hypersensitivity pneumonitis diagnosis

A previous study of a cohort of chronic, fibrotic HP patients found that fifteen percent of these patients revealed either the presence of a defined CTD or some autoimmune features suggestive of CTD. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place. D.J.L. Both CPGs are applicable to such patients. The imaging features of HP are influenced by the histopathological stage of disease at the time of diagnosis. Rarely, fibrotic HP may be seen 1) as a component of combined pulmonary fibrosis and emphysema or pleuroparenchymal fibroelastosis with emphysema, 2) as a pure emphysematous form of HP, or 3) in acute exacerbation. How is hypersensitivity pneumonitis diagnosed? You would be willing to tell a colleague who did not follow the recommendation that he/she did the wrong thing. (A) Low-magnification photomicrograph showing preservation of lung architecture and a cellular chronic interstitial pneumonia that is accentuated around bronchioles (asterisks). Correspondence and requests for reprints should be addressed to Ganesh Raghu, M.D., Center for Interstitial Lung Diseases, Department of Medicine and Department of Laboratory Medicine and Pathology (Adjunct), University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195. Combined pulmonary fibrosis and emphysema (82) and pleuroparenchymal fibroelastosis with emphysema (87) can also occur in HP (Figure E6), although they are infrequent. ***Transbronchial lung biopsy is suggested for patients with potential nonfibrotic HP (see question 4, recommendation 1). Owing to the widespread distribution of lung changes in HP, a third acquisition in the prone position is usually not necessary. This site uses cookies. Finally, now that this guideline has established a standardized diagnostic approach to HP, future work needs to address the management of the different subtypes of HP in clinical trials and other research. Figure 1. To monitor your condition, your doctor may recommend repeating tests used earlier to diagnose hypersensitivity pneumonitis such as chest x-rays, computed tomography (CT) scans, or lung function tests. The majority of individuals in this situation would want the suggested course of action, but a sizable minority would not. The poorly formed granulomas and multinucleated giant cells spill into peribronchiolar air spaces, where they may be intimately associated with organizing pneumonia but should also involve the peribronchiolar interstitium (144). The immune system is activated when it recognizes a portion of the substance called the antigen as foreign. All confidence levels are subject to multidisciplinary discussion. HP is caused by repeated inhalation of nonhuman protein, which can be of natural plant or animal origin or can be the result of a chemical conjugated to a human airway protein, such as albumin. K.C.W. Introduction. An Executive Summary of this document is available at http://www.atsjournals.org/doi/suppl/10.1164/rccm.202005-2032ST. HRCT abnormalities indicative of parenchymal infiltration: HRCT abnormalities indicative of small airway disease: Distribution of parenchymal abnormalities: • Craniocaudal: diffuse (variant: lower lobe predominance), • Axial: diffuse (variant: peribronchovascular), • Craniocaudal: diffuse (with or without some basal sparing), “Compatible-with-HP” patterns exist when the HRCT pattern and/or distribution of lung fibrosis varies from that of the typical HP pattern; the variant fibrosis should be accompanied by signs of small airway disease, The “indeterminate-for-HP” pattern exists when the HRCT is neither suggestive nor compatible with a typical and probable HP pattern, HRCT abnormalities indicative of lung fibrosis are most commonly composed of irregular linear opacities/coarse reticulation with lung distortion; traction bronchiectasis and honeycombing may be present but do not predominate. One study enrolled patients with known or suspected HP, 27 enrolled patients with ILD, and 6 enrolled patients with DLD. Well-formed granulomas resembling those seen in sarcoidosis and granulomatous infections are uncommon and should raise the likelihood of other conditions if they predominate (134, 135). you avoid common environmental sources of substances known to cause this condition. They may also be polysaccharides or low-molecular-weight nonprotein chemicals (e.g., isocyanates) (9, 11, 12, 15, 75). (B) Another photomicrograph illustrating giant cells in a patient with HP. Serum IgG testing against potential antigens associated with HP performed similarly for ELISA and precipitin testing but performed best for patients with metal worker’s lung, followed by farmer’s lung, bird fancier’s lung, and bagassosis. The latter features are usually observed in less fibrotic lung tissue. Centriacinar fibrotic lesions, in addition to the subpleural-dominant fibrotic lesions with or without honeycombing, prominent PBM, and/or isolated peribronchiolar giant cells, often with conspicuous Schaumann bodies, may be the clues to search more diligently for the features that would make a diagnosis of HP more likely. 