SESSION TITLE: Diffuse Lung Disease Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Hypersensitivity pneumonitis (HP) or extrinsic allergic alveolitis syndrome, presents nonspecific symptoms and clinical signs leading to frequent sub-diagnosis, being confused with infectious or different pulmonary diseases. Three main categories of antigens that cause HP: animal proteins, low molecular weight chemicals and microbial antigens. In High Resolution Computed Tomography (HRCT), the presence of two of this signs is indispensable: ground-glass opacities, mosaic perfusion (expiratory air trapping) and central lobular nodules. A very well documented by image HP case is related
CASE PRESENTATION: MFPS, female, 45, artisan, resident in Rio de Janeiro, Brazil. Patient with multiple comorbidities (fibromyalgia, bronchial asthma, allergic rhinitis, anxiety and depression) making use of antidepressants, anxiolytics, inhaled and nasal corticosteroids. Monitored by the pulmonology clinic due to respiratory allergy chronic state, relatively controlled, with occasional episodes of dry cough and dyspnea, frequently associated by emotional instability periods without additional medical treatment necessity. In certain moment report clinical worsening with intense cough with mucus sputum, respiratory discomfort and general condition decline. Emerged pulmonary sounds atypically developed (squawks). Denied fever, weight loss or any symptoms. The radiographic evaluation showed diffuse bilateral pulmonary opacities. Was performed HRCT of the chest revealing multifocal opacities in ground glass, interlobular septum thickening and air trapping (mosaic perfusion pattern). Functional pulmonary evaluation at this moment revealed FVC pre BD 52%, post BD 58% (change 8%), FEV1 pre BD 58%, post BD 61%, variation 6% and FEV1/FVC ratio 0.90 and 0.87. Carbon monoxide diffusing capacity of 68% predicted. Reported that clinical worsening began simultaneously at the period she became keeper of birds in confinement. The association of clinical presentation, imaginological features, pulmonary sounds compatible with squawks with epidemiological aspects led to suspicion of PH. Taking account the clinical stability, the initial therapeutic approach was to request the removal of the possible precipitating factors with close monitoring of the rolling aspect, not starting any specific drug treatment. After an absence period of 3 months was prompted new pulmonary function evaluation with pre BD FVC 83.5%, post BD 89.9%, variation of 7.7%, pre BD FEV1 90.5%, 93.7% post BD, variation 3.5% and FEV1/FVC 0.88 and 0.84, and new imaginologic review observed improvements with complete resolution of the changes found on the initial HRCT, leaving discrete areas of air trapping.
DISCUSSION: The association of clinical presentation with symptoms that suddenly appeared in (ssociated with exposure to predisposing factors (avian antigens) and imaging findings on HRCT led to formulation of the diagnosis of PH.Due to the clinical stability of the patient was decided to therapy based on removal of the trigger factor with close monitoring of the progress n order to identify any type of clinical worsening or appearance of some manifestation that could raise suspicion of alternative diagnoses making some kind of additional therapeutic approach necessary. After three months of removal was performed new tests for pulmonary function and chest images where it can be seen significant clinical improvement and complete resolution of the changes found in the initial chest tomography as well as the parameters of the evaluation of pulmonary function.
CONCLUSIONS: PH is presented often as a diagnostic challenge and is associated to numerous inadequate therapeutic approaches on account of its nonspecific aspects and occasional difficulty to associate the development of pulmonary changes with the triggering agent. In this particular case, the association was performed very clearly due to concomitant clinical factors and the start of contact with antigen aviary, which facilitated both the issues of diagnosis and the choice of a conservative approach that revealed itself adequate.
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Reference #2: Dalphin, J.C; Didier, A. Environmental causes of the distal airways disease. Hypersensivity pneumonitis and rare causes. Rev Mal Respir. Oct;30(8):669-81, 2013.
Reference #3: Selman, M; Buendía-Roldán, I. Immunopathology, diagnosis, and management of hypersensitivity pneumonitis. Semin Respir Crit Care Med. Oct;33(5):543-54, 2012.
DISCLOSURE: The following authors have nothing to disclose: Gilmar Zonzin, Luise Oliveira, Marina Freitas, Marina Faria, Bruno Severino, Mariana Rolim, Lais Poncheli, Ricardo Laviola
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