Pigeon breeder`s disease as a cause of hypersensitivity pneumonia in children.

BACKGROUND AND OBJECTIVES: Hypersensitivity pneumonia is a complex condition due to exposure time, intensity, different clinical presentation, and treatment practices. We aimed to evaluate the patients that were diagnosed with hypersensitivity pneumonia (HSP) due to exposure to pigeons and a review of the literature for diagnosis and treatment of Pigeon Breeder`s Disease (PBD) in children. METHOD: Between the years of 2009-2018, patients who were diagnosed with HSP due to PBD were included in the study in a pediatric pulmonology department. Findings of our patients, treatments, and prognoses were compared with 17 articles in the literature about PBD in children. RESULTS: In a 9 year-period, 6 patients were diagnosed as HSP due to PBD. The mean age of the patients was 8.8 ± 5.4 years and the average duration of pigeon exposure was 60.1 ± 6.5 days. Precipitating antibodies were positive in 3 patients. In four cases, symptoms were resolved with only prevention of pigeon exposure. Two patients who had close contact with pigeons needed oxygen supplementation and steroid therapy. CONCLUSION: Hypersensitivity pneumonia should be considered for the differential diagnosis of patients that present with respiratory distress, cough, fever, and weight loss. Prolonged exposure and close contact may worsen the clinical symptoms. In most cases, only exposure prevention is enough, while steroid therapy, oxygen support, and intensive care monitoring may be required in severe cases.

Bird fancier's lung: a state-of-the-art review.

Bird fancier's lung (BFL) resulting from avian antigen exposure is a very common form of hypersensitivity pneumonitis. Its pathogenesis is modified by genetic polymorphisms located within the major histocompatibility complex, and also by smoking, which may decrease serum antibody response to inhaled antigen. Acute, subacute, and chronic presentations of BFL are recognized, but often overlap clinically. Continued antigen exposure in the chronic phase portends a worse prognosis. Chronic bronchitis symptoms may be part of the BFL clinical spectrum, and rhinitis may suggest an allergic component. The diagnosis of BFL is enhanced by a high index of suspicion of exposure to avian antigen, recurrent symptomatic episodes occurring 4-8 h after exposure, inspiratory "velcro" crackles on auscultation, weight loss, and positive IgG precipitins to the antigen. Characteristic findings on high-resolution computed tomography of the chest include centrilobular nodules, ground-glass opacification, and mosaicism due to air trapping. Bronchoalveolar lavage will classically show >25% lymphocytosis, a CD4/CD8 ratio of <1.0 and >1% mast cells in the acute phase. Lung biopsies, if obtained in the subacute phase of the disease, typically show loosely formed granulomas, giant cells, a lymphoplasmacytic interstitial infiltrate, and possibly some degree of fibrosis. In some patients, usual interstitial pneumonia or fibrotic non-specific interstitial pneumonia patterns may be seen on surgical biopsy. Skin testing, serological testing, and bronchial provocation tests for BFL frequently suffer from a lack of standardization. Effective treatment for BFL consists mainly of antigen avoidance, as corticosteroids likely do not alter long-term prognosis. Lung transplantation can be considered for progressive chronic disease refractory to medical measures.

Not all children with nodular interstitial lung patterns in South Africa have TB-A rare case of paediatric "Bird Fanciers' disease".

Bird Fancier's disease is an allergic alveolitis that is rare in children. We describe the relevance of adequate history for making the diagnosis in children and the difficulty distinguishing this entity on chest radiographs and CT from imaging patterns caused by infections such as tuberculosis and HIV in developing countries. Pediatr. Pulmonol. 2011; 46:1134-1136. © 2011 Wiley Periodicals, Inc.

The prevalence of "pigeon breeder's disease" in a Turkish city and review of the literature.

