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Importance of High Index of Suspicion in Diagnosing Hypersensitivity Pneumonitis: A Case Series FREE TO VIEW

Lahari Rampur*, MBBS; Shravan Kooragayalu, MBBS; Purvi Parikh, MD; Sunit Jariwala, MD; Golda Hudes, MD; D. Roseinstreich, MD
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Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY

Chest. 2012;142(4_MeetingAbstracts):473A. doi:10.1378/chest.1390806
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SESSION TYPE: ILD Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Hypersensitivity pneumonitis (HP) is a known cause of non-caseating granuloma. Without a thorough history, diagnosis can be missed. Since exposure elimination can be curative, diagnosis is crucial. We present three initially misdiagnosed patients with different lung disorders, but based on environmental history and elevated antigen-specific antibodies, were found to have HP.

CASE PRESENTATION: A 58-year-old female presented with cough but subsequently developed progressive dyspnea with pulmonary infiltrates, not resolved after multiple antibiotics. Evaluation revealed carpal tunnel, Raynaud’s, positive rheumatoid factor and high sedimentation rate. Initially diagnosed as scleroderma lung disease, although autoimmune work up was negative. Lung biopsy showed scattered, peribronchial, poorly formed granulomas, lymphocytic fibrosis, and eosinophils. Further questioning revealed that, dyspnea began after the patient moved to a new workplace. HP antibody panel was significantly positive for A.fumigatus precipitins, supporting HP. 44-year-old woman presented with cough for two months. Cough and rhinoconjunctivitis began shortly after cleaning her backyard. Imaging revealed bilateral hilar lymphadenopathy and lymph node biopsy revealed non-necrotizing granulomas with eosinophils. She was treated for sarcoidosis with steroids and improved without further treatment. However, autoimmune markers were never elevated. Further evaluation revealed positive hypersensitivity screen for Thermoactinomyces vulgaris IgG. Avoiding her backyard, she has remained asymptomatic, and her infiltrates/lymphadenopathy have resolved. 50-year-old male living in a damp basement presented with asthma, positive skin test to mold allergens, pulmonary infiltrates, and negative hypersensitivity screen and was originally diagnosed and treated as allergic bronchopulmonary aspergillosis. Chest CT revealed nodules bilaterally. Nodules, septal perforation and positive P-ANCA led to diagnosis of vasculitis. Nasal biopsy however revealed only chronic inflammation without evidence of vasculitis or granulomas. Lung biopsy revealed non-necrotizing granulomas, which the pathologist felt to be consistent with HP. The patient moved out of the moldy basement and not only clinically improved, but the p-ANCA became negative.

DISCUSSION: These initially misdiagnosed cases demonstrate unusual presentations of HP. Two patients had abundant eosinophils in their granulomas not commonly seen with HP. Negative hypersensitivity screen in the third patient does not exclude HP in the setting of strong history of exposure, radiologic and histologic findings, and improvement after removal of the offending agent.

CONCLUSIONS: High level of suspicion and a thorough environmental history are crucial in diagnosing HP.

1) Hypersensitivity Pneumonitis: A Historical, Clinical, and Radiologic Review-Jan V. Hirschmann, MD, Sudhakar N. J. Pipavath, MBBS and J. David Godwin, MD

DISCLOSURE: The following authors have nothing to disclose: Lahari Rampur, Shravan Kooragayalu, Purvi Parikh, Sunit Jariwala, Golda Hudes, D. Roseinstreich

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Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY




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