Treatment, prevention, and prognosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis)
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a syndrome characterized by diffuse inflammation of lung parenchyma and airways in response to the inhalation of antigens to which the patient has been previously sensitized. Numerous inciting agents have been described including, but not limited to, agricultural dusts, bioaerosols, and certain reactive chemical species. (See "Epidemiology and causes of hypersensitivity pneumonitis (extrinsic allergic alveolitis)".)
Because both environmental and host factors are involved in the production of the HP syndromes, management theoretically can involve modification of the environment or of the host immune response . However, the pathogenesis of HP is incompletely understood, and emphasis on environmental control remains the cornerstone of therapy . The prevention, treatment, and prognosis of HP will be reviewed here. The diagnosis of HP is reviewed separately. (See "Diagnosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis)".)
The incidence of HP can be reduced by diminishing exposure to provocative antigens. This may be accomplished by minimizing contact with potential inciting agents, reducing microbial contamination of the work or home environment, or using protective equipment.
Reduction of antigenic burden — Alteration in the handling and storage of potential sources of microbial antigens can diminish the occurrence of HP. As examples, dispersion of actinomycetes spores is decreased by wetting compost prior to handling, and use of antimicrobial solutions in sugar cane processing diminishes fungal growth and the development of bagassosis.
Design of facilities — Indoor microbial contamination is usually related to problems with moisture control . Appropriate design of facilities may reduce stagnant water that is prone to microbial overgrowth. Thus, humidity in occupied buildings should be maintained below 60 percent, carpeting should be avoided in areas where persistent moisture is likely to be present, and water in heating, ventilating, and air conditioning systems should not be recirculated.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Am J Respir Crit Care Med 2012; 186:314.
- Girard M, Israël-Assayag E, Cormier Y. Pathogenesis of hypersensitivity pneumonitis. Curr Opin Allergy Clin Immunol 2004; 4:93.
- Rose CS. Water-related lung diseases. Occup Med 1992; 7:271.
- Cormier Y, Bélanger J. Long-term physiologic outcome after acute farmer's lung. Chest 1985; 87:796.
- Braun SR, doPico GA, Tsiatis A, et al. Farmer's lung disease: long-term clinical and physiologic outcome. Am Rev Respir Dis 1979; 119:185.
- Jacobs RL, Andrews CP, Jacobs FO. Hypersensitivity pneumonitis treated with an electrostatic dust filter. Ann Intern Med 1989; 110:115.
- Rose C. Hypersensitivity pneumonitis and other disorders caused by organic agents. In: Pulmonary Respiratory Therapy Secrets, Parsons PE, Heffner JE (Eds), Hanley & Belfus, Philadelphia 1997. p.298.
- Cuthbert OD, Gordon MF. Ten year follow up of farmers with farmer's lung. Br J Ind Med 1983; 40:173.
- Barbee RA, Callies Q, Dickie HA, Rankin J. The long-term prognosis in farmer's lung. Am Rev Respir Dis 1968; 97:223.
- Craig TJ, Hershey J, Engler RJ, et al. Bird antigen persistence in the home environment after removal of the bird. Ann Allergy 1992; 69:510.
- Tsutsui T, Miyazaki Y, Kuramochi J, et al. The amount of avian antigen in household dust predicts the prognosis of chronic bird-related hypersensitivity pneumonitis. Ann Am Thorac Soc 2015; 12:1013.
- Mönkäre S. Influence of corticosteroid treatment on the course of farmer's lung. Eur J Respir Dis 1983; 64:283.
- Kokkarinen JI, Tukiainen HO, Terho EO. Effect of corticosteroid treatment on the recovery of pulmonary function in farmer's lung. Am Rev Respir Dis 1992; 145:3.
- Xu JF, Shen L, Zhang Y, et al. Lung biopsy-proved hypersensitivity pneumonitis without known offending antigen: characteristics and follow-up. Clin Respir J 2014; 8:297.
- Ohshimo S, Bonella F, Guzman J, Costabel U. Hypersensitivity pneumonitis. Immunol Allergy Clin North Am 2012; 32:537.