Hypersensitivity pneumonitis (HP) is a rarely encountered inflammatory interstitial lung disease caused by various antigens. Studies in the literature report contradictory rates about its prevalence. The aim of the present study was to determine the prevalence of "pigeon breeder's disease" (PBD) among pigeon breeders in Samsun province. The present study was performed in two phases. In the first phase, we contacted the Samsun Serinofil Association (Samsun Serinofil Dernegi) and a detailed questionnaire was given to the pigeon breeders to fill out. In the second phase, advanced diagnostic tests such as chest X-ray, high-resolution chest computed tomography, pulmonary function tests, natural provocation, bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TBLB) were used to verify the diagnosis in those suspected with PBL. The questionnaire was administered to 185 male volunteers, of whom 11 had suspicious findings. Of eight subjects in whom the natural provocation was performed, one had a positive (acute PBL) response. After discontinuation of exposure, clinical improvement was observed in the second subject (subacute HP), of whom the radiological findings, BAL, and TBLB results were consistent with PBL. The third subject, who had dyspnea for 28 years, was diagnosed with chronic PBL. Consequently, the prevalence of PBL and the positivity of the natural provocation were 1.6 and 12.5%, respectively. In the present study, in which the prevalence of PBL was determined using natural provocation for the first time, the prevalence of HP (1.6%) was quite low compared with previous studies. The present study has demonstrated that a study solely based on a questionnaire is not adequate in determining the prevalence of HP.

Hypoxemia: an early indication of pigeon breeders' disease. Clinical and laboratory findings among pigeon breeders in the Salonica area.

The purpose of this study is to identify pathological findings among pigeon breeders in the Salonica area. Fifty-four volunteer breeders with varying intensity of contact with pigeons participated in the study. All the breeders, after filling in a questionnaire that included questions about the existence of conjunctivitis, rhinitis, chronic cough and sputum, were subjected to clinical examination and spirometric, hematological (arterial and venous), radiographic and immunologic tests. Twenty-five point nine percent of the breeders suffered from conjunctivitis, 31.5% from rhinitis and 33.3% from chronic cough and sputum. Fourteen point eight percent of them had class I precipitins, 7.4% had class II, 5.6% had class III and 16.7% had class IV and a positive correlation of precipitin class with the number of pigeons bred was found. Seven breeders (13%) had hypoxemia at rest and other 8 (14.8%) presented with hypoxemia after the exercise testing. Two breeders presented with a combination of findings of allergic alveolitis that satisfied the criteria of the Pigeon Breeders' Disease (PBD). A substantial number of the examined pigeon breeders were sensitized to pigeon serum antigens. Arterial hypoxemia, either at rest and/or after exercise was observed in 27.8% of breeders. Three point seven percent of breeders presented with clinical and laboratory findings consistent with PBD. Chronic cough and sputum in pigeon breeders should be considered as a possible manifestation of PBD.

Neumonitis por hipersensibilidad en la ciudad de México / hypersensitivity pneumonitis in Mexico City

Objetivo. Determinar la asociación entre la zona urbana de origen del paciente en la ciudad de México y la prevalencia de neumonitis por hipersensibilidad inducida por antígeno aviario. Material y métodos. Se trata de un estudio de casos y controles realizado en el Instituto Nacional de Enfermedades Respiratorias, en la ciudad de México, en el año de 1999. Se estudiaron 109 casos con neumonitis por hipersensibilidad y 184 controles: de éstos, 39, con fibrosis pulmonar idiopática; 63, con tuberculosis pulmonar, y 82, con asma. La ciudad de México y las zonas conurbadas se dividieron en cinco zonas geográficas: centro, noreste, sureste, noroeste y el suroeste. Se calcularon las prevalencias de las diferentes enfermedades por zona urbana de los pacientes que participaron en el estudio; como medida de asociación, se estimó la razón de momios, con un intervalo de confianza al 95 por ciento. Asimismo, se realizó regresión logística múltiple ajustando por edad, sexo y estrato socioeconómico. Resultados. Ochenta casos de neumonitis por hipersensibilidad se concentraron en el sur del noreste de las zonas conurbadas y la parte norte del sureste de la ciudad de México, 48 y 32, respectivamente (RM= 3.86, IC 95 por ciento 2.17-6.96). Treinta y seis controles de asma se localizaron en el suroeste de la ciudad de México, zona donde se ubica el Intituto Nacional de Enfermedades Respiratorias (p<0.05) y cuatro en la zona co-nurbada. Los controles de tuberculosis pulmonar y fibrosis pulmonar idiopática estuvieron dispersos en la ciudad de México y en las zonas conurbadas. Conclusiones. La zona sur del noreste y el norte de la sureste están asociadas a la neumonitis por hipersensibilidad. Las causas de esta asociación no parece ser geográfica, pero existe el antecedente de que esa zona fue basurero de la ciudad, por lo que partículas orgánicas en el ambiente pudieran coadyuvar a la aparición de esta enfermedad.

