Hypersensitivity pneumonia associated with metallic straw of mate (chimarrão): A case report.

This case report describes a 61-year-old male who sought treatment for sudden symptoms of dry cough, chest pain and severe dyspnea. On admission, the patient had hypoxemia and predominantly medullary infiltrate that we could observe on his imaging exams. After hospital discharge, he presented two similar episodes, with clinical and radiological improvement with oxygen therapy alone. He denied exposure to birds, mold or chemical agents. However, the patient noticed the onset of symptoms soon after drinking chimarrão. Given the compatible clinical, radiological and laboratory history, the diagnosis of hypersensitivity pneumonitis was performed. The patient was instructed by the medical team not to consume the drink anymore, remaining asymptomatic for more than two years.

[Girl with hypersensitivity pneumonitis. A case report]. / Niña con neumonitis por hipersensibilidad. Reporte de un caso.

BACKGROUND: Hypersensitivity pneumonitis entails several inflammatory lung diseases that preferentially affect the alveolar and perialveolar tissue. It is a very rare disease in children, with a complicated diagnosis due to the fact that antigen exposure usually goes unnoticed. CASE REPORT: A 12-year-old girl with dry cough, dyspnea, wheezing, and tachypnea, with partial improvement after treatment with inhaled bronchodilators and corticoids. The spirometry showed a restrictive pattern and reduced lung diffusion capacity; in the CT scan, centrilobular ground-glass opacities were observed, and a lymphocyte count of CD4/CD8 of 2.46 (lymphocytosis) was obtained from the bronchoalveolar lavage. IgG positivity to bird feathers was obtained. CONCLUSIONS: The treatment of hypersensitivity pneumonitis is based on avoiding exposure to the causative agent, which is determined by the prognosis; for which taking an extensive medical history is of paramount importance. Corticosteroids can be prescribed based on the clinical response, the pulmonary function, and the radiological improvement.

Antecedentes: La neumonitis por hipersensibilidad agrupa varias enfermedades inflamatorias pulmonares que afectan preferentemente el tejido alveolar y perialveolar. En niños se trata de una enfermedad muy rara, con diagnóstico complicado debido a que la exposición antigénica suele pasar desapercibida. Caso clínico: Niña de 12 años que presentaba tos seca, disnea, sibilancias y taquipnea con mejoría parcial al tratamiento con broncodilatadores y corticoides inhalados. En la espirometría presentó un patrón restrictivo y una capacidad de difusión pulmonar reducida; en la tomografía computarizada se observaron opacidades centrolobulillares en vidrio esmerilado y del lavado broncoalveolar se obtuvo un cociente de linfocitosis CD4/CD8 de 2.46. Se obtuvo IgG positiva a plumas de aves. Conclusiones: El manejo de la neumonitis por hipersensibilidad se basa en evitar la exposición al agente causante, lo que determina el pronóstico; de ahí que resulta de vital importancia realizar una historia clínica exhaustiva. Pueden indicarse corticosteroides en función de la respuesta clínica, la función pulmonar y la mejoría radiológica.

Small airway dysfunction in chronic hypersensitivity pneumonitis.

BACKGROUND AND OBJECTIVE: Lung biopsies from patients with hypersensitivity pneumonitis (HP) have demonstrated small airway (SA) involvement, but there is no information concerning SA function in HP, and it is unknown whether pharmacological treatment could modify its function. SA function in patients with chronic HP using ultrasonic pneumography (UPG) and impulse oscillometry (IOS) was explored. We also compared initial results with those obtained after 4 weeks of standardized treatment with azathioprine and prednisone. METHODS: The study group consisted of adults with recent diagnoses of HP. All patients completed UPG, IOS, spirometry, body plethysmography, single-breath carbon monoxide diffusing capacity (DLCO ) and the 6-min walk test (6MWT). The fraction of exhaled nitric oxide (FENO ) was obtained to assess eosinophilic airway inflammation. Measurements were taken at diagnosis and after 4 weeks of treatment. RESULTS: A total of 20 consecutive patients (16 women) with chronic HP participated in the study. Median age was 50 years (interquartile range (IQR): 42-54). At diagnosis, the UPG phase 3 slope was abnormally high, consistent with maldistribution of ventilation. For IOS, all patients had low reactance at 5 Hz (X5) and elevated reactance area (AX) reflecting low compliance, and only eight (40%) patients had elevated R5 (resistance at 5 Hz (total)) and R5-20 (resistance at 5 Hz-resistance at 20 Hz (peripheral)) attributed to SA resistance. In contrast, FENO parameters were within normal limits. After treatment, forced vital capacity (FVC), the 6-min walk distance and the distribution of ventilation showed significant improvement, although DLCO did not. CONCLUSION: Patients with chronic HP have SA abnormalities that are partially revealed by the UPG and IOS tests. Lung volumes, but not gas exchange, improved after treatment with azathioprine and prednisone.