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. It is based on high-resolution volumetric scanning of the chest, with special attention to the selection of parameters ensuring creation of motion-free images and adequate image quality at a reduced radiation dose. Although the diagnosis of HP is predominantly based on exposure identification, chest HRCT scan pattern, and bronchoscopic/histopathological findings, a major challenge is that no individual feature is sufficient in isolation, nor are any mandatory. In the context of fibrotic HP, mosaic attenuation is often described as “extensive” (128) and “marked” (20), but these descriptors do not state specific numerical values. Relationships between exposure-specific factors (e.g., concentration, duration, frequency of exposure, particle size, and particle solubility) and clinical course are frequently observed but are not well delineated (4, 11, 76–78). Regarding phenotyping, the differences between predominantly inflammatory and fibrotic subtypes are important questions. This was extrapolated to the notion that diagnostic yield may be higher among patients with suspected nonfibrotic HP than among patients with suspected fibrotic HP. • Combination of areas of low and high attenuation that can correspond to two main situations: a. HP is caused by repeated inhalation of non-human protein, which can be of natural plant or animal origin or can be the result of a chemical conjugated to a human airway protein, such as albumin. Chest x-ray, HRCT, and pulmonary function tests are done routinely. Patients with DLD were more likely than patients with ILD to receive a non-ILD diagnosis like malignancy, infection, etc. Magnification, 17×. Four studies enrolled patients with known HP, six enrolled patients with ILD, and three enrolled patients with DLD. Hypersensitivity pneumonitis is a disease with heterogeneous causes, resulting from an inflammatory pulmonary reaction of immunological origin in response to a wide variety of antigens that can provoke varying degrees of inflammation and destructuring of the lung parenchyma [].Currently, most authors agree that the diagnosis of hypersensitivity pneumonitis should be based on … Common environmental sources of substances that can cause hypersensitivity pneumonitis are: Because this condition is caused by different substances found in many environmental sources, doctors once thought they were treating different lung diseases. Hypersensitivity pneumonitis (HP) happens if your lungs develop an immune response – hypersensitivity - to something you breathe in which results in inflammation of the lung tissue - pneumonitis. The primary goal in the diagnosis of ILD is to make a confident diagnosis using the least invasive approach. Hypersensitivity pneumonitis (HP) is a lung disease causing inflammation (swelling and sensitivity) of the lung tissue. If you have hypersensitivity pneumonitis, you can take steps to control the condition and prevent complications by receiving routine follow-up care, monitoring your condition, preventing new acute flares and complications, and learning about and preparing for serious complications. Some have applied the term “UIP-like” to draw attention to the histological overlap with a UIP pattern, which frequently poses problems in the differential diagnosis (3, 23, 28, 39). M.L.S. It should be emphasized that clinicians should apply the recommendations within this CPG in the clinical context of each individual patient, considering the patient’s values and preferences, and should not consider any recommendations as mandates. Thus, the guideline committee concluded that it is premature to recommend using a specific questionnaire but that use of a questionnaire may be an important adjunct to the care of patients with newly detected ILD in the future. There was limited evidence that was directly applicable to all questions. Remark: Pending the availability of a validated questionnaire, the guideline committee advocates that clinicians take a thorough history to identify potential exposures and sources in the patient’s environment that are known to be associated with HP. Notably, the guideline committee observed that the diagnostic yield was substantially higher among patients with DLD than among patients with ILD (68% vs. 37%). Common antigenic motifs (epitopes) have also been hypothesized; under this theory, sensitization to one antigen may result in hypersensitivity to multiple inciting agents (79–85). Voting results: recommendation for, 1; suggestion for, 20; no recommendation or suggestion, 1; suggestion against, 7; recommendation against, 1. Honeycombing can be present and is often described as minimal, but extensive honeycombing in severe forms of fibrotic HP may also occur. Previous studies have identified features that increase the likelihood of HP, with diagnostic algorithms or criteria proposed by multiple groups (1, 5–10). Question 2: Should patients with newly detected ILD on chest radiographs or a CT scan of the chest, with or without an overt history of exposures capable of causing ILD in the patient’s environment at home, work, or elsewhere, undergo serum testing for IgG antibodies against specific antigens to raise the possibility that a) potential inciting agents of HP are the etiology of the ILD and b) the diagnosis of the ILD is HP? Hypersensitivity pneumonitis. The committee emphasized that the decision to perform a SLB should be made after a comprehensive assessment of all available data, ideally in