Diagnosis Of HP Research Articles

ATS/JRS/ALAT Hypersensitivity Pneumonitis Guidelines for Diagnosis of humidifier lung and summer-type hypersensitivity pneumonitis

BackgroundThe ATS/JRS/ALAT Guidelines for the Diagnosis of Hypersensitivity Pneumonitis (GL for HP) were published in 2020. Humidifier lung and summer-type HP are forms of HP, but it is unclear whether they can be diagnosed using GL for HP. This study examined the level of confidence where humidifier lung and summer-type HP can be diagnosed with GL for HP. MethodsData from 23 patients with humidifier lung and 20 patients with summer-type HP (mean age, 67.3 and 57.4 years, respectively) diagnosed between October 2012 and January 2022 were retrospectively reviewed. We evaluated high resolution computed tomography (HRCT) patterns, bronchoalveolar lavage fluid (BALF) findings, exposures, and histopathological findings to determine the level of confidence where a diagnosis of HP could be made using the GL for HP. ResultsHRCT pattern was classified as typical HP in 5 (22%) and compatible with HP in 18 (78%) patients with humidifier lung and considered as typical HP in 17 (85%) and compatible with HP in 3 (15%) patients with summer-type. The confidence level for diagnosis of HP was definite in 2 (8.7%), moderate in 14 (60.9%), and low in 7 (30.4%) patients with humidifier lung. It was definite in 12 (60%), high in 3 (15%), and moderate in 5 (25%) patients with summer-type HP. ConclusionsGL for HP showed utility in diagnosing humidifier lung in many patients with a moderate to low confidence. However, there was a definite to high confidence for patients with summer-type HP.

Impact of diagnostic guidelines on the diagnosis of hypersensitivity pneumonitis.

Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease from exposure to environmental antigens. Diagnosing HP could be challenging. The American College of Chest Physicians (CHEST) and American Thoracic Society/Japanese Respiratory Society/and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) have published diagnostic guidelines in 2021 and 2020 respectively. The CHEST guideline uses four grades of confidence: confident (>90%), provisional high (70-89%), provisional low (51-69%), and unlikely (≤50%). The ATS/JRS/ALAT guideline uses five grades of confidence: definite (>90%), high (80-89%), moderate (70-79%), low (51-69%) and not excluded (≤50%). In this study, we determined how these two guidelines could have affected the diagnosis of HP made before the guidelines. Two hundred and fifty-nine adult patients from a previous cohort with HP (ICD-9:495) made between Jan. 1, 2008, and Dec. 31, 2013, at Duke University Medical Center were included. We simplified the diagnostic confidence into three categories so we could compare the guidelines: high (≥90%), intermediate (51-89%), and low (≤50%). There were 156 female and 103 male. Mean age was 58 (range: 20-90). 68.8% of the patients had restrictive defects (FVC < 80% pred) and 48.6% had lung biopsy. The CHEST guideline classified 33.6% of the patients into high, 59.5% into intermediate and 6.9% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.7% of the patients into high, 21.2% into intermediate and 49.0% into low confidence categories (p < 0.0001 vs. CHEST). Cohen's kappa was 0.331. In patients with identifiable inciting agents (IAs) (N = 168), the CHEST guideline classified 32.1% of the patients into high, 64.3% into intermediate and 3.6% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.2% of the patients into high, 20.8% into intermediate, and 50.0% into low confidence categories. Cohen's kappa was 0.314. In our HP cohort with two-thirds of the patients with restrictive defects, we found the two guidelines had fair agreement in diagnosing HP with or without identifiable IAs. They agreed more when the diagnostic confidence was high. When the diagnostic confidence was lower, however, the ATS/JRS/ALAT guideline was more stringent. Clinicians should be aware of the differences between the two guidelines when evaluating patients suspicious of HP.

