Allergic. Alveolitis. Asthma bronchiale richtig erkennen, richtig behandeln

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1 Allergic Asthma bronchiale richtig erkennen, Alveolitis richtig behandeln Dr. med. Florian Fuchs Division of Respiratory Medicine Department of Medicine 1 (Chairman: Prof. Dr. med. M.F. Neurath) florian.fuchs@uk-erlangen.de

2 Extrinsic allergic alveolitis = hypersensitivity pneumonitis is a complex health syndrome of varying intensity, clinical presentation, and natural history. HP is the result of an immunologically induced inflammation of the lung parenchyma in response to inhalation exposure to a large variety of antigens.

3 Extrinsic allergic alveolitis = hypersensitivity pneumonitis a pulmonary disease with symptoms of dyspnea and cough resulting from the inhalation of an antigen to which the patient has been previously sensitized.

4 Extrinsic allergic alveolitis = hypersensitivity pneumonitis lung disease with or without systemic manifestations (fever, weight loss) It is caused by the inhalation of an antigen to which the subject is sensitized and hyperresponsive. Sensitization and exposure alone in the absence of symptoms do not define the disease, as many exposed subjects develop an immune response manifested by the presence of serum IgG antibodies to the antigen and often by the presence of large number of lymphocytes in their lungs but never develop lung disease.

5 Repeated antigen inhalation (1 5 µm) Granuloma Lymphocytic alveolitis Neutrophil alveolitis Healing Fibrosis (UIP, NSIP or COP Pattern) Alveolar damage Emphysema

6 HP associated with farming Moldy hay, grain, silage Moldy on pressed sugar cane (bagassosis, very rare cases) Tobacco plants (tobacco grower's lung) Mushroom worker's lung Potato riddler's lung (moldy hay around potatoes) Paprika slicer's lung (moldy paprika pods) Wine maker's lung Cheese washer's lung Coffee worker's lung Tea grower's lung Thermophilic actinomycetes, such as Faenirecti virgula (also known as Micropolyspora faeni or Saccharopolyspora rectivirgula) Fungus, such as Aspergillus umbrosus Thermoactinomyces sacchari, T. vulgaris Aspergillus sp Scopulariopsis brevicaulis Mushroom spores, Thermophilic actinomycetes Thermophilic actinomycetes T. vulgaris, F. rectivirgula, Aspergillus sp Mucor stolonifer Botrytis cincrea Penicillium casei, Aspergillus clavatus Coffee-bean dust Tea plants

7 HP associated with ventilation and waterrelated contamination Humidifier fever Unventilated shower Hot-tub lung (mists; mold on ceiling and around tub) Sauna taker's lung Summer-type pneumonitis Lifeguard lung Contaminated basement (sewage) pneumonitis Thermoactinomyces (T vulgaris, T sacchari, T candidus) Klebsiella oxytoca Naegleria gruberi Acanthamoeba polyphaga Acanthamoeba castellani Epicoccum nigrum Cladosporium sp Mycobacterium avium complex Aureobasidium sp, other sources Trichosporon cutaneum Aerosolized endotoxin from pool-water sprays and fountains Cephalosporium

8 HP associated with birds and poultry handling Bird fancier's lung (parakeets, budgerigars, pigeons) Poultry worker's lung (feather plucker's disease) Turkey handling disease Canary fancier's lung Duck fever Droppings, feathers, serum proteins Serum proteins (chicken products) Serum proteins (turkey products) Serum proteins Feathers, serum proteins

9 HP associated with veterinary work and animal handling Laboratory worker's lung (rats, gerbils) Pituitary snuff taker's disease Furrier's lung (sewing furs; animal fur dust) Bat lung (bat droppings) Fish meal worker's lung Coptic lung (mummy handler's lung) Urine, serum, pelts, proteins Dried, powdered neurohypophysis (bovine and porcine pituitary proteins) Animal pelts Bat serum protein Fish meal Cloth wrappings of mummies

10 HP associated with grain and flour processing Grain measurer's lung Miller's lung (dustcontaminated grain) Malt worker's disease (moldy barley) Cereal grain (Sporobolomyces) Grain dust (mixture of dust, silica, fungi, insects, and mites) Sitophilus granarius (ie, wheat weevil) Aspergillus fumigatus, Aspergillus clavatus