- Patel AM, Ryu JH, Reed CE. Hypersensitivity pneumonitis: current concepts and future questions. J Allergy Clin Immunol 2001; 108:661.
- Carlsen KH, Leegaard J, Lund OD, Skjaervik H. Allergic alveolitis in a 12-year-old boy: treatment with budesonide nebulizing solution. Pediatr Pulmonol 1992; 12:257.
- Mönkäre S, Haahtela T. Farmer's lung--a 5-year follow-up of eighty-six patients. Clin Allergy 1987; 17:143.
- Lota HK, Keir GJ, Hansell DM, et al. Novel use of rituximab in hypersensitivity pneumonitis refractory to conventional treatment. Thorax 2013; 68:780.
- Keir GJ, Maher TM, Ming D, et al. Rituximab in severe, treatment-refractory interstitial lung disease. Respirology 2014; 19:353.
- Morisset J, Johannson KA, Vittinghoff E, et al. Use of Mycophenolate Mofetil or Azathioprine for the Management of Chronic Hypersensitivity Pneumonitis. Chest 2017; 151:619.
- Adegunsoye A, Oldham JM, Fernández Pérez ER, et al. Outcomes of immunosuppressive therapy in chronic hypersensitivity pneumonitis. ERJ Open Res 2017; 3.
- Kern RM, Singer JP, Koth L, et al. Lung transplantation for hypersensitivity pneumonitis. Chest 2015; 147:1558.
- Vourlekis JS, Schwarz MI, Cherniack RM, et al. The effect of pulmonary fibrosis on survival in patients with hypersensitivity pneumonitis. Am J Med 2004; 116:662.
- Ohtani Y, Saiki S, Kitaichi M, et al. Chronic bird fancier's lung: histopathological and clinical correlation. An application of the 2002 ATS/ERS consensus classification of the idiopathic interstitial pneumonias. Thorax 2005; 60:665.
- Sahin H, Brown KK, Curran-Everett D, et al. Chronic hypersensitivity pneumonitis: CT features comparison with pathologic evidence of fibrosis and survival. Radiology 2007; 244:591.
- Gimenez A, Storrer K, Kuranishi L, et al. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. Thorax 2017.
- Ley B, Ryerson CJ, Vittinghoff E, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med 2012; 156:684.
- Ryerson CJ, Vittinghoff E, Ley B, et al. Predicting survival across chronic interstitial lung disease: the ILD-GAP model. Chest 2014; 145:723.
- Tateishi T, Ohtani Y, Takemura T, et al. Serial high-resolution computed tomography findings of acute and chronic hypersensitivity pneumonitis induced by avian antigen. J Comput Assist Tomogr 2011; 35:272.
- Walsh SL, Sverzellati N, Devaraj A, et al. Chronic hypersensitivity pneumonitis: high resolution computed tomography patterns and pulmonary function indices as prognostic determinants. Eur Radiol 2012; 22:1672.
- Mooney JJ, Elicker BM, Urbania TH, et al. Radiographic fibrosis score predicts survival in hypersensitivity pneumonitis. Chest 2013; 144:586.
- Chung JH, Zhan X, Cao M, et al. Presence of Air Trapping and Mosaic Attenuation on Chest Computed Tomography Predicts Survival in Chronic Hypersensitivity Pneumonitis. Ann Am Thorac Soc 2017; 14:1533.
- Chiba S, Tsuchiya K, Akashi T, et al. Chronic Hypersensitivity Pneumonitis With a Usual Interstitial Pneumonia-Like Pattern: Correlation Between Histopathologic and Clinical Findings. Chest 2016; 149:1473.
- Jacob J, Bartholmai BJ, Rajagopalan S, et al. Automated computer-based CT stratification as a predictor of outcome in hypersensitivity pneumonitis. Eur Radiol 2017; 27:3635.
- Lalancette M, Carrier G, Laviolette M, et al. Farmer's lung. Long-term outcome and lack of predictive value of bronchoalveolar lavage fibrosing factors. Am Rev Respir Dis 1993; 148:216.
- Kokkarinen JI, Tukiainen HO, Terho EO. Recovery of pulmonary function in farmer's lung. A five-year follow-up study. Am Rev Respir Dis 1993; 147:793.