Predictors of pulmonary hypertension in patients with hypersensitivity pneumonitis

BackgroundHypersensitivity pneumonitis (HP) is an immunologically induced inflammation of the lung parenchyma that occurs in susceptible individuals in response to a variety of antigens. Repeated exposures to the causative antigens lead to chronic HP. The condition could be complicated with pulmonary hypertension (PH).Methodology60 patients with established diagnosis of HP were included, clinical examination, high resolution computed tomography (HRCT) of chest, arterial blood gases, six minute walking test (6MWT), desaturation index, spirometry, echocardiography were performed to all patients and right heart catheter was done for patients with high echo probability of PH.ResultsThe mean age of patients was 41.67 ± 13.4 years with female predominance 83.3% of patients had history of raising birds. 71.7% of cases suffered from resting hypoxia with oxygen saturation 89 ± 11% with desaturation index 9% ± 8%, Echo probability of PH ranged from low to high 71.67, 21.67 and 6.67% respectively, mean pulmonary artery systolic pressure was 63.65 (18.48) mmHg. PH was diagnosed in 17 (28.33%) patients. HP with PH patients were significantly more symptomatic with predominant fibrotic pattern in HRCT chest P < 0.001, 82% of them had hypoxia P < 0.001 with significant desaturation after 6MWT P = 0.001. Predictors of PH in study group were fibrotic pattern in HRCT chest and hypoxia OR = 62.22, P < 0.001; 49.2, P < 0.001 respectively.ConclusionPH was prevalent in 28.33% of patients with HP, predictors of development of PH were fibrotic pattern in HRCT chest and hypoxia.Trial registration: Retrospectively registered, registration number is NCT05458635, date of registration 07/12/2022.

Does avian antigen-induced chronic hypersensitivity pneumonitis lead to more severe PH than other causes of the same?

Sir, Chronic hypersensitivity pneumonitis (CHP) is a prominent aetiology of diffuse parenchymal lung disease (DPLD), contributing to over 47% of the inclusions in the ILD-India registry.[1] The diagnosis of CHP is difficult because the pathological description needs lung biopsy that remains mostly undone. The high-resolution computed tomography (HRCT) chest, however, can give some definite clues for the possibility.[2] In our series, the HRCT diagnosis of HP was done by a pulmonologist and a radiologist on an agreement for the probability of HP in their independent interpretation of HRCT chest pictures. The radiologically possible-HP diagnosis was supported by positive IgG precipitin titre for avian antigen by immunoCAP method.[3] A precipitin titre value >30 mg mgA/L was taken as significant.[3] The clinico-radio-serological positivity was further supported by history of exposure to pigeons/birds to build up a nearly definite avian antigen–induced diagnosis of CHP. However, the possible CHP cases from other causes could not be evaluated serologically as the panel with common antigens was not available to us at that point of time. The study did not essentially include subjects with features of CHP without any etiological confirmation and exclude other causes like connective tissue disease associated-interstitial lung disease (CTD-ILD) and sarcoidosis. The latter was done by a thorough clinical exercise (noting the American Rheumatology Association [ARA]) criteria for the common CTDs supported by the relevant serological tests whenever possible in the real-world situation. Sarcoidosis was diagnosed with demonstration of non-ceasing granuloma with exclusion of tuberculosis. All the patients underwent Doppler echo-cardiography by a single dedicated non-invasive cardiologist who looked systematically for evidence of pulmonary hypertension (PH) in addition to other parameters. Furthermore, we looked for the presence of clinical and radiological XRay -posterio-anterior (PA) view (chest X-ray [PA view] and HRCT) features of PH to satisfy the clinico-radio-echocardiographic screening criteria of the institute for the presence of PH.[4] We had 95 cases of suspected HP included in the evaluation from 2018 to 2019. These patients were sub-divided into two groups - CHP caused due to exposure to avian antigen and CHP likely from other possible etiologies. The above two groups were thus compared on the basis of demographic, spirometric, functional health status and echo-cardiographic variables [Table 1].Table 1: Demographic, spirometric, and functional health status and echocardiographic parameters between the two groups of chronic hypersensitivity pneumonitis (CHP) patientsThe results reflect that the two groups were similar on demographical and spirometric lung function variables, but the patients with CHP from avian antigen had significantly higher systolic pulmonary artery pressure (PAP). To appreciate the relative contribution of the variables for the difference between the two groups, we used the VIP plot that suggested the presence of PAP as the most effective discriminant between the two groups [Figure 1a]. However, the overlap between the clusters was very high, suggesting limited applicability of the information [Figure 1b]. In one of our previous observations, we found a very high frequency HRCT-chest that suggested PH in CHP patients induced by chronic exposure to avian antigen.[4] Such exposure of avian antigen has been found to be one of the common causes of CHP. Avian exposure was present in 21.4% of 513 HP patients in the ILD-India registry,[1] with the adjusted odds ratio of 3.52 (P < 0.001) for developing HP after exposure.[2] Pulmonary hypertension is found quite frequently in CHP[5] and is associated with poor survival prospect.[5] The subjects having CHP with history of exposure to avian antigen had a lesser but statistically insignificant mean duration of illness compared to the other group. The standard deviation in both the groups was very wide for the illness duration, making it unsuitable for interpretation through VIP plot [Figure 2]. Despite the weakness of having no biopsy-proven diagnosis of HP, a non-stringent exclusion of other aetiologies, non-inclusion of treatment history, and dearth of haemodynamic confirmation by right heart catheterisation, our observation demands attention. Furthermore, objective validation of our observation is, thus, warranted.Figure 1: (a) The VIP plot with the variables represents the relative contribution of the parameters to the variance between the study groups, (b) 2D score scatter plot of principal component analysis (PCA) to distinguish the two study groups [avian exposure related and other causes of CHP (chronic hypersensitivity pneumonitis)]showing a significant overlapFigure 2: Comparison of the disease duration between the two study groups [avian exposure related and other causes of CHP (chronic hypersensitivity pneumonitis)]Financial support and sponsorship The research was funded by the organization itself. Conflicts of interest There are no conflicts of interest.

