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Weekly Chest CasesArchive of Old Cases

Case No : 1119 Date 2019-04-08

  • Courtesy of Seo Jin Jang, Yoon Ki Cha, Jeung Sook Kim / Dongguk University Ilsan Hospital
  • Age/Sex 57 / F
  • Chief Complaintdyspnea, cough, yellowish sputum, and intermittent febrile sense for 3 weeks
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Subacute hypersensitivity pneumonitis
Radiologic Findings
Fig 1. Chest radiograph shows diffuse ground-glass opacities (GGO) and ill-defined nodular opacities in both lungs.
Fig 2-3. High resolution CT demonstrates bilateral diffuse GGOs and numerous small ill-defined centrilobular nodules in both lungs with discrete lobular area of decreased attenuation in both lower lobes.
Figs 4-5. Follow up HRCT at 2 month after corticosteroid therapy and removal from exposure shows decreased extent of geographic GGOs and small ill-defined centrilobular nodules.
Figs 6-7. Another follow up HRCT at 1 year after first HRCT shows progression of geographic GGOs and small ill-defined centrilobular nodules in both lungs with discrete lobular area of decreased attenuation in both lower lobes.

In bronchoalveolar lavage (BAL) fluid, the percentage of lymphocyte was 40% and CD4/CD8 ratio was 0.7. She is a Buddhist monk who built roof tile in a temple. Her symptoms and radiologic findings have gradually improved after initiation of corticosteroid therapy but aggravated after discharge and return to the temple.

Fig 4-5. after 2 months steroid therapy

Fig 6-7. after 1 year

Brief Review
Hypersensitivity pneumonitis (HP) refers to a constellation of granulomatous, interstitial, bronchiolar, and alveolar filling pulmonary diseases caused by repeated exposure and sensitization to a variety of organic and chemical antigens. Early recognition of the disease and prevention of long term antigen exposure are necessary to avoid progression to irreversible fibrosis.
HP traditionally has been classified as manifesting in three phases: acute, subacute, and chronic. Subacute HP is caused by intermittent or continuous exposure to low doses of antigen. The symptoms may appear gradually over weeks or months. Patients usually present with exertional dyspnea and cough.
Chest radiographs obtained in many patients with HP are normal. Abnormal radiographic findings observed in some patients include numerous poorly defined small (less than 5 mm) opacities throughout both lungs, sometimes with sparing of the apices and bases. Airspace disease is represented often as GGO (which can be patchy or diffuse, resembling pulmonary edema) or, more rarely, as consolidation.
HRCT has greatly improved the radiologic diagnosis of HP: abnormalities are seen in more than 90% of patients. Typical findings of subacute HP include patchy bilateral GGO and small ill-defined centrilobular nodules. Another common manifestation of subacute HP is the presence of focal areas of decreased attenuation on inspiratory HRCT, air trapping on expiratory HRCT, or both. These areas usually have sharply defined margins and a configuration consistent with involvement of single or multiple adjacent pulmonary lobules.
In the presence of a history of exposure and consistent clinical and radiologic findings, the diagnosis of HP can be confirmed by visualization of increased numbers of lymphocytes in BAL fluid and occasionally by findings at transbronchial biopsy.
Most cases of HP, whether acute or insidious, include the following four histologic features in variable amounts and combinations: cellular bronchiolitis, diffuse chronic interstitial inflammatory infiltrates (primarily consisting of lymphocytes and plasma cells), and poorly circumscribed interstitial nonnecrotizing (noncaseating) granulomas.
Please refer to
Case 59, Case 271, Case 341, Case 427, Case 462, Case 605, Case 666,
KSTR imaging conference 2018 Spring  Case 8 ,
KSTR Imaging Conference 2016 Spring  Case 10 ,
Thoracic Imaging 2003- Korean & Japanese Film Interpretation -  Case 7 ,
KSTR Imaging Conference 2001 Spring  Case 15,
References
1. C. Isabela S. Silva, Andrew Churg, Nestor L. Müller. Hypersensitivity Pneumonitis: Spectrum of High-Resolution CTand Pathologic Findings. AJR Am J Roentgenol 2007;188(2):334-344.
2. Hirschmann JV, Pipavath SN, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics 2009;29(7):1921-1938.
3. Craig S. Glazer, Cecile S. Rose, David A. Lynch. Clinical and Radiologic Manifestations of Hypersensitivity Pneumonitis. Journal of Thoracic Imaging 2002;17:261–272.
4. Webb, Muller, Naidich. High-Resolution CT of the Lung. 5th edition. 376-383.
Please refer to
Keywords
lung, Subacute Hypersensitivity Pneumonitis ,

No. of Applicants : 80

▶ Correct Answer : 43/80,  53.8%
  • - radiologist, aditya imaging centre , India VIVEK PATEL
  • - istanbul , Turkey AYHAN YILMAZ
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - , Korea (South) JANG SEONG WON
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - , Korea (South) HYEWON CHOI
  • - Seoul National University Hospital , Korea (South) JI HEE KANG
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Seoul National University Hospital , Korea (South) Ju Gang Nam
  • - Fujieda Municipal General Hospital , Japan HAYATO NOZAWA
  • - Jiangsu province hospital , China WANGJIAN ZHA
  • - Dae Jin Medical Center , Korea (South) JIYOUNG CHOI
  • - Lille , France BENOIST CAPON
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - The First Affiliated Hospital of Nanjing Medical University , China TENG ZHANG
  • - , Korea (South) HYEYOUNG CHOI
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
  • - Kurashiki Central Hospital , Japan HISATAKA ITO
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Chonbuk National University Hospital , Korea (South) EUN HA JUNG
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - Niigata University , Japan ATSUSHI UEHARA
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - , Korea (South) CHO HYE SOO
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Seoul National University Hospital , Korea (South) SE WOO KIM
  • - Other , Korea (South) SEONGSU KANG
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Ajou University Hospital , Korea (South) YOO YOUNGJIN
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - , Japan YUMI MAEHARA
  • - Columbia asia refferal hospital,Bengaluru , India PRAVIN KUMAR M
  • - The University of Kyoto Hospital , Japan TOMOAKI OTANI
▶ Correct Answer as Differential Diagnosis : 18/80,  22.5%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Gyeongsang National University Hospital , Korea (South) KWON HWANWOONG
  • - McGill University Health Center , Canada Alexandre Semionov
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Mallinckrodt Institute of Radiology , United States Naganathan BS Mani
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - National Taiwan University Hospital Hsin-Chu Branch , Taiwan LI-TA KENG
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Ajou University School of Medicine , Korea (South) JUNG YONG JUN
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Ajou University Hospital , Korea (South) SUNG HYUN AN
  • - Ajou University Hospital , Korea (South) SUBIN HEO
  • - TB centre kasaragod. , India rikhy krishnan
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