the typically progressive disorder and permanently impaired lung function. Corticosteroids may be needed in cases with severe acute courses (starting with 0.5-1 mg prednisone/kg). Less sever acute courses abate without treatment.
XB testified in occupational diseases litigation on behalf of here described plaintiff cases and provide independent expert opinion for social courts or statutory insurances.
- Blatman KH, Grammer LC. Chapter 19: Hypersensitivity pneumonitis. Allergy Asthma Proc. 2012;33 Suppl 1:S64–6.View ArticlePubMedGoogle Scholar
- Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest. 2012;142:208–17.View ArticlePubMedGoogle Scholar
- Selman M, Pardo A, King Jr TE. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Am J Respir Crit Care Med. 2012;186:314–24.View ArticlePubMedGoogle Scholar
- Baur X. Hypersensitivity pneumonitis (extrinsic allergic alveolitis) induced by isocyanates. J Allergy Clin Immunol. 1995;95:1004–10.View ArticlePubMedGoogle Scholar
- Robertson W, Robertson AS, Burge CB, Moore VC, Jaakkola MS, Dawkins PA, et al. Clinical investigation of an outbreak of alveolitis and asthma in a car engine manufacturing plant. Thorax. 2007;62:981–90.View ArticlePubMed CentralPubMedGoogle Scholar
- Weiss W, Baur X. Antigens of powdered pearl-oyster shell causing hypersensitivity pneumonitis. Chest. 1987;91:146–8.View ArticlePubMedGoogle Scholar
- Baur X, Behr J, Dewair M, Ehret W, Fruhmann G, Vogelmeier C, et al. Humidifier lung and humidifier fever. Lung. 1988;166:113–24.View ArticlePubMedGoogle Scholar
- Fox J, Anderson H, Moen T, Gruetzmacher G, Hanrahan L, Fink J. Metal working fluid-associated hypersensitivity pneumonitis: an outbreak investigation and case-control study. Am J Ind Med. 1999;35:58–67.View ArticlePubMedGoogle Scholar
- Lacasse Y, Cormier Y. Hypersensitivity pneumonitis. Orphanet J Rare Dis. 2006;1:25.View ArticlePubMed CentralPubMedGoogle Scholar
- Rose C, King Jr TE. Controversies in hypersensitivity pneumonitis. Am Rev Respir Dis. 1992;145:1–2.View ArticlePubMedGoogle Scholar
- Dalphin JC, Debieuvre D, Pernet D, Maheu MF, Polio JC, Toson B, et al. Prevalence and risk factors for chronic bronchitis and farmer's lung in French dairy farmers. Br J Ind Med. 1993;50:941–4.PubMed CentralPubMedGoogle Scholar
- Lacasse Y, Selman M, Costabel U, Dalphin JC, Ando M, Morell F, et al. Clinical diagnosis of hypersensitivity pneumonitis. Am J Respir Crit Care Med. 2003;168:952–8.View ArticlePubMedGoogle Scholar
- Hanak V, Golbin JM, Hartman TE, Ryu JH. High-resolution CT findings of parenchymal fibrosis correlate with prognosis in hypersensitivity pneumonitis. Chest. 2008;134:133–8.View ArticlePubMedGoogle Scholar
- Munoz X, Sanchez-Ortiz M, Torres F, Villar A, Morell F, Cruz MJ. Diagnostic yield of specific inhalation challenge in hypersensitivity pneumonitis. Eur Respir J. 2014;44:1658–65.View ArticlePubMedGoogle Scholar
- Vandenplas O, Suojalehto H, Aasen TB, Baur X, Burge PS, De Blay F, et al. Specific inhalation challenge in the diagnosis of occupational asthma: consensus statement. Eur Respir J. 2014;43:1573–87.View ArticlePubMedGoogle Scholar
- Lima MS, Coletta EN, Ferreira RG, Jasinowodolinski D, Arakaki JS, Rodrigues SC, et al. Subacute and chronic hypersensitivity pneumonitis: histopathological patterns and survival. Respir Med. 2009;103:508–15.View ArticlePubMedGoogle Scholar
- Takemura T, Akashi T, Ohtani Y, Inase N, Yoshizawa Y. Pathology of hypersensitivity pneumonitis. Curr Opin Pulm Med. 2008;14:440–54.View ArticlePubMedGoogle Scholar
- Budnik LT, Preisser AM, Permentier H, Baur X. Is specific IgE antibody analysis feasible for the diagnosis of methylenediphenyl diisocyanate-induced occupational asthma? Int Arch Occup Environ Health. 2013;86:417–30.View ArticlePubMed CentralPubMedGoogle Scholar
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