An unexpected effect of teleworking: acute clinical manifestations of a hypersensitivity pneumonitis to home parrots

Abstract Hypersensitivity pneumonitis (HP) is a complex inflammatory and/or fibrotic immune-mediated disease that involves lung parenchyma and small airways caused by an inhaled antigen in susceptible individuals. It is currently the third most frequent interstitial lung disease (ILD) after idiopathic pulmonary fibrosis (IPF) and connective tissue disease with ILD. Diagnosis of HP is often challenging as identifying a causative agent is one of the main arguments in diagnosis along with specific serum IgG testing, suggestive HRCT and/or BAL, and in some cases histopathological findings. However, in up to 60 % of cases, exposure is not identified despite a thorough exposure history. HP is more frequent associated with occupational exposures, up to 20%, but non-occupational environmental exposure remains an important cause. We present a case of bird fancier’s lung that illustrates the challenges and the importance of identifying the culprit antigen as the elimination of exposure in combination with corticosteroids can lead to improvement in lung function, symptoms and leads to a better prognosis and may stop of evolving in sever fibrotic forms of HP.

Current and Future Perspectives in the Diagnosis and Management of Helicobacter pylori Infection.

Helicobacter pylori (Hp) is a prevalent organism infecting almost half the global population. It is a significant concern, given its associated risk of gastric cancer, which is the third leading cause of cancer death globally. Infection can be asymptomatic or present with dyspeptic symptoms. It may also present with alarm symptoms in the case of progression to cancer. Diagnosis can be achieved non-invasively (breath tests, stool studies, or serology) or invasively (rapid urease test, biopsy, or culture). Treatment involves acid suppression and regimens containing several antibiotics and is guided by resistance rates. Eradication is essential, as it lowers the risk of complications and progression to cancer. Follow-up after eradication is similarly important, as the risk of cancer progression remains. There have been many recent advances in both diagnosis and treatment of Hp. In particular, biosensors may be effective diagnostic tools, and nanotechnology, vaccines, and potassium-competitive acid blockers may prove effective in enhancing eradication rates.