The value of family history in the diagnosis of hypersensitivity pneumonitis in children.

Hypersensitivity pneumonitis (HP), or extrinsic allergic alveolitis, is an immunologically mediated disease resulting from the inhalation of organic substances that trigger an inflammatory response in the alveolar wall, bronchioles, and interstitium in susceptible individuals. Although HP is predominantly an occupational disease, seen in adulthood, cases in children have been described. The diagnosis of HP requires a high degree of suspicion. The treatment consists in avoiding contact with the antigen, and, in some cases, systemic corticosteroids might be necessary in order to prevent its progression to pulmonary fibrosis. We report the clinical cases of three children with a history of contact with birds and a family history of HP. All three patients presented with cough and dyspnea on exertion. The disease was diagnosed on the basis of the clinical history and ancillary diagnostic test results consistent with the diagnosis, including a predominance of lymphocytes (> 60%, CD8+ T lymphocytes in particular) in bronchoalveolar lavage fluid and a ground-glass pattern seen on HRCT of the chest. Early diagnosis is crucial in order to prevent HP from progressing to pulmonary fibrosis. Hereditary factors seem to influence the onset of the disease.

The value of family history in the diagnosis of hypersensitivity pneumonitis in children / O valor da história familiar no diagnóstico de pneumonite de hipersensibilidade em crianças

Hypersensitivity pneumonitis (HP), or extrinsic allergic alveolitis, is an immunologically mediated disease resulting from the inhalation of organic substances that trigger an inflammatory response in the alveolar wall, bronchioles, and interstitium in susceptible individuals. Although HP is predominantly an occupational disease, seen in adulthood, cases in children have been described. The diagnosis of HP requires a high degree of suspicion. The treatment consists in avoiding contact with the antigen, and, in some cases, systemic corticosteroids might be necessary in order to prevent its progression to pulmonary fibrosis. We report the clinical cases of three children with a history of contact with birds and a family history of HP. All three patients presented with cough and dyspnea on exertion. The disease was diagnosed on the basis of the clinical history and ancillary diagnostic test results consistent with the diagnosis, including a predominance of lymphocytes (> 60%, CD8+ T lymphocytes in particular) in bronchoalveolar lavage fluid and a ground-glass pattern seen on HRCT of the chest. Early diagnosis is crucial in order to prevent HP from progressing to pulmonary fibrosis. Hereditary factors seem to influence the onset of the disease.

A pneumonite de hipersensibilidade (PH), ou alveolite alérgica extrínseca, é uma doença imunologicamente mediada, resultante da inalação de substâncias orgânicas que desencadeiam uma reação inflamatória na parede dos alvéolos, bronquíolos e interstício em indivíduos susceptíveis. Apesar de ser uma doença ocupacional de predomínio na idade adulta, estão descritos casos em crianças. O diagnóstico de PH requer grande suspeição, e seu tratamento consiste na ausência de contato com o antígeno e, em alguns casos, pode ser necessária corticoterapia sistêmica, evitando-se a progressão para fibrose pulmonar. Relatamos três casos clínicos de crianças com história de contato com aves e história familiar de PH. Todos os casos se apresentaram com tosse e dispneia aos esforços. O diagnóstico foi possível por história clínica e exames auxiliares de diagnóstico compatíveis, incluindo lavado broncoalveolar com predomínio de linfócitos (> 60%, especialmente linfócitos T CD8+) e TCAR de tórax com padrão em vidro fosco. O diagnóstico precoce é fundamental na PH para se prevenir a evolução para fibrose pulmonar. Fatores hereditários parecem influenciar seu aparecimento.

The effect of CTLA-4Ig, a CD28/B7 antagonist, on the lung inflammation and T cell subset profile during murine hypersensitivity pneumonitis.

