INTRODUCTION: Hypersensitivity Pneumonitis (HP) is a complex immune mediated reaction to a wide variety of various antigens. We present a case of HP from yet another offending agent, freshly printed bank notes, “Hard Cash”.
CASE PRESENTATION: A 45-year-old, life long non-smoker female was admitted with frequent episodes of productive cough, and dyspnea of 6 months duration. Her past medical history was unremarkable. She had been working as a money counter at a local bank for 20 years. She complained of strong odor, especially while counting freshly minted and cut banknotes. This was often followed by dry cough and tightness in the chest requiring hospitalizations on a few occasions. She denied any other occupational exposures. Physical examination revealed bibasilar crackles involving her lungs. Her C-reactive protein (CRP) and IgG level were elevated and IgE level was normal. Chest x-ray (CXR) revealed diffuse bilateral reticulonodular infiltrates. Pulmonary function tests revealed a mild restrictive defect (FEV1: 75%, FVC: 78 %, FEV1/FVC:81) and a normal diffusion capacity. She had mild hypoxemia (PO2:68mmHg). High resolution computerized tomography of the chest (HRCT) demonstrated diffuse ground glass opacities in a mosaic pattern suggestive of HP. Bronchoaleveolar Lavage revealed lymphocytosis (80%) with predominance of CD4+ T cells, transbronchial lung biopsy revealed foamy, alveolar macrophages, lymphocytes and plasma cells in form of granulomas along with minimal interstitial fibrosis. Her peak expiatory flow rates were best in the early mornings, got worse with the advanced hours of the day and were worst at the end of the week proving relationship between her occupation and symptoms. Hypersensitivity pneumonitis profile was not available. Based on clinical, radiological and bronchoscopy findings diagnosis of “subacute HP” was established. She was advised to keep away from counting the fresh banknotes and was started on Prednisolone 1mg/kg/day which was tapered to discontinue over the next 6 months. She improved clinically and her HRCT abnormalities significantly improved within 2 month of the therapy. She retired on the third month of the therapy and no recurrence has been observed since.
DISCUSSIONS: HP represents a heterogeneous group of diseases that result from repeated inhalation of and sensitization to various dispersed antigens which provokes a diffuse immunopathologic reaction of the small airways and the lung paranchyma. The development of disease is related to several factors, such as the nature and the amount of inhaled antigen, the duration and level of exposure and the host immune response which may be presented with a variety of clinical abnormalities. Based on these its presentation is classified as Acute, Subacute or Chronic.
CONCLUSION: To our knowledge, this is the first report of a “Hard Cash Hypersensitivity Pneumonitis”. Possible mechanisms such as inhalation of chipping dust of the money or printing dye and possible pathophysiology of HP will be discussed.
DISCLOSURE: Elif Kupeli, No Financial Disclosure Information; No Product/Research Disclosure Information