Peritoneal hydatidosis: An exceptional case report

Hydatidosis is a cosmopolitan parasitic disease that presents a real public health problem, especially in endemic countries of which Morocco is part. The objective of the present work is to analyze the clinical, paraclinical, therapeutic, evolutionary, and prognostic aspects of disseminated peritoneal hydatidosis with multiple localization. Peritoneal hydatidosis represents the whole of the phenomena due to the seeding, essentially secondary, of the peritoneal serosa by Echinococcus Granulosus larvae. Peritoneal hydatidosis is characterized by its polymorphic symptomatology, and the diagnosis is based on a combination of epidemiological, clinical, biological, and imaging findings. We report a case of a particular form of peritoneal hydatidosis in the department of visceral surgery I of the ibn rochd hospital in Casablanca. Our patient was admitted for management of disseminated peritoneal hydatidosis. The clinical examination, apart from an epigastric crust, was unremarkable. The biological work-up showed a slightly disturbed liver balance and the hydatid serology was strongly positive. The preoperative diagnosis of HP was established by CT scan showing a supra- and sub-mesocolic peritoneal hydatidosis with a multi-cystic spleen and a liver with a type V segment V hydatid cyst measuring 4 cm by 6 cm. The treatment consisted of a total cystectomy of the hydatid cysts, almost 100 cysts with multiple peritoneal and parietal locations, one of which was fistulized in the skin, associated with a total splenectomy, retrograde appendectomy, and a disconnection of the cholecysto-duodenal fistula with duodenal closure and a retrograde cholecystectomy associated with a choledecotomy with the extraction of 3 stones at the level of the choledochus and drainage of the VBP by Kehr drain. The postoperative course was simple and the patient was discharged on the sixth day with adjuvant treatment with albendazole for three months. Through this observation and in the light of the data in the literature, we were able to insist in our present work on the diagnostic difficulties generated by this unusual location of the hydatid cyst as well as the considerable contribution of imaging (CT++) allowing both a positive and very precise topographic diagnosis. We were also able to focus on surgical treatment as an indispensable pillar of the management of this disease as well as the increasingly fundamental role of medical treatment, particularly in the prevention of recurrences.

Haemosuccus pancreaticus: a diagnostic challenge and its management through interventional radiology

BackgroundHaemosuccus pancreaticus (HP), also known as pseudohaemobilia, is defined as upper gastrointestinal tract hemorrhage originating from the pancreatic duct into the duodenum via the ampulla of Vater or major pancreatic papilla. Pseudoaneurysm formation from the splenic artery is a common complication of pancreatitis; however, upper gastrointestinal bleed resulting from rupture of splenic artery pseudoaneurysm into the pancreatic duct is unusual and challenging to diagnose.Case presentationA 26-year-old patient presented with multiple episodes of hematemesis, melena, and intermittent abdominal pain. A contrast-enhanced computed tomography (CECT) scan was performed that demonstrated chronic calcific pancreatitis with a pseudoaneurysm in the splenic artery in close relation to the main pancreatic duct. The patient was immediately shifted for endovascular management, and the pseudoaneurysm was successfully embolized. Post embolization, the patient developed splenic abscess, which was managed by percutaneous catheter drainage.ConclusionDue to its rarity and being challenging to diagnose, the mortality rate of HP is high. A high level of expertise is required to diagnose HP, and it should be considered in all upper gastrointestinal bleed patients associated with acute or chronic pancreatitis. Rapid initial CECT and angiography should be performed to confirm the diagnosis, followed by embolization of the bleeding pseudoaneurysm to eliminate the need for surgery. This case report highlights the challenges in the diagnosis and management of HP.

Defining and predicting progression in non-IPF interstitial lung disease

Randomized placebo-controlled trials demonstrated the efficacy of antifibrotic treatment in non-IPF progressive fibrosing ILD (fILD). Currently, there is no consensus on how progression should be defined and clinical data of non-IPF fILD patients in a real-world setting are scarce.Non-IPF fILD patients presenting at the University Hospitals Leuven between 2012 and 2016 were included. Different definitions of progression according to the selection criteria of the INBUILD, RELIEF and the uILD study were retrospectively evaluated at every hospital visit. Univariate and multivariate analyses were performed to identify predictors of progression and mortality.The study cohort comprised 120 patients; 68.3%, 54.2% and 65.8% had progressive disease based on the INBUILD, RELIEF and uILD study, respectively. A large overlap of progressive fILD patients according to the different clinical trials was observed. Median transplant-free survival time of progressive fILD patients was 3.9, 3.9, 3.8 years and the median time-to-progression after diagnosis was 2.0, 3.1 and 2.3 years according to the INBUILD, RELIEF and uILD study, respectively. We identified several predictors of mortality, but only an underlying diagnosis of HP and uILD was independently associated with progression.Our data show a high prevalence of progressive fibrosis among non-IPF fILD patients and a discrepancy between predictors of mortality and progression. Mortality rate in fILD is high and the identification of progressive disease is only made late during the disease course. Moreover, future treatment decisions will be based upon disease behavior. Therefore, more predictors of progressive disease are needed to guide treatment decisions in the future.