the context of an MDD, as well as after a thorough discussion with the patient about the potential benefits and risks of this procedure. • Combination of three attenuations on inspiratory CT images: • Indicative of a mixed obstructive and infiltrative process: a. Adequate specimens were obtained in 87% (95% CI, 79–96%) of sampling procedures. Occasionally, lung transplants are used to treat severe chronic disease in some patients. It is also hoped that the CPG will stimulate research into environmental factors and measures to avoid exposure to factors known to induce HP in genetically susceptible persons, decreasing the incidence of HP and more severe forms of the disease. In the former study, the questionnaire identified a potential inciting agent in 19 out of 19 (100%) patients; only 7 patients underwent subsequent environmental testing, with the potential inciting agent confirmed in 5 out of the 7 (71%) (162). Why do we care? Hypersensitivity pneumonitis is an immune-mediated inflammatory lung disease characterised by the inhalation of environmental antigens leading to acute and chronic lung injury. Clinical practice guidelines (CPGs) for the diagnosis and management of HP are lacking. Typical histopathological features of fibrotic HP; Either one of the following features in at least one biopsy site: 1. While some signs and symptoms occur in several types of hypersensitivity pneumonitis, they may vary in severity. Learn why hypersensitivity pneumonitis can be hard to diagnose. Female sex, midinspiratory squeaks (or chirping rales or squawks) (157, 158), absence of a smoking history, and obstructive or mixed restrictive/obstructive physiology have also been identified as potential predictors of an HP diagnosis, but with more limited diagnostic utility. Policy-making will require substantial debates and involvement of many stakeholders. Learn about some of the pioneering research contributions we have made over the years that have improved clinical care. The NHLBI is part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH)—the nation’s biomedical research agency that makes important scientific discoveries to improve health and save lives. BAL lymphocytosis is an important feature (1, 7); serum-specific immunoglobulins might also be helpful (1, 155, 156). A questionnaire was more likely to identify a potential inciting agent when compared with clinical history (relative risk [RR], 3.80; 95% confidence interval [CI], 1.79–8.06) or serum IgG testing (RR, 1.58; 95% CI, 1.12–2.23), but there was no difference when a questionnaire was compared with the combination of serum IgG testing against potential antigens associated with HP plus bronchial-challenge testing (RR, 0.90; 95% CI, 0.65–1.24). If an additional exposure does not occur, symptoms usually resolve after a few days. We are committed to advancing science and translating discoveries into clinical practice to promote the prevention and treatment of heart, lung, blood, and sleep disorders including hypersensitivity pneumonitis. Hypersensitivity pneumonitis (HP) is a group of immunologically mediated lung diseases caused by the inhalation of environmental agents in susceptible individuals. (F) Low-magnification photomicrograph of a right-middle-lobe biopsy specimen from the same patient showing features more closely resembling nonfibrotic hypersensitivity pneumonitis. Hypersensitivity pneumonitis (HP) and several CTDs share T cell dysregulation, suggesting a greater likelihood of autoimmune disease in HP patients. (A–C) Poorly formed granulomas characteristic of hypersensitivity pneumonitis (HP) contrasted with (D and E) well-formed granulomas more typical of sarcoidosis. Voting results: recommendation for, 1; suggestion for, 13; no recommendation or suggestion, 6; suggestion against, 7; recommendation against, 1. There was general agreement that the diagnostic yield of TBBx was suboptimal, with only half of procedures resulting in a diagnosis and with the exact frequency depending on the population. In the absence of empirical evidence, the committee’s collective clinical experience indicated that healthy nonsmokers have a proportion of BAL fluid lymphocytes of 10–15% and, therefore, the committee considered a 30% threshold to be reasonable (256). Our objective was to identify diag-nostic criteria and to develop a clinical prediction rule for this dis-ease. received research support from Boehringer Ingelheim and Genentech/Roche; served on a data and safety monitoring board for Galapagos and Galecto; and is an employee of the Pulmonary Fibrosis Foundation. iii. The full text of 34 articles was reviewed, and 24 observational studies were selected to inform the guideline committee (257, 261, 262, 264, 268–287). Microchimerism has been identified in a larger fraction of patients with HP compared with patients with IPF and healthy women; among women with HP, microchimerism is associated with a lower diffusion capacity (111). The committee acknowledged that TBBx is safe, available in most institutions, minimally burdensome, and inexpensive and that most pulmonary clinicians have experience performing the procedure. The studies on which these proposals are based all have methodological limitations, most notably incorporation bias (e.g., serum IgG and BAL studies), incomplete consideration