Pigeon fanciers' lung: effects of smoking on serum and salivary antibody responses to pigeon antigens.

A reduced prevalence of pigeon fanciers' lung has been reported in pigeon breeders who smoke cigarettes. Serum and salivary antibodies to pigeon intestinal mucin and pigeon serum proteins were investigated in 227 pigeon fanciers, subdivided according to smoking habit and clinical status. Smokers had a lower incidence of precipitating antibodies to pigeon antigens and lower titres of serum IgG and IgA antibodies to mucin and to pigeon serum proteins in ELISA compared with non-smokers and ex-smokers. In contrast, IgG antibody titres to tetanus toxoid were similar in smoking and non-smoking groups. In contrast to serum antibodies, salivary IgA antibody titres to pigeon antigens were similar in smokers and non- or ex-smokers. Approximately one third of the smokers reported symptoms consistent with pigeon fanciers' lung but did not have precipitating antibodies. Only some individuals with precipitating antibodies had disease symptoms, and IgG antibody titres in these individuals were not significantly higher than in many asymptomatic individuals. Salivary IgA titres against pigeon mucin were significantly higher in asymptomatic individuals, consistent with a protective role for these antibodies. The results confirm that smoking is associated with a decreased serum antibody response to inhaled pigeon antigens, affecting IgG1, IgG2 and IgA responses, but this impairment does not extend to salivary IgA or to antibody responses to a parenterally administered protein antigen. The fact that responses to pigeon serum proteins and to pigeon intestinal mucin were similarly affected suggests that cigarette smoking depresses both T-independent and T-dependent responses to inhaled antigens.

[Sensitization in budgerigar owners]. / Sensibilisierungen bei Wellensittichhaltern.

In a prospective study 258 adults were investigated for sensitisation against bird antigens (budgerigar, canary, pigeon) using intracutaneous test. 18 of 78 budgerigar keepers were sensitised against budgerigar feathers. 30 (38%) showed a positive skin reaction at least with one of the three extracts tested. In none bird exposed persons a sensitisation was found in 18/96 (19%) against budgerigar and in 24/96 (25%) against at least one of the three allergen extracts. Late reactions occurred in 5/70 (7%) budgerigar keepers, 4/5 with pigeon feathers. The frequency of sensitisation against budgerigar antigens increased to 48% of bird keepers (24/50) if the birds could fly in their homes instead of being caged always (4/22, 18%). Three of the 78 budgerigar keepers (4%) had a positive nasal provocation with feathers extract, they were skin positive against all three bird antigens tested.

[Lung function in workers in a chicken slaughterhouse in the city of Maracaibo, Venezuela]. / Estudio de la función pulmonar en trabajadores de una industria beneficiadora de pollos en la ciudad de Maracaibo, Venezuela.