CYSTIC LUNG DISEASE: AN USUAL PRESENTATION OF SP-C

TOPIC: Pediatrics TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cystic interstitial lung disease (ILD) is rare in pediatrics. The differential includes genetic, congenital and acquired diseases. Often, diagnosis can be made by history and radiologic findings. However, lung biopsy and genetic testing is often necessary. CASE PRESENTATION: A 13-year-old male with PMH of asthma, allergic rhinitis (AR), eczema, chronic urticaria and no hospitalizations or surgeries was seen by an allergist for urticaria after initiation of immunotherapy. A CXR, obtained for RUL crackles heard on exam, demonstrated bilateral, R>L, upper lobe infiltrates and R hilar adenopathy. He was referred to pulmonology. Medications were Flovent and Claritin, NKDA and was a healthy term baby. No family history of asthma or CF, but mother has AR and his deceased father and paternal grandmother had sarcoidosis. No exposure to smokers, pets, carpet, farms or birds. At his pulmonology visit, repeat CXR, CBC, CMP, IgE, Aspergillus Ab, QuantiFERON gold and HP were obtained. They were normal except for the CXR, which had increased perihilar and suprahilar interstitial densities. HP panel had positive antibodies from underlying allergies. CXR prompted a chest CT which showed cystic ILD in the mid and upper lobes bilaterally with a few lesions in the lower lobes. Ground glass opacities with a honeycombing pattern were in the lung apices, but no bronchiectasis. Initial PFT showed mixed obstructive-restrictive pattern. Follow up PFT confirmed restriction, TLC 65%. DLCO mildly reduced. Normal sweat test and echo. At his bronchoscopy he complained of dyspnea on exertion. Bronchoscopy was normal. Lung biopsy showed advanced fibrotic ILD with honeycomb changes and focal dense eosinophilic aggregates, consistent with HP or surfactant deficiency. Due to dyspnea, he had pulse steroids (30mg/kg dailyx3 days), transitioned to daily steroids and weaned over 8 weeks. He was discharged with presumed diagnosis of HP, pending genetic studies. During the steroid wean, surfactant panel showed a heterozygous mutation in the surfactant protein C gene (SFTPC), c.218T>C. He was diagnosed with SP-C deficiency and started on hydroxychloroquine 400mg/day and Azithromycin 500mg 3x/week. Pulse steroids are biweekly. DISCUSSION: SP-C mutation comprises 0.36 cases per million children. Surfactant proteins A and D are involved in the immune defense and SP-B and -C prevent alveolar collapse. SP-C is a dominant condition with 55% mutations arise spontaneously. SP-C mutations are difficult to diagnose due to variability in presentation. Prognosis is variable. An interesting aspect is the family history of sarcoidosis, a disease without a definitive test. It is possible the father had SP-C deficiency and was misdiagnosed. CONCLUSIONS: This case illustrates the variable presentation of SP-C deficiency, with cystic lesions and ground glass opacities on CT. It serves as a reminder that the differential should include SP-C deficiency. REFERENCE #1: PMID: 30094155 REFERENCE #2: PMID: 24605255 REFERENCE #3: https://doi.org/10.1542/peds.2015-2725 DISCLOSURES: No relevant relationships by Emma Segal, source=Web Response No relevant relationships by Heather Staples, source=Web Response

Occupational causes of hypersensitivity pneumonitis: a systematic review and compendium.

BackgroundHypersensitivity pneumonitis (HP) is caused by a variety of antigens and low-molecular-weight chemicals, often through occupational exposure. Making a diagnosis of HP and identifying a cause are challenging. Cryptogenic cases are frequently reported, and missing or incomplete exposure histories can cause misclassification.AimsTo provide an evidence-based compendium of sources of exposure and causes of HP for the clinician, through systematic review of medical literature.MethodsArticles related to HP causative agents and occupational exposure were searched from the databases OVID Medline (1946 to October 2020) and EMBASE (1974 to October 2020). s and full texts of articles were screened by two reviewers. Data on causative antigens, occupational source of exposure and any associated eponymous name were extracted and grouped according to source of exposure.ResultsA total of 1790 articles were identified, from which 305 articles met the inclusion criteria. An additional 22 articles were identified from citation lists of the selected review articles. Sources of exposure identified for HP were sorted into 14 categories of work (agricultural, plant matter processing, wood, animal-related, foodstuff, food processing, metal processing, polymers, other manufacturing, chemicals, aerosolized water, service, waste and sewage and wind instruments).ConclusionsThis work is a comprehensive list of occupational causative agents and exposures causing HP. Cases are grouped by source of exposure, allowing an immediately accessible compendium of causes for use during occupational exposure assessment, which could also form the basis for a clinical questionnaire.

