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A Lady and Her Bird
Occupational and Environmental Lung Diseases SESSION TITLE: Student/Resident Case Report Poster - Occupational and Environmental Lung Diseases SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Ross Humes MD* Whittney Warren MD; and Erik Osborn MD Walter Reed National Military Medical Center, North Bethesda, MD INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung disease caused by immune reactions to inhaled agents. Known offending agents include agricultural dust, aerosolized contaminated water, bird droppings, and mold, among others. Diagnosis is made when clinical suspicion is high, and with the aid of high-resolution CT scan, bronchioalveolar lavage (BAL), lung biopsy, and at times, antigenic panels. CASE PRESENTATION: A fifty-one-year-old woman with history of poorly-controlled asthma was referred to pulmonology clinic for evaluation of chronic cough and wheezing. Initial work-up included a chest x-ray revealing prominent interstitial markings, an elevated IgE level and a negative anti-nuclear antibody. The patient was started on Spiriva without improvement. Computed tomography of the chest was performed, displaying interstitial lung disease, concerning for HP. Upon further questioning, the patient had an indoor pet bird, further strengthening the suspicion for HP. An HP panel (aspergillus fumigatus, micropolyspora faeni, thermoactinomyces vulgaris, aurebasidium pullilans, thermoactinomyces sacchari, and pigeon serum) was negative, however, causing the patient to question the underlying etiology of her symptoms.The patient was instructed to remove the bird from her house, but was hesitant to do so given her negative HP panel. To rule out other etiologies, bronchoscopy with BAL was performed. Results yielded elevated lymphocyte and eosinophil counts, but negative cultures. These findings were consistent with a diagnosis of HP. At follow-up, the patient’s clinical course had deteriorated and she required supplemental oxygen. The patient was treated with steroids, and was again instructed to remove the bird from her home. Reluctantly, the patient did so. One month later, the patient’s chronic respiratory symptoms had improved. She no longer required supplemental oxygen. DISCUSSION: Hypersensitivity pneumonitis is a severe, but reversible, cause of interstitial lung disease. The utility of antigenic panels in the diagnosis of HP is controversial. It has been shown that these panels can be useful if one chooses appropriate antigens for the geographical region of interest. However, it has also been shown that a positive antigenic panel does not correlate with symptoms of HP. In this case, the use of an antigenic panel was detrimental to the treatment of the patient, as it led to questioning of the diagnosis and inciting allergen. This led to a delay in the primary treatment of this condition, which is removal of the offending agent. CONCLUSIONS: Antigenic panels can be useful, provided they contain pertinent antigens to the geographic region or animal of interest, but these tests must be considered within the context of the entire patient case, when diagnosing HP. Reference #1: Spagnolo P, Rossi G, Cavazza A, Bonifazi M, et al. Hypersensitivity Pneumonitis: A Comprehensive Review. J Investi Allergol Clin Immunol. 2015; vol.25(4):237-250 DISCLOSURE: The following authors have nothing to disclose: Ross Humes, Whittney Warren, Erik Osborn No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1038
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
937A
OCCUPATIONAL AND ENVIRONMENTAL LUNG DISEASES
A Lady and Her Bird
Ross Humes MD* Whittney Warren MD; and Erik Osborn MD Walter Reed National Military Medical Center, North Bethesda, MD INTRODUCTION: Hypersensitivity pneumonitis (HP) is a broad characterization of interstitial lung disease caused by immune reactions to inhaled agents. Known offending agents include agricultural dust, aerosolized contaminated water, bird droppings, and mold, among others. Diagnosis is made when clinical suspicion is high, and with the aid of high-resolution CT scan, bronchioalveolar lavage (BAL), lung biopsy, and at times, antigenic panels. CASE PRESENTATION: A fifty-one-year-old woman with history of poorly-controlled asthma was referred to pulmonology clinic for evaluation of chronic cough and wheezing. Initial work-up included a chest x-ray revealing prominent interstitial markings, an elevated IgE level and a negative anti-nuclear antibody. The patient was started on Spiriva without improvement. Computed tomography of the chest was performed, displaying interstitial lung disease, concerning for HP. Upon further questioning, the patient had an indoor pet bird, further strengthening the suspicion for HP. An HP panel (aspergillus fumigatus, micropolyspora faeni, thermoactinomyces vulgaris, aurebasidium pullilans, thermoactinomyces sacchari, and pigeon serum) was negative, however, causing the patient to question the underlying etiology of her symptoms.The patient was instructed to remove the bird from her house, but was hesitant to do so given her negative HP panel. To rule out other etiologies, bronchoscopy with BAL was performed. Results yielded elevated lymphocyte and eosinophil counts, but negative cultures. These findings were consistent with a diagnosis of HP. At follow-up, the patient’s clinical course had deteriorated and she required supplemental oxygen. The patient was treated with steroids, and was again instructed to remove the bird from her home. Reluctantly, the patient did so. One month later, the patient’s chronic respiratory symptoms had improved. She no longer required supplemental oxygen. DISCUSSION: Hypersensitivity pneumonitis is a severe, but reversible, cause of interstitial lung disease. The utility of antigenic panels in the diagnosis of HP is controversial. It has been shown that these panels can be useful if one chooses appropriate antigens for the geographical region of interest. However, it has also been shown that a positive antigenic panel does not correlate with symptoms of HP. In this case, the use of an antigenic panel was detrimental to the treatment of the patient, as it led to questioning of the diagnosis and inciting allergen. This led to a delay in the primary treatment of this condition, which is removal of the offending agent. CONCLUSIONS: Antigenic panels can be useful, provided they contain pertinent antigens to the geographic region or animal of interest, but these tests must be considered within the context of the entire patient case, when diagnosing HP. Reference #1: Spagnolo P, Rossi G, Cavazza A, Bonifazi M, et al. Hypersensitivity Pneumonitis: A Comprehensive Review. J Investi Allergol Clin Immunol. 2015; vol.25(4):237-250 DISCLOSURE: The following authors have nothing to disclose: Ross Humes, Whittney Warren, Erik Osborn No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1038
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
937A
OCCUPATIONAL AND ENVIRONMENTAL LUNG DISEASES
A Lady and Her Bird