In order to evaluate the respiratory health status in workers exposed to antigenic substances (chicken feathers, serum and dropping), typical of usual practice in the avian slaughter-house, pulmonary function was studied on 49 exposed workers, and in a sample of 49 people with similar anthropometric characteristics, non exposed to these substances, by means of occupational-medical history, spirometric tests, hematologic and biochemical tests, and postero-anterior chest x-rays. The values for the spirometric parameters varied with sex, age, weight, size, smoking habits, length of employment and exposure time, and there were no significant differences between exposed and control groups as a whole; showing significant differences with decreasing values for CVF, VEF1, PFE, FEF-25% and FEF-50% in the intermediate zone workers, and in subjects with short exposure time (< 1 year). Prevalence of clinical findings in the exposed population was significantly higher than the non exposed group (p < 0.001). Laboratory tests showed reduction of monocytes cells in the exposed group (p < 0.05) in addition, in the exposed women there was an increase of the eosinophiles, total proteins and globulines (p < 0.05). The frequency of radiographic findings was significantly higher in the exposed group (p < 0.006), and they were no specific. The lack of association between clinical findings, laboratory and radiographic findings, with the spirometric results, could be explained by the short period of exposure, individual and collectives hygienic conditions and size of the sample.

[Extrinsic allergic alveolitis of occupational origin]. / Les alvéolites allergiques extrinsèques d'origine professionnelle.

Occupational factors encountered in farming and other agricultural activities produce a particular risk for respiratory diseases. For some, such as extrinsic allergic alveolitis, diagnosis depends upon a range of epidemiological, clinical, radiological and immunological arguments. Farmer's lung is one of the most common form of extrinsic allergic alveolitis. Bird breeder's lung is another, the list is long. The environmental allergens likely to affect alveoli and interstitial tissues have been identified, but simple detection of antibodies does not constitute a pathognomonic criterion of extrinsic allergic alveolitis. Co-immuno-electrodiffusion is a rapid and sensitive technique for the demonstration of remarkable precipitating systems of extrinsic allergic alveolitis. This investigation enables subjects who really have the disease to be distinguished from contact subjects. Diagnosis is important to prevent development of a disabling and irreversible pulmonary fibrosis.

Relationships between characteristics of exposure to pigeon antigens. Clinical manifestations and humoral immune response.

An extensive clinical study has been performed on pigeon breeders in the Canary Islands. Three hundred forty-three subjects have participated in this study through the filling of a clinical and epidemiologic questionnaire. A venous blood sample was also taken from each fancier for a further serologic analysis. Detection of specific IgG antibodies was made by an indirect enzyme-linked immunosorbent assay (ELISA) using pigeon serum as antigenic material. Twenty-nine (8 percent) breeders fulfilled the "classic" pigeon breeders' disease (PBD) criteria. One hundred six (31 percent) had rhinitis, 62 (19 percent) had immediate bronchial symptoms, and 51 (15 percent) suffered from chronic bronchitis. A significant level of specific IgG was detected in 139 (40 percent) cases. Rates were correlated with pneumonitis symptomatology (p < 0.001) and with chronic bronchitis (p < 0.05). There was a significant association between the number of pigeons and the level of sensitization (p < 0.001). Finally, a statistical relationship between the intensity of exposure and specific IgG response was also found (p < 0.001). Titers of specific IgE could not be related either to the reported symptomatology in the questionnaire or to any of the exposure parameters analyzed.

Elevated levels of bronchoalveolar lavage vitronectin in hypersensitivity pneumonitis.