Hypersensitivity pneumonitis: Current concepts in pathogenesis, diagnosis, and treatment.

Hypersensitivity pneumonitis is an immune-mediated interstitial lung disease caused by an aberrant response to an inhaled exposure, which results in mostly T cell-mediated inflammation, granuloma formation, and fibrosis in some cases. HP is diagnosed by exposure identification, HRCT findings of ground-glass opacities, centrilobular nodules, and mosaic attenuation, with traction bronchiectasis and honeycombing in fibrotic cases. Additional testing including serum IgG testing for the presence of antigen exposure, bronchoalveolar lavage lymphocytosis, and lung biopsy demonstrating granulomas, inflammation, and fibrosis, increases the diagnostic confidence. Treatment for HP includes avoidance of the implicated exposure, immunosuppression, and anti-fibrotic therapy in select cases. This narrative review presents the recent literature in the understanding of the immunopathological mechanisms, diagnosis, and treatment of HP.

Hypersensitivity pneumonitis (HP)- Global and Indian scenario

Pulmonologists face a challenge in the diagnosis of HP which has multiple clinical phenotypes. In all newly diagnosed interstitial lung disease, HP should always be considered. The current guidelines classify HP into two main criteria based on clinical, radiological and pathological subtypes. They are acute/inflammatory HP and chronic/fibrotic HP. Patients who have a positive exposure history with a typical/classical pattern on HRCT and with BAL lymphocytosis, a diagnosis with high confidence can be made. Additional histopathological sampling should be done after multidisciplinary discussion in patients when an alternative diagnosis cannot be established. All efforts must be undertaken in patients of HP to identify the environmental inducers and eliminate the source to prevent and minimize exposure to the same and prevent the progression of the disease. Systemic corticosteroids still continue to remain the mainstay of treatment. Randomized clinical trials with existing and/new antifibrotic agents are required for effective management of patients with chronic HP. Lung transplantation offers some hope for patients with chronic progressive HP and patients should be evaluated early for the same

Clinical significance of serum anti-granulocyte\u2013macrophage colony-stimulating factor autoantibodies in patients with sarcoidosis and hypersensitivity pneumonitis

BackgroundAnti-granulocyte–macrophage colony-stimulating factor autoantibody (GMAb) has been recognized as a diagnostic biomarker for autoimmune pulmonary alveolar proteinosis (aPAP). The aims of this study were to know the incidence of increased level of serum GMAb in granulomatous lung diseases (sarcoidosis and hypersensitivity pneumonitis [HP]) and to clarify the role of GMAb. Consecutive individuals diagnosed with sarcoidosis (n = 92) and HP (n = 45) at National Hospital Organization Kinki-Chuo Chest Medical Center were retrospectively analyzed. We measured serum GMAb levels at the diagnosis. Cut-off values of GMAb discriminating aPAP (n = 110) from healthy controls (n = 31) were determined by receiver operating characteristic (ROC) curve analysis. We compared the clinical features of sarcoidosis and HP patients with GMAb levels above the cut-off value (“Elevated-GMAb”) with those of patients whose GMAb levels below the cut-off value (“Low-GMAb”). Radiological and pathological findings in elevated-GMAb patients were re-evaluated to elucidate the role of GMAb in granulomatous lung diseases.ResultsAnalysis of ROC indicated a sensitivity and specificity of 100% at GMAb level of 3.33 μg/mL for discriminating aPAP from healthy controls (area under curve = 1.000, p < 0.0001). The percentages of elevated-GMAb sarcoidosis and HP patients were 5.4% (n = 5) and 11.1% (n = 5), respectively. The number of comorbid sarcoidosis and HP patients with aPAP was two and one, respectively. Elevated-GMAb sarcoidosis patients presented with significantly higher serum levels of Krebs von den Lungen (KL)-6, surfactant protein-D (SP-D), lactate dehydrogenase, and the requirement of systemic corticosteroid therapy. Elevated-GMAb HP patients demonstrated older age, higher serum KL-6, SP-D, carcinoembryonic antigen, and cytokeratin fragment 21-1 levels, and a higher percentage of lymphocytes in bronchoalveolar lavage than low-GMAb patients. A subset of patients presented with radiological and pathological findings characteristic of aPAP.ConclusionsWe demonstrated the percentage of elevated-GMAb sarcoidosis and HP patients who presented with several features suggestive of aPAP. Elevated-GMAb sarcoidosis and HP patients without definitive aPAP diagnosis may have subclinical or early-stage aPAP and may not necessarily indicate false positives. Upon diagnosis of sarcoidosis or HP, measurement of GMAb may be useful in detecting possible comorbidity of subclinical or early-onset aPAP.

