Bird fancier's lung: clinical-radiological presentation in 15 cases.

INTRODUCTION: Bird fancier's lung (BFL) is a type of hypersensitivity pneumonitis occurring in response to avian antigens (usually inhaled proteins in bird feathers and droppings). The diagnosis is based on a combination of clinical, radiological, and biopsy characteristics. The present study was planned to highlight the clinico-radiological presentation in cases of BFL. MATERIAL AND METHODS: The present study is a retrospective analysis of cases of bird fancier's lung diagnosed in a unit of Vallabhbhai Patel Chest Institute over a period of two years, from 2013-2014. The clinico-radiological features of the subjects were analysed. The diagnosis of BFL was made as per criteria laid down by Mark Schuyler and Yvon Cormier. RESULTS: There were a total of fifteen cases diagnosed with BFL during the study period, comprising twelve females and three males with a mean age of 54.93 ± 14.21 years. All the studied subjects gave significant history of exposure to pigeons and were non-smokers. The period of symptoms prior to presentation varied from one to eight years. The main symptoms on presentation were exertional breathlessness and cough. Radiologically, diffuse centrilobular nodules, ground glassing - diffuse or patchy predominant in upper lobes, fibrosis with or without traction bronchiectasis, honeycombing, and mediastinal lymphadenopathy were seen. Bronchoscopy showed ill-defined granulomas and chronic interstitial inflammation. CONCLUSIONS: BFL can exhibit a wide range of radiological patterns, and a high index of suspicion must be maintained, with particular attention to detailed exposure history in every case of interstitial lung disease.

[Acute bird-related hypersensitivity pneumonitis: radiological findings in a case in the early phase after onset].

A 71-year-old woman was admitted to our hospital four times because of high fever and dyspnea from September to November in 2007. We treated her with antibiotics on her first two admissions. HOwever, we suspected hypersensitivity pneumonitis on the third admission because she suffered from fever and dyspnea soon after she had been discharged and returned home. She recovered only with the oxygen therapy on the last two admissions. Computed tomography of the chest showed early phase localized consolidation but changed to ground-glass opacities spreading over the entire lung field later during her third and fourth admissions. Bronchial alveolar lavage showed increases in total cell count, lymphocytes and IgA of pigeon-dropping extracts' and budgerigar-dropping extracts. TBLB showed epithelioid cell granulomas without caseous necrosis and alveolar septal inflammation. Inhalation challenge test using freeze-dried pigeon-dropping extracts was positive, therefore we finally established a diagnosis of acute bird related hypersensitivity pneumonitis. This is apparently the first report of acute bird-related hypersensitivity pneumonitis showing localized consolidation initially and later changing to diffuse ground-glass opacities. These radiological observations are significant in considering the onset and the progression of this disease.

[Bird fancier's lung disease (report of two cases)]. / Kus besleyicisi hastaligi (iki olgu nedeniyle).

Bird fancier's lung disease (BFLD) is a hypersensitivity pneumonia which develops in response to organic bird products. Two patients (25 y/M, 43 y/F) were admitted to our clinic with complaints of dyspnea, fewer and weight loss, both had history of pigeon exposure and we investigated them for BFLD. First patient had restrictive pulmonary function tests with DLCO of 49%, and the second patient had obstructive pulmonary function tests with DLCO of 33%. HRCT of both patients revealed nodular infiltrations. With these findings and history of pigeon exposure (the first patient at his job, the second patient at home) the diagnosis of BFLD was established. First patient had complete remission after removal of pigeons from the environment. Initial inhaled corticosteroid and later systemic corticosteroid therapy was given to second patient. In conclusion, if BFLD, a rare disease, is considered initially in the differential diagnosis and environmental exposure is evaluated, the diagnosis and treatment is possible.

[Three cases of chronic bird fancier's lung associated with the use of feather bedclothes].

We report here 3 cases of chronic bird fancier's lung diagnosed immunologically using antibodies to pigeon dropping extract. None of the patients were bird fanciers but had indirect exposure to birds in their living environment, and had been using feather-filled duvets or pillows for a long time. Two of 3 cases were positive for environmental provocation tests and 2 cases had pathological findings of hypersensitivity pneumonitis such as multinucleated giant cells and non-necrotizing epithelioid cell granulomas. One case was resistant to steroid therapy alone and was successfully treated by coadministration of prednisolone and cyclosporin A. Another case was treated by steroid alone but died of acute exacerbation of unknown cause. These cases suggest that not only feathers but two or more kinds of bird-related antigens were involved in the sensitization immunology and development of bird fancier's disease, and that clinicians should perform thorough history taking with environmental surveillance relevant to birds.