Vitronectin is an adhesive glycoprotein that is present in plasma and the extracellular matrix. Hypersensitivity pneumonitis (HP) is characterized by pulmonary inflammation and damage to the extracellular matrix. Perhaps reflecting this, fibronectin has been found to be elevated in the lower respiratory tract of subjects with HP. Vitronectin, like fibronectin, binds to both extracellular matrix components and cells and may mediate tissue remodeling. Thus, it was investigated whether vitronectin might be increased in bronchoalveolar lavage (BAL) fluid of patients with HP. Vitronectin and, for comparison, fibronectin were measured in BAL fluid from 16 patients with HP and nine healthy control subjects by enzyme-linked immunosorbent assay. Vitronectin was significantly increased in the HP group (658.4 +/- 121.8 ng/ml) compared with the controls (58.4 +/- 11.1 ng/ml, p < 0.001) and was found to be positively correlated with fibronectin. Patients whose last antigenic exposure was 4 or fewer days before the BAL had statistically significantly higher BAL vitronectin and fibronectin than did patients whose last exposure was 5 or more days before the BAL. The serum vitronectin levels did not differ. There was no significant relationship between the lavage fluid vitronectin and fibronectin levels and the BAL cell profile in HP. This study confirms that vitronectin, like fibronectin, is a normal constituent of the lower respiratory tract, and demonstrates that vitronectin is elevated in the lower respiratory tract of patients with HP and may play a role in tissue remodeling and fibrosis in this disease.

A comparison of the seroepidemiology of chlamydial infection in pigeon fanciers and farmers in the U.K.

A detailed comparative seroepidemiological study of antibody responses was performed in 271 pigeon fanciers and 100 farmers. Overall 73% of pigeon fanciers had IgG antibodies at a titre greater than or equal to 16 to Chlamydia pneumoniae, 39% to Chlamydia psittaci, and 6.6% to Chlamydia trachomatis. The prevalence of chlamydial antibodies was significantly lower in the farmers at 47% for C. pneumoniae, 6% for C. psittaci, and 2% for C. trachomatis. Both populations were exposed to complex microbiological and antigenic environments: 50.5% of the pigeon fanciers had antibodies to pigeon antigens, 34% to egg membrane, and 0.73% to yolk sac antigen, and 59% of the farmers had antibodies to Micropolyspora faeni, but the high prevalence of chlamydial antibodies could not be attributed to interaction with these antigens. There was considerable overlap of chlamydial antibody responses in the pigeon fanciers but not in the farmers: 36% of the pigeon fanciers had antibodies to C. pneumoniae alone, 5% to C. psittaci alone, and 31% to both agents, whereas only 3% of farmers had antibodies to both C. pneumoniae and C. psittaci. The high prevalence of antibodies to C. psittaci in the pigeon fanciers is compatible with the known avian reservoir for this infection. The particularly high prevalence of antibodies to C. pneumoniae suggests that complex interactions may be occurring in a population exposed to two chlamydial organisms, whereby infection with one species may provoke an anamnestic response against other chlamydial organisms with which the subject has previously been infected.

Prevalence of high hematocrits in patients with interstitial lung disease in Mexico City.

Erythrocytosis, a known response to chronic hypoxemia, is considered infrequent in interstitial lung diseases. We studied the prevalence of high hematocrit (Hct) values and the relationship between Hct and SaO2 in 79 patients with chronic pigeon breeder's lung (PBL) and 34 with idiopathic pulmonary fibrosis (IPF), all of whom lived in the Mexico City metropolitan area (2,240 m above sea level). Lung biopsy was performed in 31 patients with IPF and 71 with PBL. We analyzed only one simultaneous measurement of Hct and SaO2 per patient (usually the initial measurement) before treatment. No additional cause for anemia or erythrocytosis was detected. Forty-eight percent of the patients with PBL (38/79) and 62 percent of those with IPF (21/34) had high Hct values (greater than 2 SD above mean values for Mexico City); in 14 (12.3 percent) of the 113 patients (nine with PBL and five with IPF), the Hct was above 60 percent. The Hct and SaO2 values displayed a poor correlation for the whole group: Hct = 65.7-0.16(SaO2), r = 0.24, p = 0.012. The correlation between Hct and SaO2 was nonsignificant if patients were separated by diagnosis. For an SaO2 of less than 80 percent, the slope of SaO2 vs Hct was zero. Half of our patients with PBL and IPF had Hct values that were high for the altitude. In most cases, Hct responses fell within the confidence limits reported as normal at high altitudes. We found a poor relationship between Hct and awake SaO2.