Importance of The Medical History in The Diagnosis of Hypersensitivity Pneumonitis: A Case Report

Introduction: Hypersensitivity pneumonitis, most frequent types are those related to farming and bird breeding. In this paper, a patient with occupational exposure to metal dusts and welding fumes but diagnosed with HP thanks to the guidance of detailed anamnesis revealing inhalational exposure to pigeon antigens both at home and in workplace Case: 32-year-old male. He applied with shortness of breath, dry cough. He has been working production of kitchen equipment made from stainless steel. When environmental exposures questioned, he declared that he bred up to ten pigeons at the basement of his house and up to fifteen pigeons at a coop next to workplace building. Spirometry revealed restrictive pattern. In patient’s chest X-ray, bilateral increased reticular densities were observed. Computed tomography of thorax revealed radiological findings supporting subacute hypersensitivity pneumonitis such as bilateral diffuse millimetric centrilobular ground-glass nodules which are coalescing in some areas, mosaic perfusion and air trapping in basal areas. Bronchoalveolar lavage cytology revealed percentages of lymphocytes as 85%. Discussion: Detailed anamnesis revealing environmental and occupational inhalational exposures guides the physician in diagnosis of HP. After initial suspicion, supporting laboratory and radiologic findings confirm the diagnosis to provide appropriate management.

Magnifying i-scan Imaging for Endoscopic Diagnosis of Helicobacter pylori Infection: A Prospective Study

Abstract Background DEFINA (EPK 3000) plus (with i-scan) is a digital chromoendoscopy. It uses surface/tone/contrast enhancement for detection, demarcation, and characterization of lesions. The aim of this study was to compare the usefulness of i-scan and conventional magnification white light endoscopy (M-WLE) for diagnosing Helicobacter pylori (Hp) infection in stomach. Patients and Methods Subjects undergoing evaluation for functional dyspepsia were prospectively enrolled at Ramaiah Medical College and Hospitals, Bangalore from November 2018 to February 2019. In total, 68 participants underwent gastroscopy with standard M-WLE followed by i-scan. Two biopsies from greater curve at 3 cm from the angulus were collected for histology. Successful diagnosis of Hp using imaging modality with M-WLE and i-scan were compared with histology. Results A total of 68 (36 men and 32 women) patients with a mean age of 47 ± 13 years (range 18–75 years) were enrolled in our study. The prevalence of Hp on the biopsies was 41%; 64% of the patients used proton pump inhibitors, 20% were current smokers; 25% of the patients were consuming alcohol. The sensitivity: 96.4%; specificity: 95%; accuracy: 95.5% of i-scan in diagnosis of Hp gastritis is better than the sensitivity: 50%; specificity: 50%; accuracy: 50% with M-WLE. Conclusion In conclusion, the diagnostic ability of i-scan (95%) for predicting Hp status is acceptable as compared with M-WLE (50%) for accurate diagnosis. The results suggest that i-scan improves endoscopic diagnostic accuracy of Hp infection compared with M-WLE.

Research progress in relation of Helicobacter pylori infection with pregnancy-related diseases and adverse pregnancy outcomes.

Helicobacter pylori (Hp) is a Gram-negative microaerobic bacterium, which is parasitic on gastric mucosa and is associated with the pathogenesis of chronic gastritis, gastric ulcer, gastric cancer and other gastric diseases. Meanwhile, the Hp infection is related with pregnancy-related diseases, pregnancy outcomes, and the health status of offspring, such as infertility, premature delivery, abortion, Hp infection of newborn and neural tube defects. Hp infection is also related to hyperemesis of pregnancy, preeclampsia, gestational diabetes mellitus, iron deficiency anemia, idiopathic thrombocytopenic purpura. It has been suggested that early diagnosis and eradication of Hp and standardized the anti-Hp treatment will benefit pregnant women and their offspring.