Hypersensitivity pneumonitis (HP) is an inflammatory lung disease characterized by an influx of activated T cells to the lung, in which the CD28/B7 costimulatory signals are essential for the T cell activation and the outcome of the inflammatory response. In this study, we investigated the effect of the CD28/B7 antagonist, CTLA-4Ig, on the lung inflammation and the T cell subset profile in experimental Saccharopolyspora recivirgula (SR)-induced HP. C57BL/6 mice were treated with SR or saline during two and three weeks and in addition of CTLA-4Ig was administrated after either the second or third week and mice were sacrificed seven days later. The extent of the lung inflammation was quantified by histopathology and the lung T cell subsets (Treg, Th17, γδT and NKT) were analyzed by flow cytometry. Mice treated with CTLA-4Ig showed a significant decrease in the extent of lung damage (p<0.05), and exhibited a decreased number of inflammatory cells in the bronchoalveolar lavage (BAL) with diminished CD4/CD8 T cell ratio. Also, a significant increase in the percentage of lung γδT (p<0.01) and NKT (p<0.05) cells was observed in two weeks SR-treated mice with the administration of CTLA-4Ig/SR. At 3 weeks, SR-treated mice showed an increased percentage of regulatory T cells but no significantly differences were found in the percentage of Th17 cells when compared with CTLA-4Ig/SR-treated mice. Our findings suggest that the treatment with CTLA-4Ig affects the HP progression and the lung T cell subset kinetics in mice.

Effect of Mercurius solubilis on the bacteriological response in the alveolitis process in rats.

OBJECTIVE: The purpose of this study was to assess the bacteriological response in alveolitis in rats treated with the homeopathic medicine Merc solubilis (Merc sol.) 12 cH. METHODS: The study was randomized and observer blind. The animals were anesthetized and the upper right incisor extracted resulting in alveolitis. Animals were randomly assigned to groups (n=18/group): Water control, Alcohol control and Merc sol. 12 cH. These groups were subsequently divided into 3 subgroups (n=6/subgroup): Early Euthanasia (EE), Mid Euthanasia (ME) and Late Euthanasia (LE), killed at the 6th, 15th and 21st days respectively. The perialveolar microbiota was collected by swab in Brain Heart Infusion (BHI) for seeding and bacterioscopy. After seeding, the Petri dishes were incubated at 37 degrees C for 48 h. RESULTS: Quantitative and qualitative changes were observed in the perialveolar microbiota when the groups were compared. Water control and Alcohol control had the highest counts of pathogenic bacteria, the microbiotica of the Merc sol. group remained closer to normal. CONCLUSIONS: Merc sol. 12 cH did not reduce bacterial growth, but the microbiotica remained within the parameters of normality, obtaining the best results at 21 days after treatment.

The triterpenoid lupeol attenuates allergic airway inflammation in a murine model.

Asthma is a chronic inflammatory disease of the airways associated with a Th2 immune response. Despite their side effects, corticosteroids are the most used and effective drugs for treatment of asthma. In this work we investigated the efficacy of lupeol, a triterpenoid isolated from Lonchocarpus araripensis [corrected] Benth. (Fabaceae), in the treatment of bronchial asthma in BALB/c mice immunized with ovalbumin. Administration of lupeol caused the reduction of cellularity and eosinophils in the bronchoalveolar lavage fluid. Treatment with lupeol also reduced the production of mucus and overall inflammation in the lung. Levels of Type II cytokines IL-4, IL-5 and IL-13 were significantly reduced in mice treated with lupeol, an effect that was similar to that observed in dexamethasone-treated mice. In contrast, IgE production was not significantly altered after treatment with lupeol. In conclusion, our results demonstrate that lupeol attenuates the alterations' characteristics of allergic airway inflammation. The investigation of the mechanisms of action of this molecule may contribute for the development of new drugs for the treatment of asthma.

LC characterisation of guaco medicinal extracts, Mikania laevigata and M. glomerata, and their effects on allergic pneumonitis.

