Rituximab therapy in a patient with steroid-refractory bird fancier's lung

Abstract

A 62-year-old woman presented with a 3-month history of shortness of breath on exertion and dry cough. On examination, she was noted to have fine end-inspiratory crepitations over the upper zone of the lungs. Pulmonary function tests (PFTs) showed a restrictive defect. Initial chest radiography revealed diffuse reticular interstitial shadowing while high-resolution CT scan of the thorax showed fibrotic changes. Avian precipitins were also highly positive for pigeons, parrots and budgerigars. Taking into account these results, the patient was diagnosed with hypersensitivity pneumonitis. Antigen avoidance, oral glucocorticoids and azathioprine achieved an initial improvement in PFTs and symptoms; however, the patient still deteriorated, requiring long-term oxygen therapy. While working the patient up for lung transplantation, rituximab was given to good effect (acting as a bridging therapy) as it achieved symptomatic relief and stabilisation of her PFTs.

Keywords: immunology; interstitial lung disease; radiology.

Figure 1

Chest X-ray showing diffuse reticular interstitial shadowing.

Figure 2

(A, B) High-resolution CT showing diffuse ground-glass changes predominantly in the upper lobes, with mosaicism and signs of air trapping.

Figure 3

Graph highlighting the spirometric progression pre-oral and post-oral corticosteroids, AZA, intravenous methylpred and rituximab. OCS, oral corticosteroids; AZA, azathioprine; DLCO, diffusion limit of carbon monoxide; FVC, forced vital capacity; methylpred, methylprednisolone.