Hypersensitivity pneumonitis in a teenager

Abstract Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD), consequence of an alveolar allergic reaction against various inhaled allergens occurring in susceptible individuals, manifesting as an acute or chronic granulomatous alveolar allergic process against inflammation of the lung parenchyma. The clinical presentation can mimic acute respiratory infections (in acute form) or an idiopathic ILD (in chronic form); the diagnosis of HP is difficult if the exposure to allergen is not suspected. We present the case of a male teenager, pigeon breeder, presenting with recurrent episodes of dyspnoea and fever, initially considered and treated as pneumonia. The diagnosis of HP was based on suggestive imaging changes, lymphocytic alveolitis at bronchoalveolar lavage with a low CD4/CD8 ratio and a thorough anamnesis for exposure and positive IgG serum precipitins against pigeon debris. The patient improved over a few months only by avoiding exposure to the incriminated allergen. ILDs in children and adolescents are considered rare diseases, with HP being one of the possible causes in older children and adolescents.

Incidence, comorbidity and survival rate of hypersensitivity pneumonitis: a national population-based study.

Background and objectivesHypersensitivity pneumonitis (HP) is a rare disease, which can lead to premature death. Few studies have investigated HP on a national level. The objective of this study was to investigate incidence, survival rate, and comorbidity of HP in Denmark.MethodsUsing the Danish National Patient Registry we identified all patients with a first-time diagnosis of HP between 1998 and 2010. Patients with HP were matched 1:4 with controls by sex, age and geography in this case-control study. Comorbidity 3 years prior to diagnosis was explored by the Charlson score index. Survival rates were assessed using Kaplan–Meier curves and hazard ratios.ResultsWe identified 753 patients during the observation period equalling an average HP incidence of 1.16 per 100 000 citizens. Patients with HP had a significantly higher Charlson score index when compared with the matched controls and an increased risk of dying (hazard ratio 1.98, CI 1.61–2.58, se 0.14, p<0.001). Survival rates of HP were lower at all time points when compared with the matched control population. The decline in survival was observed for both male and female patients with HP with no clear sex difference. Most deaths were related to diseases of the heart and lungs.ConclusionsIn this Danish longitudinal nationwide observational study we found an increased Charlson score index combined with a higher mortality without sex difference among patients with HP compared with a healthy control group, mainly due to diseases of the heart and lungs.

A prospective randomized study of colonoscopy using blue laser imaging and white light imaging in detection and differentiation of colonic polyps.

Background and study aims Published data on blue laser imaging (BLI) for detection and differentiation of colonic polyps are limited compared to narrow band imaging (NBI). This study investigated whether BLI can increase the detection rate of colonic polyps and adenomas when compared to white light imaging (WLI), and examined use of NICE (NBI International Colorectal Endoscopic) and JNET (Japan NBI Expert Team) classifications with BLI. Patients and methods Patients aged 50 years and above referred for colonoscopy were randomized to BLI or WLI on withdrawal. Detected polyps were characterized using NICE and JNET classifications under BLI mode and correlated with histology. Primary outcome was adenoma detection rate. Secondary outcomes were utility of NICE and JNET classifications to predict histology using BLI. Results A total of 182 patients were randomized to BLI (92) or WLI (90). Comparing BLI with WLI, the polyp detection rate was 59.8 % vs 40.0 %, P = 0.008, and the adenoma detection rate was 46.2 % vs 27.8 %, P = 0.010. NICE 1 and JNET 1 diagnosed hyperplastic polyps with sensitivity of 87.18 % and specificity of 84.35 %. NICE 2 diagnosed low- (LGD) or high-grade dysplasia (HGD) with sensitivity of 92.31 % and specificity of 77.45 %. JNET 2A diagnosed LGD with sensitivity of 91.95 %, and specificity of 74.53 %. Four cases of focal HGD all had JNET 2A morphology. Conclusion BLI increased adenoma detection rate compared to WLI. NICE and JNET classifications can be applied when using BLI for endoscopic diagnosis of HP and LGD but histological confirmation remains crucial.