11 HP associated with milling and construction Wood dust pneumonitis (oak, cedar, and mahogany dust, pine and spruce pulp) Sequoiosis (moldy wood dust) Maple bark disease Alternaria sp, Bacillus subtilis Graphium, Pullularia, Trichoderma sp., Aureobasidium pullulans Cryptostroma corticale Wood trimmer's disease Wood pulp worker's disease (oak and maple trees) Rhizopus sp, Mucor sp Penicillium sp Suberosis (moldy cork dust) T. viridis, Penicillium glabrum. Conidia Composter's lung Dry rot lung Thatched-roof lung (huts in New Guinea) Esparto dust ("Stipatosis"; Stipa tesnacissima is a grass of the graminea family) T. vulgaris, Aspergillus Merulius lacrymans Saccharomonospora viridis (dead grasses and leaves) Aspergillus fumigatus T. Actinomycetes

12 HP associated with plastic manufacturing, painting, electronics industry, and other chemicals Chemical HP Detergent worker's lung (washing powder lung) Pauli's reagent alveolitis Vineyard sprayer's lung Pyrethrum (pesticide) Epoxy resin lung Bible printer's lung Machine operator's lung Diphenylmethane diisocyanate (MDI) Toluene diisocyanate (TDI) Bacillus subtilis enzymes Sodium diazobenzene sulfate Copper sulfate (bordeaux mixture) Pyrethrum Phthalic anhydride (heated epoxy resin) Moldy typesetting water Pseudomonas fluorescens Aerosolized metal working fluid

13 HP associated with textile workers Byssinosis ("brown lung") (unclear if a true cause of HP; asthma is common) "Velvet" worker's lung Upholstery fabric (nylon filament, cotton/polyester, and latex adhesive) Lycoperdonosis (lycoperdon puffballs) Cotton mill dust (carding and spinning areas of cotton, flax, and soft-hemp) Unknown (? nylon velvet fiber, tannic acid, potato starch) Aflatoxin-producing fungus, Fusarium sp Puffball spores

14 Epidemiology High variability farming population 9-12% pigeon fancier 15% Reduced prevalence in smokers Reduced prevalence in dry regions Germany 2,5/ /Jahr UK 0,9/ /Jahr

15 Initial presenting Is it really asthma? Lacasse et al., Chest 2012

16 Richerson s classification 1989 Classification Acute HP Subacute HP Chronic HP Classification Clinical description Symptoms begin 2 9 h after exposure, peak typically between 6 and 23 h, and last from hours to days. Influenza-like symptoms often predominate: chills, fever, sweating, myalgias, lassitude, headache and nausea. Respiratory symptoms, such as cough and dyspnea, are common but not universal May appear gradually over several days to weeks. Marked by cough and dyspnea, and may progress to severe dyspnea and cyanosis, leading to hospitalization. Insidious onset over a period of months. Increasing cough and exertional dyspnea. Fatigue and weight loss may be prominent symptoms. Richerson et al., J Allergy Clin Immunol 1989

17 Classification Lacasse et al., Int Arch Allergy Immunol 2009

18 Diagnostic criteria 1. Known exposure to offending antigen(s): A. History of appropriate exposure. B. Positive Investigations of the environment. C. Presence of specific IgG antibodies in serum. 2. Compatible clinical, radiographic, or physiologic findings: A. Typical symptoms, association with antigen exposure. B. Reticular, nodular, or ground glass opacity on CT. C. Altered PFT. 3. BAL with lymphocytosis: A. Usually with low CD4 to CD8 ratio B. Positive specific immune response to the antigen by lymphocyte transformation testing 4. Positive inhalation challenge testing 5. Histopathology showing compatible changes positive positive 1+2A+3+5 positive positive Schuyler et al., Chest 1997

19 Diagnostic criteria Diagnostic tools: PFT HRCT Specific IgG antibodies BAL Histology? Lacasse et al., AJRCCM 2003

20 PFT

21 HRCT

22 Treatment Contact avoidance Systemic steroids (only in severe cases?) Inhaled steroids? Other immunosuppressive drugs? Therapy of chronic lung insufficiency (O 2, NIV, TX)

23 Summary Broad spectrum of (uncommon) antigens No consistent definition No consistent diagnostic criteria No consistent classification Contact avoidance only specific treatment Don t miss to consider HP

24 Differential diagnosis Asthma ODTS = organic dust toxic syndrome Other interstitial lung disease Toxic alveolitis Lung infection