Lung fibrosis in hypersensitivity pneumonitis. Association with CD4+ but not CD8+ cell dominant alveolitis and insidious onset.

Seventeen cases of hypersensitivity pneumonitis (HP) at a symptomatic phase were categorized into two groups based on computed tomographic (CT) findings and histologic features of transbronchial lung biopsy specimens, HP accompanied by lung fibrosis (fibrosis group), and HP unaccompanied by lung fibrosis (nonfibrosis group). The fibrosis group comprised bird fancier's lung and HP of unknown etiology, whereas the nonfibrosis group mainly comprised summer-type HP. Comparison of results of pulmonary function tests between these two groups confirmed a restrictive impairment in the fibrosis group. Analyses of cellular components of bronchoalveolar lavage (BAL) fluids revealed lymphocytes, especially CD8+ T lymphocytes, were significantly increased in the nonfibrosis group in comparison with the fibrosis group, whereas CD4+ T cells were increased to the same level in the both groups. Analyses of the onset of disease showed that acute onset was observed mainly in nonfibrosis group and strongly correlated with increased CD8+ T lymphocytes in BAL fluids, while insidious onset was related to lung fibrosis and relatively increased CD4+ T lymphocytes in BAL fluids. These findings raise the possibility that highly elevated CD8+ T cells might have a protective effect on pulmonary fibrosis or that relatively increased CD4+ T cells might play an important role in the pathogenesis of pulmonary fibrosis of HP at the chronic phase.

Extrinsic allergic alveolitis: problems in diagnosis and a potential use for computed tomography.

Bird fancier's lung, the most common form of extrinsic allergic alveolitis in Britain, can be a difficult diagnostic problem. The symptoms are non-specific, often insidious in onset and frequently misdiagnosed as influenza or a viral or bacterial pneumonia. Frequently there is a delay in eliciting the history of exposure to the antigen. The chest radiograph is often less impressive than the clinical presentation and may be normal despite severe symptoms, impaired respiratory function and florid pathological changes. We present three cases demonstrating these diagnostic problem. In two cases, high resolution computed tomography demonstrated the typical 'ground glass' opacification seen in active alveolitis. This allowed targeting of transbronchial biopsies which revealed an inflammatory infiltrate of the interstitium with granuloma formation and inflammatory cells in some alveoli. The problems in diagnosis and the potential role of high resolution computed tomography are discussed.

Suberosis and bird fancier's disease: a comparative study of radiological, functional and bronchoalveolar lavage profiles.

Hypersensitivity Pneumonitis (HP) is an immunologically mediated interstitial lung disease that may result from repeated inhalation of many different environmental agents. Heterogeneity of the clinical presentation and bronchoalveolar lavage profiles have been described, possibly related to different occupational exposures. The aim of our study was to compare bronchoalveolar lavage fluid (BALF), clinical, functional and radiological characteristics of the two most frequent forms of HP seen in our practice: Suberosis (an HP related to moldy cork dust exposure) and bird fancier's disease (BFD). We included 81 patients with Suberosis, with a mean age of 38.8 +/- 11.3 years and a mean exposure of 20.0 +/- 10.5 years and 32 patients with BFD, with a mean age of 46.3 +/- 11.8 years and mean exposure of 10.5 +/- 1.0 years. Patients with BFD had more acute forms, while subacute and chronic presentations predominated in Suberosis. Restrictive defect was the most frequent pattern of lung function impairment, and more severe in BFD. Ground glass opacities were the most frequent pattern in high-resolution computed tomography. A normal chest x-ray was more frequently seen in Suberosis. Both types of HP had lymphocytic alveolitis in BALF: Suberosis - 6.6 +/- 5.7 x 10(5) ml-l cells, 58.8 +/- 18.9% lymphocytes; bird fancier's disease - 9.0 +/- 6.5 x 105 ml-l cells, 61.7 +/- 22.2% lymphocytes. Although BALF CD8+ lymphocytes predominated in both diseases, the proportion of CD4+ and CD4/CD8 ratios were significantly higher in bird fancier's disease (Suberosis: 0.47 +/- 0.33 versus BFD: 1.1 +/- 1.5; p < 0.005). Moreover, BALF cellularity and mast cell counts were also significantly higher in BFD. In conclusion, Suberosis and bird fancier's disease are HP with different clinical and laboratory profiles, suggesting that despite their pathophysiological similarities, different antigenic exposures may cause different immune and inflammatory response dynamics in the lung.