The leaves of guaco (Mikania glomerata and M. laevigata) are widely used for the treatment of asthma and bronchitis. An LC method for the quantification of coumarin and O-coumaric acid in medicinal extracts was developed and validated for linearity, limit of detection, accuracy, precision, as well as intra- and inter-day variations. Extracts and isolated markers were tested in the mice allergic pneumonitis model and the histopathological profile of the lung tissue was analysed. The values found for coumarin and O-coumaric acid in a fluid extract were 1.53 and 1.69 mg/mL, respectively, for M. glomerata, and 0.96 and 0.38 mg/mL for M. laevigata. The values found for the lyophilised aqueous extract were 0.22 and 0.11 mg/mL of coumarin and O-coumaric acid in M. glomerata and 0.05 and 0.02 mg/mL in M. laevigata, respectively . The analysed samples from the species M. glomerata presented more coumarin and O-coumaric acid than the analogous M. laevigata species. Both coumarin and O-coumaric acid are part of the phytocomplex which is responsible for the therapeutic activity of the guaco species. The lyophilisation process generated some alterations in the extract, in comparison with the fresh aqueous extract, and these extracts did not present anti-inflammatory activity. Comparing the histopathological images of the groups tested, a haemorrhagic profile of lung tissue of animals treated with lyophilised extract, O-coumaric acid and coumarin is observed, but not for the group treated with hydroalcoholic extract. It is probable that some protective effect of the whole extract (lost during the lyophilisation process) blocks the harmful effects of the isolated markers.

Pneumonia de hipersensibilidade crônica: análise de oito casos e revisão da literatura / Chronic hypersensitivity pneumonia: analysis of eight cases and review of the literature

A pneumonia de hipersensibilidade é uma doença de natureza imunológica secundária à inalação crônica de poeiras orgânicas ou químicas. O diagnóstico na sua fase crônica é difícil devido à apresentação clínica e radiológica semelhante à de outras doenças intersticiais, sendo freqüentemente necessária a realização de biópsia pulmonar para seu diagnóstico. Os autores revisam os casos confirmados nos últimos 11 anos, atendidos no Instituto de Doenças do Tórax/UFRJ. Foram encontrados nesse período oito casos confirmados por estudo histopatológico. Os sintomas preponderantes foram tosse e dispnéia. Todos apresentavam infiltrado intersticial no estudo radiológico e padrão restritivo funcional foi encontrado em cerca de 70 por cento dos casos. Nos sete pacientes em que foi iniciado tratamento com corticosteróide, todos apresentaram melhora clínica, porém não houve correlação entre a resposta clínica e a evolução radiológica ou funcional. Uma vez diagnosticado, o paciente deve ser afastado da exposição, visto a possibilidade de evolução para fibrose pulmonar nos continuamente expostos

Aspergilosis pulmonar: sindromes de hipersensibilidad / Pulmonary aspergillosis: hypersensitivity syndromes

Las especies de hongos del género Aspergillus, presentan especial predilección por el tejido pulmonar, originando variados cuadros clínicos según se presenten como síndromes de hipersensibilidad o infecciones invasivas y diseminadas. En esta oportunidad se presentan dos casos clínicos de hipersensibilidad pulmonar al Aspergillus con las formas de Alveolitis Alérgica Extrínseca y Aspergilosis Broncopulmonar Alérgica. Ambos tratados con Itraconazol 400 mg/día vía oral en forma exitosa y con negativización de la serología para Aspergillus. Esta patología debe ser sospechada en pacientes con broncoobstrucción, bronquiectasias e infiltrados pulmonares que no responden al tratamiento habitual o bien ante el antecedente de exposición al hongo. El tratamiento con Itraconazol por vía oral puede ser eficaz al disminuir la carga micótica en estos pacientes.

Aspergilosis pulmonar: sindromes de hipersensibilidad / Pulmonary aspergillosis: hypersensitivity syndromes

Las especies de hongos del género Aspergillus, presentan especial predilección por el tejido pulmonar, originando variados cuadros clínicos según se presenten como síndromes de hipersensibilidad o infecciones invasivas y diseminadas. En esta oportunidad se presentan dos casos clínicos de hipersensibilidad pulmonar al Aspergillus con las formas de Alveolitis Alérgica Extrínseca y Aspergilosis Broncopulmonar Alérgica. Ambos tratados con Itraconazol 400 mg/día vía oral en forma exitosa y con negativización de la serología para Aspergillus. Esta patología debe ser sospechada en pacientes con broncoobstrucción, bronquiectasias e infiltrados pulmonares que no responden al tratamiento habitual o bien ante el antecedente de exposición al hongo. El tratamiento con Itraconazol por vía oral puede ser eficaz al disminuir la carga micótica en estos pacientes. (AU)

[Extrinsic allergic alveolitis. Clinical experience at the Instituto National de Enfermedades Respiratorias (INER)]. / Alveolitis alérgica extrínseca. Experiencia clínica del INER.

