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Editorial
. 2025 Oct;211(10):1738-1740.
doi: 10.1164/rccm.202505-1297ED.

Rethinking the Computed Tomography and Histopathological Nomenclature of Hypersensitivity Pneumonitis: Unveiling Bronchiolocentric Patterns of Interstitial Pneumonia

Evans R Fernández Pérez  1 , William D Travis  2 , David A Lynch  3
Affiliations
Editorial

Rethinking the Computed Tomography and Histopathological Nomenclature of Hypersensitivity Pneumonitis: Unveiling Bronchiolocentric Patterns of Interstitial Pneumonia

Evans R Fernández Pérez et al. Am J Respir Crit Care Med. 2025 Oct.
No abstract available

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Figures

Figure 1.
Figure 1.
The figure illustrates a spectrum of features, often overlapping, that may favor or challenge the clinical diagnosis of hypersensitivity pneumonitis (HP) within the context of multidisciplinary discussions. For example, a patient with idiopathic bronchiolocentric interstitial lung disease (ILD) may present with disease progression despite no identifiable exposure(s) and chest computed tomography (CT) with typical small-airway findings, and the histopathology may show a bronchiolocentric pattern without granulomas. Conversely, a patient with systemic autoimmune rheumatic disease may exhibit similar CT and histopathological findings to those in HP, with or without alternative findings (e.g., esophageal dysmotility and pericardial effusion on CT, germinal centers and pleuritis on biopsy). However, systematic clinical–radiological–histopathological studies—ideally prospective multicenter studies with predefined hypotheses—are necessary to clarify these and other similar scenarios. Notably, the term HP, which lacks pathognomonic specificity, has been excluded from high-resolution computed tomography (HRCT) and histopathological spectrum of findings to mitigate the risk of misclassification with other ILDs. As the field evolves, it is expected that these descriptive HRCT and histopathological features organized into confidence level categories (not shown) that do not rely on the term HP will undergo further refinement as additional clinical, radiological, pathological, and biological molecular evidence is gathered through research and practical application. *Typical small-airway HRCT findings may include inspiratory mosaic with the three-density sign, profuse centrilobular nodules affecting all lung zones, and expiratory multilobular air trapping. **The term bronchiolocentric pattern is used to denote the primary involvement of the small airways and their surrounding tissue. MDD = multidisciplinary discussion.
See this image and copyright information in PMC

Comment on

  • Outcomes of a Typical Fibrotic Hypersensitivity Pneumonitis Pattern on Chest Computed Tomography.
    Ryerson CJ, Marinescu DC, Muller NL, Hague CJ, Murphy D, Churg A, Wright JL, Al-Arnawoot A, Bilawich AM, Bourgouin P, Cox G, Elliot T, Ellis J, Fisher JH, Fladeland D, Grant-Orser A, Goobie GC, Guenther Z, Haider E, Hambly N, Huynh J, Karjala G, Khalil N, Kolb M, Leipsic J, Lok S, MacIsaac S, McInnis M, Manganas H, Marcoux V, Mayo J, Morisset J, Scallan C, Sedlic T, Shapera S, Sun K, Tan V, Wong AW, Zheng B, Khor YH, Johannson KA. Ryerson CJ, et al. Am J Respir Crit Care Med. 2025 Oct;211(10):1802-1810. doi: 10.1164/rccm.202411-2215OC. Am J Respir Crit Care Med. 2025. PMID: 40505139

References

    1. Fernandez Perez ER, Kong AM, Raimundo K, Koelsch TL, Kulkarni R, Cole AL. Epidemiology of hypersensitivity pneumonitis among an insured population in the United States: a claims-based cohort analysis. Ann Am Thorac Soc . 2018;15:460–469. - PubMed
    1. Fernández Pérez ER, Brown KK. Fibrotic hypersensitivity pneumonitis. Curr Respir Care Rep . 2014;3:170–178.
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    1. Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M. et al. Diagnosis and evaluation of hypersensitivity pneumonitis: CHEST guideline and expert panel report. Chest . 2021;160:e97–e156. - PubMed
    1. Ryerson CJ, Marinescu DC, Muller NL, Hague CJ, Murphy D, Churg A. et al. Outcomes of a typical fibrotic hypersensitivity pneumonitis pattern on chest computed tomography. Am J Respir Crit Care Med . 2025;211:1802–1810. - PubMed

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