Editorial
Hypersensitivity Pneumonitis. Toward a Less Invasive Diagnostic Procedure
Neumonitis por hipersensibilidad. Estudio diagnóstico menos invasivo
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Toward a Less Invasive Diagnostic Procedure" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "445" "paginaFinal" => "446" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ferran Morell, Iñigo Ojanguren, María Jesús Cruz" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ferran" "apellidos" => "Morell" "email" => array:1 [ 0 => "fmorell@vhebron.net" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Iñigo" "apellidos" => "Ojanguren" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "María Jesús" "apellidos" => "Cruz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Vall d’Hebron Institut de Recerca (VHIR), Servei de Pneumologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER Enfermedades Respiratorias CIBERES, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonitis por hipersensibilidad. Estudio diagnóstico menos invasivo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonologists treating patients with interstitial lung disease (ILD) know that there is some chance that the diagnosis will be hypersensitivity pneumonitis (HP). To arrive at that diagnosis, we must remember that HP patients are usually non-smokers, younger than 60 years of age, almost always without nail clubbing, normal auscultation, or else auscultation with non-velcro crackles, and occasionally, a few high-pitched, end-inspiratory wheezes, known as chirping rales.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the acute form, high-resolution computed tomography (HRCT) will reveal the characteristic centrilobular nodules and ground glass opacities, particularly in the upper lobes and in the middle lobe and lingula, or a mosaic attenuation pattern with ground glass opacities combined with other clear/hyperlucent areas indicating hyperinflation from inflammatory centrilobular bronchiolar involvement. In the chronic form, mosaic attenuation patterns and centrilobular nodules, already indicating some degree of fibrosis, will be visualized, along with honeycombing areas, also in the lung bases. HP cannot be ruled out if HRCT shows images of usual interstitial pneumonia, non-specific interstitial pneumonia, or organizing pneumonia, and even if a combination of emphysema and fibrosis is revealed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A meticulous case history must be obtained, looking for evidence of previous contact with birds, feathers (down comforters, etc.), or fungi (damp environments, aerosols with contaminated water, spas, steam iron, moldy walls, etc.). Other etiologies, such as isocyanates, cutting fluids, inhaled proteins, hard metals, etc., are less common. Specific immunoglobulin G (sIgG) against the serum (but not the droppings) of various birds and some fungi will be determined. This will help clarify if there has been contact with these antigens, inducing an immunological response.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Bronchoalveolar lavage (BAL) and cryobiopsy should be performed, since a lymphocyte concentration of greater than 20% in BAL and in the biopsy, interstitial lymphoplasmacytic inflammation, along with bronchiolitis, and in some cases the finding of granulomas or giant cells in the interstitium will help confirm the diagnosis. Transbronchial biopsy in ILD has a low diagnostic yield of around 20%–38%.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">If the cause is suspected to be an organic material or liquid possibly contaminated by fungi, a culture should be performed to identify the microorganisms.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, if the patient interview and/or positive sIgG results and/or culture raises the suspicion of an antigen, a specific bronchial challenge test using that antigen is recommended. If positive, this procedure will even help suggest an etiological diagnosis. This diagnostic accuracy is important, since avoiding exposure to the specific cause will improve the course of the disease.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Surgical lung biopsy (SLB) should only be performed in those few cases in which a diagnosis cannot be reached after conducting the above-mentioned clinical tests.