Difference in the phenotypes of bronchoalveolar lavage lymphocytes in patients with summer-type hypersensitivity pneumonitis, farmer's lung, ventilation pneumonitis, and bird fancier's lung: report of a nationwide epidemiologic study in Japan.

We performed a nationwide epidemiologic study of hypersensitivity pneumonitis (HP) in Japan by questionnaire and found that 835 cases of HP were recognized during the 1980s; 74.4% were summer-type HP, 8.1% farmer's lung, 4.3% ventilation pneumonitis, 4.1% bird fancier's lung, 2.3% other types, such as chemical worker's lung, and 6.8% of unknown causative agent. It was found that the CD4/CD8 ratios of bronchoalveolar lavage (BAL) lymphocytes were significantly different with the type of disease. The ratio was 0.6 +/- 0.1 (mean +/- SEM) in summer-type HP (N = 271), 4.4 +/- 0.7 in farmer's lung (N = 22), 1.6 +/- 0.3 in ventilation pneumonitis (N = 19), and 2.0 +/- 0.5 in bird fancier's lung (N = 19). In farmer's lung, the CD4/CD8 ratio in smokers was 6.2 +/- 1.9 (N = 6) in contrast with 3.4 +/- 0.7 for nonsmokers (N = 16) (p less than 0.05). It has been generally considered that the phenotypes of BAL lymphocytes in patients with HP are predominately CD8 cells. Our present results, however, indicate that the phenotypes of BAL lymphocytes vary with the type of HP, probably depending on factors such as causative agent, smoking, or staging of the disease.

Clubbing in hypersensitivity pneumonitis. Its prevalence and possible prognostic role.

To know the prevalence and prognostic significance of finger clubbing in hypersensitivity pneumonitis induced by avian antigen, this physical sign was evaluated in 82 patients who were followed up from 1 to 5 years (mean, 2.6 years). According to clinical, roentgenographic, and functional criteria, the patients were classified in one of three stages at admission as well as at least 1 year later. Digital clubbing was retrospectively recorded as present or absent by physical examination. Our results showed that 44 patients (51%) included in this study presented clubbing at the time of diagnosis. Sixteen of these patients presented with worsening of their lung disease, whereas only 5 of the 38 patients without clubbing incurred a worsening of their condition. This finding suggests that digital clubbing is frequent in pigeon breeder's disease and may help to predict clinical deterioration.

Clinical and serologic follow-up of four children and five adults with bird-fancier's lung.

We report the clinical and serologic findings in four children and five adults with chronic avian hypersensitivity pneumonitis. All subjects were treated with corticosteroids and bird exposure was reduced or eliminated. After a variable period, ranging from 6 months to 10 years, their clinical and serologic findings were reassessed. In terms of symptomatology, chest findings, and pulmonary functions, all four children improved and four adults improved, whereas one adult had a progressive clinical deterioration, ultimately resulting in her death 5 years later. In terms of serologic data, precipitating antibody tended to persist, and antibody to avian antigens, as determined by ELISA, remained positive, although the titer declined. We conclude that, while serologic positivity remains, the prognosis for children and adults with chronic avian hypersensitivity pneumonitis is very good, provided that irreversible damage has not already occurred at the time of diagnosis.

[Allergic alveolitis among pigeon breeders in the county of Funen]. / Allergisk alveolitis blandt fynske dueholdere.

Two hundred pigeon breeders from the county of Funen were invited to participate in the study. No definite cases of allergic alveolitis were found among the 68 participants. 40% had experienced airway and/or general symptoms in connection with pigeon exposure. However, most of these symptoms could be explained as irritation of the airway and chronic bronchitis. Precipitating antibodies to pigeon serum and to an aqueous pigeon bloom extract were determined. The antibody titers did not differ in pigeon breeders with or without symptoms. Smokers had lower antibody titers to pigeon antigens and a lower level of total serum IgG, but reported symptoms in connection with pigeon exposure as often as non smokers.