Hypersensitivity Pneumonitis (Allergic Alveolitis) ICD-(M Code 495.9 Pneumonitis, Hypersensitivity 1.

Definition: Is An Immunologically Mediated Inflammatory Lung Disease That Primarily Affects the Alveoli. 2. It Is Primarily A Restrictive Disease With A. Decreased Diffusion Capacity B. Decreased Lung Compliance C. Decreased Total Lung Volume 3. Immunological Evidence: A. Bronchoalveolar Lavage Specimens During The Acute Phase Have Increased Levels Of MIP-1alpha and IL-8 B. Bronchoalveolar Lavage Consistently Show Increased Numbers Of T4 & T8 Cells C. Most Patients Have Precipitating Antibodies In Their Serum, A Feature Of Type 3 (Immune Complex) Hypersensitivity. D. Igs & Complement Have Been Demonstrated By IF In The Vessel Walls Also Indicating Type 3 Hypersensitivity E. Non-Caseating Granulomas In 66% of Patients Indicate It Is Also A Type 4 Hypersensitivity Reaction to a Specific Antigen.

4. Selected Causes of Hypersensitivty Pneumonitis Syndrome Fungal & Bacterial Antigens FarmersLung Bagassosis Moldy Hay Micropolyspora faeni Moldy Pressed Thermophilic Actinomycetes Sugar Cane Maple Bark Disease Moldy Maple Bark Cryptostroma Corticale Humidifiers Lung Cool Mist Humidifier Thermophilic Actinomycetes Malt Workers Lung Moldy Barley Aspergillus Clavatus Cheese Washers Lung Moldy Cheese Penicillium Casei Insect Products Millers Lung Dust Contaminated Grain Sitophilus granarius Exposure Antigens

Animal Products: Pigeon Breeders Lung Pigeons Pigeon serum proteins in the Serum

Chemicals: Chemical Workers Lung Chemical Industry Isocyanates etc

5. Clinical Course: A. Acute Form: 1. Fever 2. Cough 3. Dyspnea 4. Last 4-6 Hours Up To 24 Hours B. Subacute Form: 1. Cough 2, Dyspnea On Exertion 3. Anorexia 4. Weight Loss C. Chronic Form: 1. Gradually Progressive Cough 2. Dsypnea 3. Malaise 4. Weight Loss 6. Physical Findings: A. Cyanosis B. Crepitant Rales C. Possible Fever 6. Workup: Major Criteria: A. Thorough History B. Investigation of Enviornment C. Serum Precipitn Test D. CXR E. BAL Lympocytosis F. Biopsy If Performed: 1. Confirm The Histologic Changes G. Controlled Inhalation Challenge Minor Criteria: A. Basilar Crackles B. Decreased Diffusion Capacity C. Arterial Hypoxemia

7. Laboratory Tests: A. Increased ESR B. Increased CRP C. Increased Leukocytosis D. Non Specific Elevated IgG & IgM E. Generaly Serum IgE & Eosinophil Count Normal F. Increased LDH G. Pulmonary Function Tests: 1. Restrictive Pattern A. Decreased FEV-1 B. Decreased FVC C. Decreased TLC D. Decreased Diffusing Capacity E. Decreased Static Compliance H. ABGs: 1. Mild Hypoxemia 2. Increased A-a Gradient I. Serun Precipitin Test For IgG Antibody Against Offending Antigen Possible J. Skin Testing Possible 8. Imaging Studies: A. CXR 1. Acute/ Subacute Stage: A. Bilateral Interstitial or Alveolar Nodular Infiltrate In A Patchy Or Homogenous Distribution Apices Often Spared 2. Chronic Stage: A. Difuse Reticulonodular Infiltrate OR B. Fibrosis B. High Resolution Chest CT A. May Demonstrate Airspace and Interstitial Patterns B. Chronic Stage: Honeycombing & Bronchiectasis

9. Treatment: A. Acute General Rx: 1. Glucocorticoids A. May Accelerate Initial Lung Recovery B. Prednisone: 0.5-1 Mg/ Kg 1. Over 2 Weeeks 2. Taper Over 4 Weeks 10. Disposition/Prognosis: Acute 4-48 Hours: A. Clinical : Fever, Chills, Cough, Hypoxia, Malaise B. HRCT: Ground Glass Infiltrate C. Histpathology: Alveolitis, Immune Complex Deposition D. Prognosis: Good Subacute Phase: A. Clincal : Dyspnea, Cough , Episodic Flares B. HRCT: Micronodules, Air Trapping C. Immunopathology: Broncholitis, Granulomas D. Prognosis: Good Chronic Phase: A. Clinical: Dyspena, Fatigue, Cough, Weight Loss B. HRCT: Fibrosis (+/-), Honeycombing, Emphysema C. Immunopathology: 1. Lymphocyte Infiltrate 2. Fibrosis 3. Neutrophil Mediated Air Space Destruction 11. Referrral : A. Bronchoscopy: 1. BAL: A. Intensive Lymphocytosis Typically T Cells >50% Predominantly CD8 + Suppressor Cells

B. Acute Stage: Neutrophils Predominate C. Chronic Stage: Increased CD+4/ CD+8 Cells B. Lung Biopsy: 1. Histopathologic Features A. Distinctive But Not Pathognomic B. Bronchiolitis & Interstitial Pneumonitis With Granuloma Formation .