- Erkinjuntti-Pekkanen R, Kokkarinen JI, Tukiainen HO, et al. Long-term outcome of pulmonary function in farmer's lung: a 14 year follow-up with matched controls. Eur Respir J 1997; 10:2046.
- Erkinjuntti-Pekkanen R, Rytkonen H, Kokkarinen JI, et al. Long-term risk of emphysema in patients with farmer's lung and matched control farmers. Am J Respir Crit Care Med 1998; 158:662.
- Reynolds HY. Hypersensitivity pneumonitis: correlation of cellular and immunologic changes with clinical phases of disease. Lung 1988; 166:189.
- Phanuphak P, Salvaggio J, Fink J, Kohler P. Incidence of serum precipitins against organic-dust antigens in different populations by counterimmunoelectrophoresis. Chest 1975; 68:753.
- Hapke EJ, Seal RM, Thomas GO, et al. Farmer's lung. A clinical, radiographic, functional, and serological correlation of acute and chronic stages. Thorax 1968; 23:451.
- Laviolette M, Cormier Y, Loiseau A, et al. Bronchoalveolar mast cells in normal farmers and subjects with farmer's lung. Diagnostic, prognostic, and physiologic significance. Am Rev Respir Dis 1991; 144:855.
- Leblanc P, Bélanger J, Laviolette M, Cormier Y. Relationship among antigen contact, alveolitis, and clinical status in farmer's lung disease. Arch Intern Med 1986; 146:153.
- Grammer LC, Roberts M, Lerner C, Patterson R. Clinical and serologic follow-up of four children and five adults with bird-fancier's lung. J Allergy Clin Immunol 1990; 85:655.
- Remy-Jardin M, Remy J, Wallaert B, Müller NL. Subacute and chronic bird breeder hypersensitivity pneumonitis: sequential evaluation with CT and correlation with lung function tests and bronchoalveolar lavage. Radiology 1993; 189:111.
- Pérez-Padilla R, Salas J, Chapela R, et al. Mortality in Mexican patients with chronic pigeon breeder's lung compared with those with usual interstitial pneumonia. Am Rev Respir Dis 1993; 148:49.
- Buschman DL, Gamsu G, Waldron JA Jr, et al. Chronic hypersensitivity pneumonitis: use of CT in diagnosis. AJR Am J Roentgenol 1992; 159:957.
- Fink JN, Sosman AJ, Barboriak JJ, et al. Pigeon breeders' disease. A clinical study of a hypersensitivity pneumonitis. Ann Intern Med 1968; 68:1205.
- Bourke SJ, Banham SW, Carter R, et al. Longitudinal course of extrinsic allergic alveolitis in pigeon breeders. Thorax 1989; 44:415.
- Allen DH, Williams GV, Woolcock AJ. Bird breeder's hypersensitivity pneumonitis: progress studies of lung function after cessation of exposure to the provoking antigen. Am Rev Respir Dis 1976; 114:555.
- de Gracia J, Morell F, Bofill JM, et al. Time of exposure as a prognostic factor in avian hypersensitivity pneumonitis. Respir Med 1989; 83:139.
- Schmidt CD, Jensen RL, Christensen LT, et al. Longitudinal pulmonary function changes in pigeon breeders. Chest 1988; 93:359.
- Sansores R, Salas J, Chapela R, et al. Clubbing in hypersensitivity pneumonitis. Its prevalence and possible prognostic role. Arch Intern Med 1990; 150:1849.
- Zacharisen MC, Schlueter DP, Kurup VP, Fink JN. The long-term outcome in acute, subacute, and chronic forms of pigeon breeder's disease hypersensitivity pneumonitis. Ann Allergy Asthma Immunol 2002; 88:175.
- Miyazaki Y, Tateishi T, Akashi T, et al. Clinical predictors and histologic appearance of acute exacerbations in chronic hypersensitivity pneumonitis. Chest 2008; 134:1265.
- Ohtani Y, Saiki S, Sumi Y, et al. Clinical features of recurrent and insidious chronic bird fancier's lung. Ann Allergy Asthma Immunol 2003; 90:604.