Gallium-67 lung uptake in extrinsic hypersensitivity pneumonitis.

Diffuse lung uptake of gallium-67 citrate was observed in a child with subsequently proven extrinsic hypersensitivity pneumonitis secondary to exposure to bird droppings.

Unusual case of diagnosis of pigeon breeder's hypersensitivity pneumonitis with ventilation-perfusion lung scan.

The authors describe a patient thought to have pulmonary embolism. Results of a perfusion scan were normal, but Tc-99m DTPA aerosol ventilation lung scan showed, in successive views, decreased activity of the deposited aerosol. The lung Tc-99m DTPA clearance was measured and was markedly increased. This suggested possible hypersensitivity pneumonitis, which was later confirmed as pigeon breeder's disease. The decreased activity observed on the DTPA ventilation scan must be directed toward increased lung clearance and its measurement.

Recurrent pneumonitis in a 10-year-old girl with pigeon breeder's disease.

Hypersensitivity pneumonitis is an allergic disease resulting from sensitization to inhaled organic dust, usually manifest with recurrent bouts of cough, dyspnea and fever. Most of the reported cases concern the adult population. The disease is rarely seen in the pediatric age group, as stated by most of the reviews on the subject. In this article, a case with hypersensitivity pneumonitis is described. Precipitating antibodies to avian protein were demonstrated in serum from a girl with recurrent bouts of pneumonitis which was otherwise unexplained.

[A case of bird fanciers' lung with endobronchial polyps].

A 34-year-old woman who had been keeping five budgerigars in her home was admitted with cough and progressive exertional dyspnea that had continued for three months. Chest CT scan demonstrated diffuse centrilobular nodular opacities throughout both lung fields. Flexible bronchoscopy revealed polypoid lesions with diameters of 2-3 mm located at the right B1/B2 spur. B3a/B3b spur and middle/lower bronchus spur. Their surfaces were glossy and smooth but slightly lobulated. The histological findings were consistent with inflammatory polyps containing lymphoid follicles in a dense infiltrate of lymphocytes. A positive environmental provocation test and precipitating antibodies confirmed the diagnosis of hypersensitivity pneumonitis (HP) caused by budgerigars (bird fanciers' lung). To our knowledge, there is no previous report of HP accompanied with endobronchial polyps, but this rare case shows the involvement of large airways in HP.

[Suberosis and bird fancier's disease: comparative study of radiological, functional and bronchoalveolar characteristics profile]. / Suberose e doença dos criadores de aves: estudo comparativo do perfil radiológico, funcional e do lavado broncoalveolar.

Extrinsic Allergic Alveolitis (EAA) is an immunologically mediated interstitial lung disease that may result from repeated inhalation of many different environmental agents. Heterogeneity of the clinical presentation and bronchoalveolar lavage profiles has been described, possibly related to different occupational exposures. The aim of our study was to compare bronchoalveolar lavage fluid (BALF), clinical, functional and radiological characteristics of the two most frequent forms of EAA seen in our practice: Suberosis and Bird Fancier's Disease (BFD). We included 81 patients with Suberosis, with a mean age of 38.8+/-11.3 years and a mean exposure of 20.0 +/- 10.5 years and 32 patients with BFD, with a mean age of 46.3+/-11.8 years and mean exposure of 10.5 +/- 1.0 years. Patients with BFD had more acute forms, while subacute and chronic presentations predominated in Suberosis. Restrictive defect was the most frequent pattern of lung function impairment, and more severe in BFD. Ground glass opacities were the most frequent pattern in high-resolution computed tomography. A normal chest x-ray was more frequently seen in Suberosis. Both types of EAA had lymphocytic alveolitis in BALF: Suberosis - 6.6 +/- 5.7 x 105 ml-1 cells, 58.8 +/- 18.9% lymphocytes; bird fancier's disease - 9.0 +/- 6.5 x 105 ml-1 cells, 61.7 +/- 22.2% lymphocytes. Although BALF CD8+ lymphocytes predominated in both diseases, the proportion of CD4+ and CD4/CD8 ratios were significantly higher in Bird Fancier's Disease (Suberosis: 0.47 +/- 0.33 versus BFD: 1.1 +/- 1.5; p <0.005). Moreover, BALF cellularity and mast cell counts were also significantly higher in BFD. In conclusion, Suberosis and bird fancier's disease are EAA with different clinical and laboratory profiles, suggesting that despite their pathophysiological similarities, different antigenic exposures may cause different immune and inflammatory response dynamics in the lung.

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.