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although this diagnostic protocol has been followed in some expert centers since 1976,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> it is striking to see that many centers with widely published experience in the study of ILD according to the recommendations of the international guidelines only obtain clinical history, physical examination, and HCRT. In European hospitals, sIgG detection and BAL are usually performed, and cryobiopsy is currently performed before deciding whether to perform SLB; in contrast, many experts in North America indicate SLB directly, as this is considered the gold standard for the diagnosis of HP.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The question lies in the diagnostic reliability of each of the tests. Quantitative methods such as ELISA have high sensitivity and low specificity for the detection of sIgG antibodies; moreover, the reliability of these techniques has only been studied for some of the antigens that induce HP. The sensitivity of qualitative methods, such as precipitin detection, is low. Determination of sIgG using quantitative methods is of great interest to experienced centers, since a positive result will: (1) establish an association between exposure and disease; (2) in the absence of suspicion on case history, positivity will hint at the possible cause; and (3) conversely, negativity, if that is the case, will determine that the HP is not secondary to exposure to fungi or feathers.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Doubts about the effectiveness of BAL can be largely dispelled by findings of recent publications that show that a percentage of lymphocytes higher than 30%,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> or even higher than 20%,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> is very suggestive of HP. Similarly, the diagnostic yield of cryobiopsy in ILD, when compared with that of SLB, appears to have been sufficiently proven.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In many studies, the specific bronchial challenge test has already demonstrated its diagnostic effectiveness in some types of HP caused by the more common antigens.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our opinion, the most appropriate clinical and ethical approach is to continue using the diagnostic protocol that we have recommended, because until validation studies are be conducted on all these diagnostic procedures, many patients will be subjected unnecessarily to an SLB, with all the discomfort and complications that this entails.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Very recent recommendations from other experts in HP are in line with our proposal.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morell F, Ojanguren I, Cruz MJ. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 30 | 12 | 42 |
| 2024 September | 46 | 18 | 64 |
| 2024 August | 58 | 35 | 93 |
| 2024 July | 39 | 26 | 65 |
| 2024 June | 55 | 38 | 93 |
| 2024 May | 81 | 42 | 123 |
| 2024 April | 30 | 37 | 67 |
| 2024 March | 38 | 22 | 60 |
| 2024 February | 37 | 19 | 56 |
| 2023 March | 16 | 6 | 22 |
| 2023 February | 36 | 27 | 63 |
| 2023 January | 31 | 59 | 90 |
| 2022 December | 73 | 40 | 113 |
| 2022 November | 42 | 31 | 73 |
| 2022 October | 60 | 39 | 99 |
| 2022 September | 26 | 31 | 57 |
| 2022 August | 29 | 49 | 78 |
| 2022 July | 23 | 42 | 65 |
| 2022 June | 27 | 31 | 58 |
| 2022 May | 31 | 38 | 69 |
| 2022 April | 23 | 36 | 59 |
| 2022 March | 47 | 52 | 99 |
| 2022 February | 60 | 33 | 93 |
| 2022 January | 26 | 37 | 63 |
| 2021 December | 29 | 50 | 79 |
| 2021 November | 38 | 34 | 72 |
| 2021 October | 85 | 55 | 140 |
| 2021 September | 40 | 42 | 82 |
| 2021 August | 37 | 44 | 81 |
| 2021 July | 28 | 29 | 57 |
| 2021 June | 47 | 39 | 86 |
| 2021 May | 29 | 44 | 73 |
| 2021 April | 95 | 85 | 180 |
| 2021 March | 74 | 22 | 96 |
| 2021 February | 35 | 37 | 72 |
| 2021 January | 22 | 14 | 36 |
| 2020 December | 26 | 17 | 43 |
| 2020 November | 33 | 18 | 51 |
| 2020 October | 21 | 25 | 46 |
| 2020 September | 28 | 15 | 43 |
| 2020 March | 13 | 9 | 22 |
| 2020 February | 18 | 22 | 40 |
| 2020 January | 26 | 8 | 34 |
| 2019 December | 21 | 10 | 31 |
| 2019 November | 30 | 19 | 49 |
| 2019 October | 45 | 22 | 67 |
| 2019 September | 20 | 8 | 28 |
| 2019 August | 25 | 16 | 41 |
| 2019 July | 14 | 19 | 33 |
| 2019 June | 26 | 12 | 38 |
| 2019 May | 39 | 10 | 49 |
| 2019 April | 31 | 34 | 65 |
| 2019 March | 23 | 20 | 43 |
| 2018 October | 2 | 4 | 6 |
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