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Review
. 2017 Sep 15;196(6):690-699.
doi: 10.1164/rccm.201608-1675PP.

Diagnosis and Treatment of Fibrotic Hypersensitivity Pneumonia. Where We Stand and Where We Need to Go

Margaret L Salisbury  1 , Jeffrey L Myers  2 , Elizabeth A Belloli  1 , Ella A Kazerooni  3 , Fernando J Martinez  4 , Kevin R Flaherty  1
Affiliations
Review

Diagnosis and Treatment of Fibrotic Hypersensitivity Pneumonia. Where We Stand and Where We Need to Go

Margaret L Salisbury et al. Am J Respir Crit Care Med. .
No abstract available

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Figures

Figure 1.
Figure 1.
(A) Inspiratory and (B) expiratory high-resolution computed tomography images of a patient with hypersensitivity pneumonitis (HP). In A, arrows mark mosaic attenuation, defined by patchwork regions of differing attenuation, and in B arrows mark air trapping, suggested by the lack of normal increase in lung attenuation during expiration. (C and D) Examples of fibrotic high-resolution computed tomography features of mixed reticular and ground-glass densities with volume loss (arrows), along with features suggesting HP including fuzzy centrilobular nodules (boxed), together suggestive of fibrotic HP.
Figure 2.
Figure 2.
(A) Low-magnification photomicrograph of a surgical lung biopsy showing classic findings of hypersensitivity pneumonia, including a cellular interstitial pneumonia centered on airways with scattered multinucleated giant cells within the peribronchiolar interstitium (hematoxylin and eosin stain; original magnification, ×40). (B) Low-magnification photomicrograph showing a combination of patchwork fibrosis and honeycomb change nearly indistinguishable from usual interstitial pneumonia in a patient with fibrotic hypersensitivity pneumonia (hematoxylin and eosin stain; original magnification, ×17). (C) Low-magnification photomicrograph of biopsy from a different site in the same patient as in B, showing features typical of hypersensitivity pneumonia including multiple isolated giant cells in peribronchiolar interstitium with associated calcified Schaumann bodies (hematoxylin and eosin stain; original magnification, ×40).
Figure 3.
Figure 3.
A diagnostic algorithm for patients with possible hypersensitivity pneumonia (HP) centers around initial evaluation for clinical features suggesting alternative interstitial lung disease (ILD) etiologies, followed by further diagnostic testing based on high-resolution computed tomographic (HRCT) findings and exposures in patients with ILD suspected of having HP. “HP Triad” refers to chronic cellular bronchiolitis, cellular chronic interstitial pneumonia with a bronchiolocentric distribution, and small, loose nonnecrotizing granulomas and/or giant cells located within the peribronchiolar interstitium. “Suggestive biopsy” refers to presence of one or more of the individual biopsy findings suggesting HP listed in the box. BAL = bronchoalveolar lavage; IPF = idiopathic pulmonary fibrosis. *Although we believe evidence supports using a combination of HRCT features plus BAL lymphocytosis or plausible exposure to raise confidence in a diagnosis of HP, robust, prospective data testing against histopathologic evaluation are lacking.
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References

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