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Chapter 282: Hypersensitivity Pneumonitis and Pulmonary Infiltrates with Eosinophilia

Praveen Akuthota; Michael E. Wechsler

HYPERSENSITIVITY PNEUMONITIS

INTRODUCTION AND DEFINITION

Hypersensitivity pneumonitis (HP), also referred to as extrinsic allergic alveolitis, is a pulmonary disease that occurs due to inhalational exposure to a variety of antigens leading to an inflammatory response of the alveoli and small airways. Systemic manifestations such as fever and fatigue can accompany respiratory symptoms. Although sensitization to an inhaled antigen as manifested by specific circulating IgG antibodies is necessary for the development of HP, sensitization alone is not sufficient as a defining characteristic, because many sensitized individuals do not develop HP. The incidence and prevalence of HP are variable, depending on geography, occupation, avocation, and environment of the cohort being studied. As yet unexplained is the decreased risk of developing HP in smokers.

OFFENDING ANTIGENS

HP can be caused by any of a large list of potential offending inhaled antigens (Table 282-1). The various antigens and environmental conditions described to be associated with HP give rise to an expansive list of monikers given to specific forms of HP. Antigens derived from fungal, bacterial, mycobacterial, bird-derived, and chemical sources have all been implicated in causing HP.

TABLE 282-1Examples of Hypersensitivity Pneumonitis
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TABLE 282-1Examples of Hypersensitivity Pneumonitis
DISEASE ANTIGEN SOURCE
Farming/Food Processing
Farmer’s lung Thermophilic actinomycetes (e.g., Saccharopolyspora rectivirgula); fungus Grain, moldy hay, silage
Bagassosis Thermophilic actinomycetes Sugarcane
Cheese washer’s lung Penicillium casei; Aspergillus clavatus Cheese
Coffee worker’s lung Coffee bean dust Coffee beans
Malt worker’s lung Aspergillus species Barley
Miller’s lung Sitophilus granarius (wheat weevil) Wheat flour
Mushroom worker’s lung Thermophilic actinomycetes; mushroom spores Mushrooms
Potato riddler’s lung Thermophilic actinomycetes; Aspergillus species Moldy hay around potatoes
Tobacco grower’s lung Aspergillus species Tobacco
Wine maker’s lung Botrytis cinerea Grapes
Birds and Other Animals
Bird fancier’s lung (also named by specific bird exposures) Proteins derived by parakeets, pigeons, budgerigars Bird feathers, droppings, serum proteins
Duck fever Duck feathers, serum proteins Ducks
Fish meal worker’s lung Fish meal dust Fish meal
Furrier’s lung Dust from animal furs Animal furs
Laboratory worker’s lung Rat urine, serum, fur Laboratory rats
Pituitary snuff taker’s lung Animal proteins Pituitary snuff from bovine and porcine sources
Poultry worker’s lung Chicken serum proteins Chickens
Turkey handling disease Turkey serum proteins Turkeys
Other Occupational and Environmental Exposures
Chemical worker’s lung Isocyanates Polyurethane foam, varnish, lacquer
Detergent worker’s lung Bacillus subtilis enzymes Detergent
Hot tub lung Cladosporium species; Mycobacterium avium complex Contaminated water, mold on ceiling
Humidifier fever (and air conditioner lung) Several microorganisms including: Aureobasidium pullulans; Candida albicans; thermophilic actinomycetes; Mycobacterium species; Klebsiella oxytoca; Naegleria gruberi Humidifiers and air conditioners (contaminated water)
Machine operator’s lung Pseudomonas species; Mycobacteria species Metal working fluid
Sauna taker’s lung Aureobasidium species; other antigens Sauna water
Suberosis Penicillium glabrum; Chrysonilia sitophila Cork dust
Summer-type pneumonitis Trichosporon cutaneum House dust mites, bird droppings
Woodworker’s lung Alternaria species; Bacillus ...

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