INTRODUCTION: Hypersensitivity pneumonitis (HP) constitutes a spectrum of granulomatous, interstitial, bronchiolar and alveolar filling lung diseases caused by exposure to wide variety of organic aerosols and low molecular weight chemical antigens. It is an immune mediated lung disease which can present in acute, sub acute or chronic form. Presenting symptoms include fever, chills, malaise, cough, chest tightness, dyspnea, and headache. The elusive diagnosis is achieved by performing clinical, radiological, physiological, and immunological evaluations. Limbrel is an anti inflammatory agent used for treatment of osteoarthritis. Here we are describing a case where use of Limbrel was associated with HP.
CASE PRESENTATION: A 64 year old female with history of hypertension and osteoarthritis presented to her physician with complaints of fever, fatigue, diarrhea, dry cough and shortness of breath for a week. Diagnosis of an acute viral illness was made. Her symptoms worsened and azithromycin was started for presumed pneumonia. Patient’s condition deteriorated and patient was admitted to the hospital. She was found to be hypoxic with oxygen saturation in low 80s. Chest x-ray showed bibasilar infiltrates and CT chest confirmed bilateral lower lobe consolidation. Her 4 day hospital course resulted in remarkable improvement and no oxygen was required on discharge. Two days after discharge patient became symptomatic again and she was hospitalized. Patient had bronchoscopy with transbronchial biopsy which showed interstitial inflammation and pattern of mild cellular interstitial pneumonitis. However, other diagnostic histologic features, such as granulomas were not present. All obtained cultures bacterial, fungal & viral nucleic acid amplification test (NAAT) were negative. Pulmonary function tests (PFT) showed normal spirometry and lung volumes however diffusion capacity was mildly reduced. She received broad spectrum antibiotics and her symptoms improved. One week after discharge, she returned to the hospital with the same symptoms. Prednisone was initiated for presumed cryptogenic organizing pneumonia. Again she showed remarkable improvement and was discharged. She remained asymptomatic for a week at home, then called with complaints that her symptoms have returned back. She disclosed that she had resumed Limbrel (Flavocoxid) one day prior and wondered if this was linked to her disease process. Detailed interrogation revealed that this medication was started 10 days prior to her initial symptoms developing. She would stop the medication upon admission to hospital but resumed it once discharged. Patient was advised to stop this medication indefinitely. Her course of prednisone taper was resumed till completion. CT chest revealed complete resolution of the infiltrates, and follow up PFT completely normalized. Patient remained free of any respiratory symptoms.
DISCUSSIONS: The acute form of HP presents after heavy exposure to the provoking antigen over a short period of time. Symptoms usually develop within 4 to 8 hours and are similar to an acute viral infection. The patient will usually recover in about 18 to 24 hours after cessation of exposure. Early treatment of acute or subacute disease results in a complete recovery for most patients. Our patient clearly demonstrated that regardless of our intervention, avoidance of inciting medication lead to remarkable improvement. Medications known to cause HP include methotrexate and gold. This presentation, to the best of our knowledge, is the first case where use of limbrel was associated with development of HP.
CONCLUSION: Acute HP frequently mimics presentation of acute viral illness, atypical pneumonia or bronchitis and can be easily misdiagnosed.Diagnosis is based on detailed clinical history, physical examination, and characteristic radiographic presentation and laboratory findings The most important aspect of management is identification of the inciting antigen so that avoidance measures can be implemented. Frequently, avoidance alone is sufficient intervention.
DISCLOSURE: John Youssef, No Financial Disclosure Information; No Product/Research Disclosure Information