Extrinsic allergic alveolitis is an interstitial lung disease caused by exposure to a variety of inhaled antigens. In Mexico, the most frequent form is due to the inhalation of avian antigens, markedly pigeon proteins. Depending on type and time exposure, the disease presents different clinical forms usually characterized by progressive dyspnea, ground glass or reticulonodular images on chest x rays, a restrictive functional pattern, rest hypoxemia worsening with exercise, and increase of T lymphocytes in bronchoalveolar lavage with an inversion in the helper/suppressor ratio. In this paper, we discuss a 15-year experience with this pathological problem in Mexico, emphasizing the differences with this disorder in Caucasian populations. Generally, our patients display a chronic form of the disease, which evolves to fibrosis in about one-half of the patients. In this sense, the diagnostic, prognostic, and therapeutic focusing exhibit different elements, and thus the development of clinical and basic research is strongly required.

Alveolitis alérgica extrínseca: experiencia clínica del INER / Extrinsic allergic alveolitis: clinical Experience at the Instituto National de Enfermedades Respiratorias

La alveolitis alérgica extrínseca es una enfermedad pulmonar intersticial difusa originada por la exposición a diversos antígenos inhalados. La forma más frecuente en México es la secundaria a la inhalación de antígenos aviarios, en especial proteínas de palomas. Dependiendo del tipo y tiempo de exposición, la enfermedad puede provocar diferentes cuadros clínicos, cuyas características más importantes incluyen la presencia de disnea progresiva, imágenes radiológicas bilaterales y difusas del tipo de vidrio despulido o reticulo-nodulares, modificaciones funcionales de tipo restrictivo con hipoxemia de reposo que se exacerba con el ejercicio y aumento de linfocitos T con inversión de las subpoblaciones cooperadoras/supresoras en el lavado bronquioloalveolar. En este artículo se presenta una revisión de la experiencia de 15 años sobre este problema en México, con énfasis en las diferencias observadas con poblaciones caucásicas. Nuestros pacientes por lo general presentan un cuadro crónico, con progresión hacia la fibrosis en cerca de la mitad de ellos, lo que hace que el enfoque diagnóstico, pronóstico y de tratamiento presente elementos diferentes, creando la necesidad de desarrollar investigación clínica y básica de manera permanente

[Salami worker's lung]. / Pulmón del sopleteador de salamines.

Hypersensitivity pneumonitis (HP) is the clinical manifestation of an pulmonary immunological reaction to inhaled antigens. The list of provocative antigens and specific illnesses grows permanently. A woman of 56 years consulted for dyspnea and cough of two months of evolution. She worked in a factory of sausages removing the dust that recovers the salamis during their stationing. She presented hypoxemia and the pulmonary function test revealed a predominantly obstructive pattern. The x-ray of the thorax was normal and the high resolution computed tomography showed a mosaic pattern. A lung biopsy confirmed the diagnosis of HP. She improved with systemic corticosteroids and the avoidance of antigen exposure. In the cultures of the material that recovers the salamis, Penicillium spp. was recovered and was interpreted as the probable etiological agent of this HP, which we have denominated "the salami worker's lung".

Pulmon del sopleteador de salamines / The salami workers lung

La neumonitis por hipersensibilidad (NH) es la manifestación clínica de una reación inmunológica en el pulmón ante una variedad de antigenos inhalados. La lista de antígenos provocadores y enfermedades específicas crece permanentemente. Se presenta una mujer de 56 años que consultó por disnea de dos meses de evolución y tos poco productiva. Trabajaba en una fábrica de embutidos sopleteando el polvillo que recubre los salamines durante su estacionamiento. Presenta hipoxemia y una espirometria con patrón predominantemente obstructivo. La radiografia de tórax fue normal y la TAC de tórax de alta resolución mostró patrón en mosaico. La biopsia de pulmón confirmó el diagnóstico de NH. La paciente respondió al tratamiento con corticoides sistémicos y al alejamiento de la exposición laboral. El material que recubre los salamines cultivó Penicillium spp, el cual se interpretó como probable agente etiológico de esta NH, a la que llamamos "pulmón del sopleteador de salamines". (AU)