1302

Abstract

Introduction: We are presenting a new case of hypersensitivity pneumonitis(HP) in a occupational nail worker.HP is a granulomatous reaction in terminal airways, alveoli and surrounding interstitium. Although farmer's lung is the most common form of HP affecting 0.4-7% of farming population, the incidence of HP in nail worker is unknown and it is the first reported case of HP due to exposure to human nail. Case Presentation: 31 year old African American woman presented with worsening dyspnea on exertion, audible wheezing, non productive cough for 2 weeks. Her symptoms had been worsening since she was working long hours in her nail salon.She recently started working in the saloon since 3 months and her work included nail buffing and filing. She was exposed to extensive nail dust.Past medical history included morbid obesity, type 2 DM.Metformin was her only medication and there was no known allergy.Family history was negative for any lung disease or autoimmune disease.She smoked 3-5 cigaretts per day and quit 2 weeks prior. She denied use of alcohol or recreational drugs.Her condition worsened requiring admission to intensive care unit and mechanical ventillation with 100% O2. CTA thorax ruled out PE but showed extensibe ground glass opacities mostly affecting lingula and bilateral lobes.She was started on broad spectrum antibiotics. Results of respiratory viral panel,Legionella,HIV,ANA,RF, sputum culture were negative.Bronchoscopy was normal and BAL was negative for Mycobacterium, Legionella, fungi. Cytology from BAL revealed respiratory bronchiolitis. She failed to improve and she was emperically treated with IV Methylprednisolone to which she responded.Finally she underwent VATS with multiple lung biopsies.Biopsy showed scattered foci of non caseating granulomatous,alveolar pneumocyte hyperplaisa, large histiocytes with foamy cytoplasm in the alveoli.Special stains for fungal and mycobacterium including AFB,GMS and PAS were negative. Immunostains for S100,CD1a,actin,and HMB45 were negative.She continued to improve and she was discharged on oral prednisone.She was no more exposed to the nail dust and was at her baseline health in 4 weeks follow up. Discussion: HP in nail workers is not a well known clinical entity and there are no gold standard diagnostic tests.Though there are some case reports of HP to Trichophyton rubrum,it is the first case reported to the best of our knowledge. Although nail workers are exposed to various chemicals in addition to the nail dust which can confound the problem, our patient didnot have exposure to chemicals. Temporal relationship of symptoms with work, no other chemical exposure, typical radiological findings, supportive pathological findings and resolution of symptoms after removal from exposure strongly suggest towards the diagnosis.