00:01
Now, to pulmonary
fibrosis.
00:05
The other major non-sarcoid cause of interstitial
lung disease are hypersensitivity pneumonitis.
00:10
This is an interstitial lung disease caused
by an immunological reaction to an inhaled
antigen. It is an allergy. And the antigen
that causes it, depends usually on either your
occupation or your hobby. The commonest examples
are Bird fancier's lung which tends to affect
people who keep parrots or may have used to be
called Pigeon fancier's lung as well because
those who kept pigeons for racing would also
get this disease; and farmer's lung where
up to 5% of farmers develop an antibody response
to moulds and unusual bacteria that can live in
a mouldy hay. And some of those patients will
develop a hypersensitivity pneumonitis as
well. There's a very large range of
funny diseases
which are hypersensitivity pneumonitis, mushroom
pickers lung, cotton pickers lung, hot tub
disease, snuff takers lung, etc etc.
There is an ILD reaction to the inhaled
antigen. It causes a cell mediated hypersensitivity
reaction forming small granulomas which are
not terribly well defined, a mononuclear infiltrate,
and that will lead to eventually fibrosis
around the small airways. There are two clinical
presentations for hypersensitivity
pneumonitis, broadly speaking. One is that there's
an acute presentation where the patient will
present with what seems to be actually a chest
infection. They're breathless, they've got
cough, they have fever, and they have crackles,
and that occurs in a few hours of exposure to
the antigen to which they're allergic. And
when you take them away from their antigen,
actually, the disease settles very quickly
within a couple of days by itself.
01:49
If you have repeated episodes of acute hypersensitivity
pneumonitis, then that might lead to chronic
hypersensitivity pneumonitis. And chronic
hypersensitivity pneumonitis presents more
like pulmonary fibrosis with chronic dyspnoea,
generally progressive over time, cough.
02:05
But in addition, they may get some systemic mild
symptoms such as fatigue and weight loss.
02:11
You don't actually have to have acute preceding
episodes of acute hypersensitivity pneumonitis
to develop chronic hypersensitivity pneumonitis.
Most patients, in fact, with chronic disease,
seem to have no clear evidence of acute episodes
previously.
02:24
The thing about hypersensitivity pneumonitis
is that to identify it, you really need to
think about it and ask the patient carefully about
potential occupational and social circumstances
that might lead them to having hypersensitivity
pneumonitis such as, do they keep budgerigars, do
they keep birds, and so on and so on to try
and identify the potential possibility of
a hypersensitivity pneumonitis. Diagnosis
falls or lies with pulmonary fibrosis with
chest X-ray, lung function, and CT scan, but
there are some differences that you get with
hypersensitivity pneumonitis compared to pulmonary
fibrosis which allow you to differentiate
these patients. For example, acute
hypersensitivity pneumonitis
would present with patchy diffuse infiltrates
that actually often mistaken for pneumonia.
03:11
Chronic hypersensitivity pneumonitis cause
reticulonodular shadowing but with an upper
lobe predominance, which is unlike fibrosis
which normally is a lower lobe predominance.
03:22
Lung function again shows restrictive changes
of an impaired transfer factor, but in fact
with hypersensitivity pneumonitis, it is often
a mixed restrictive obstructive picture, not
a pure restrictive picture which is what you
get with pulmonary fibrosis.
03:34
When you do the CT scan, again, there's
an upper lobe distribution. There's more
ground glass that you normally get with pulmonary
fibrosis, and you get some very specific changes
of centrilobular nodules that's seen by
this CT scan shown here on the right with
some cyst formations, and mosaicism which
is an evidence that there are small airways
in infiltration and that is why you get a mixed
restrictive obstructive defect, is that the
disease doesn't just affect the alveoli but it
also affects the small airways leading
to some partial airways obstruction.
Any invasive test such as bronchoscopy might
reveal a lymphocytosis that we mentioned before.
Transbronchial biopsies can identify the poorly
formed granulomas, and then a blood test should
be positive for the precipitin that causes
the disease. So the avian precipitins should
be present in somebody with Bird fancier's
lung. Treatment of hypersensitivity pneumonitis,
well, obviously, you need to stop the patient
being exposed to the antigen. Now, that requires
you having to identify the antigen and know
what is causing it. And that is not always
the case. In fact, it quite a significant
minority of patient's with hypersensitivity pneumonitis,
the antigen causing it has not been identified.
04:45
In addition, it is actually sometimes quite
hard to convince patients to get rid of a
favorite pet. If they got a parrot that is
causing hypersensitivity pneumonitis, turning
that they have to get rid of the parrot is
quite tricky. Anti-inflammatory such as systemic
corticosteroids are also probably quite useful
in the hypersensitivity pneumonitis although
there are not any particularly good data from
clinical trials.