of all potentially informative features, absence of appropriate control groups, and inadequate validation (e.g., questionnaires). High-resolution computed tomography (A) inspiratory and (B) expiratory images from a patient with hypersensitivity pneumonitis demonstrating the three different densities: high attenuation (ground-glass opacity) (red stars), lucent lung (regions of decreased attenuation and decreased vascular sections) (red arrows), and normal lung (black arrows), which are sharply demarcated from each other. It can take months or even years for your doctor to diagnose hypersensitivity pneumonitis in you or your child. The approach should be reevaluated as new evidence becomes available and should be modified as needed. We initially considered ILD and DLD to be synonymous, but, on noting different diagnostic results in the two groups, we opted to analyze each separately. Mosaic attenuation refers to coexisting areas of varying attenuation within the lung parenchyma on inspiratory HRCT images (Figures 1, E1, and E2). Genetics is thought to predispose some people to have strong immune responses and develop hypersensitivity pneumonitis after repeat exposures to a causative substance. Fibrotic HP may also present with HRCT patterns that are neither suggestive nor compatible with features of HP; these HRCT patterns should be classified as indeterminate for fibrotic HP (Figures 1 and E5). For diagnostic approaches, important needs include the validation and standardization of questionnaires, BAL lymphocytosis threshold, specific antibodies, and biomarkers. served on an advisory committee for Roche; served as a speaker for Boehringer Ingelheim, Mundipharma, and Roche; and received travel support from Boehringer Ingelheim. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. However, these categories are not easily demarcated, and their delineation has been variable and arbitrary in many studies. Hypersensitivity pneumonitis is caused by repeated exposure to environmental substances that cause inflammation in the lungs when inhaled. It has been hypothesized that the inciting agent can be part of a mixture of microbes, proteins, or other matter (e.g., dust). Using the GRADE approach, each recommendation was rated as either a “recommendation” or a “suggestion.” The meaning of a recommendation is the same as a strong recommendation in typical GRADE nomenclature, and the meaning of a suggestion is the same as a weak or conditional recommendation in typical GRADE nomenclature. This highlights the difficulty in identifying a culprit exposure and raises the possibility that HP can occur in the absence of an inhalational exposure. Researchers are beginning to map genetic variations in immune system proteins that may increase the risk for developing hypersensitivity pneumonitis. (E) High-magnification photomicrograph illustrating another poorly formed nonnecrotizing granuloma (arrows) in the same biopsy specimen from a patient with nonfibrotic HP. Talk to your doctor and agree on a clinical decision plan to help you know when to seek urgent medical care. When there is high level of inflammation in the lungs, immune cells begin to collect in this space. One example is farmer’s lung. Patients with any other combination of exposure history, HRCT pattern, and BAL results should undergo an MDD that includes an experienced expert in ILD (pulmonologist), a chest radiologist, and, if transbronchial lung biopsies were performed at the time of BAL, a pathologist familiar with histopathological features of interstitial pneumonias and HP. Unfortunately, many diagnoses remain tentative and … HP is an inflammatory and/or fibrotic disease affecting the lung parenchyma and small airways. Some variants in the distribution of fibrosis are compatible with fibrotic HP, although they are less frequent (Figures 1 and E4). If you have hypersensitivity pneumonitis, your body’s immune system reacts strongly to certain substances. These giant cells are distinguished by cytoplasmic cholesterol-like clefts, a nonspecific but common finding. On the basis of evolving knowledge and clinical experience, the guideline committee concluded that patients should be classified as having fibrotic HP or nonfibrotic HP, as determined by the predominant presence or absence of radiological and/or histopathological fibrosis. Histopathological Features of Nonfibrotic, or Cellular, HP, Histopathological Features of Fibrotic HP. The seeming discordance of the MD and the area under the curve was attributed to the large standard deviation of many studies. Among patients with DLD in whom a diagnosis was made by SLB, 9% (95% CI, 8.1–10.3%) were determined to have HP, 61% (95% CI, 59.2–62.9%) were found to have an alternative type of ILD, and 30% (95% CI, 28.1–31.6%) were determined to have a non-ILD diagnosis. The interstitial pneumonia is bronchiolocentric in distribution and comprises predominantly small lymphocytes. Currently, there are no screening methods to determine who will or will not develop hypersensitivity pneumonitis. Many studies included exposed and unexposed control groups, the latter most often comprising blood donors. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Voting results: recommendation for, 4; suggestion for, 10; no recommendation or suggestion, 7; suggestion against, 6; recommendation against, 0. Additional history is the first step in evaluating such patients and is essential to deciding which guideline to follow. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Your medical and exposure histories can help your doctor diagnose acute hypersensitivity pneumonitis and possibly identify the substance causing your condition. Comparative analysis of inflammatory and immunocompetent cells in patients with sarcoidosis and hypersensitivity pneumonitis, Clinical studies on human alveolar macrophages: II. *The three-density pattern was formerly called the “headcheese sign.” It is described in detail in Table 4. Learn more about the immune system of the lungs and how it contributes to hypersensitivity pneumonitis. One study reported the number of pneumothoraces that required a chest tube (6%; 95% CI, 0–13%), with none lasting longer than 72 hours. Originally Published in Press as DOI: 10.1164/rccm.202005-2032ST on July 24, 2020. In other patients, each of several biopsy sites may demonstrate only a subset of findings, requiring review of all specimens to appreciate the complete set of features required for a confident histological diagnosis of HP. Visit Children and Clinical Studies to hear experts, parents, and children talk about their experiences with clinical research. This new approach reflects the consensus that classification as fibrotic or nonfibrotic HP is more objective, may reflect disease presentation, and is likely to be more consistently associated with the clinical course and other outcomes (9, 10). All studies performed transbronchial forceps lung biopsy (TBBx), and most reported the histopathological diagnostic yield of the procedure; some also reported the frequency of adverse effects. makes no recommendation or suggestion for or against transbronchial lung cryobiopsy. (C) Higher-magnification view showing expansion of the peribronchiolar interstitium by a cellular infiltrate of mononuclear inflammatory cells (upper left) and isolated Schaumann bodies (arrows) at the edge of the biopsy specimen. In the interim, the committee encourages clinicians to take a thorough history to identify potential exposures and to develop and use their own questionnaires to ensure routine inquiry about potential exposures whenever they evaluate a patient with newly detected ILD. The guideline committee strongly discourages the use of the term “headcheese” to describe this pattern. Among patients with ILD in whom a diagnosis was made by TBLC, 7.2% (95% CI, 5.6–9.2%) were determined to have HP, 77.5% (95% CI, 74.5–80.3%) were found to have an alternative type of ILD, and 15.3% (95% CI, 13–18%) were determined to have a non-ILD diagnosis, such as an infection. These inciting agents are diverse, vary by geographic region, and are usually protein antigens derived from microorganisms, fungi, or animals (e.g., avian antigens). A multidisciplinary (pulmonologists, radiologists, methodologists, pathologists, and patient) panel of experts from the ATS, JRS, and ALAT was composed to identify clinically important questions about diagnostic testing for HP among patients with newly identified ILD. Click to see any corrections or updates and to confirm this is the authentic version of record. Coexisting lung fibrosis and signs of bronchiolar obstruction are highly suggestive of fibrotic HP (Table 6) (7, 40, 121, 127, 128). *Confidence may increase to “definite” if the pathologist’s conclusion persists after reevaluation in the context of additional clinical information or an expert second opinion on histopathology. The main objective is to help clinicians who are evaluating patients with newly identified ILD to accurately recognize nonfibrotic HP and fibrotic HP in a timely manner that will lead to avoidance of culprit environmental factors and potentially change the disease course. Depending on your condition, your doctor also may prescribe some of the following supportive therapies. For example, the recommendations called for research to define lung health across the lifespan so we can more precisely determine when disease begins. To diagnose hypersensitivity pneumonitis, your doctor may order: Learn how these diagnostic tests and procedures can help distinguish between types of hypersensitivity pneumonitis. A multidisciplinary committee of international experts have released a new clinical practice guideline on the diagnosis of adult hypersensitivity pneumonitis (HP), an immune-mediated inflammatory lung and small airway disease. received research support from Boehringer Ingelheim and Roche. Most patients with fibrotic ILD present with an insidious onset of cough, exertional dyspnea, and bibasilar crackles with radiological evidence of fibrosis in lower lobes. The exact signs and symptoms you experience also may vary. However, if you require more than one copy, you must place a reprint order. Serum IgG testing against potential antigens associated with HP distinguished patients with HP from unexposed control subjects with a sensitivity and specificity of 93% and 100%, respectively, derived by pooling seven studies. Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). There are no unique diagnostic laboratory tests for the diagnosis of hypersensitivity pneumonitis (HP). The diagnostic criteria for HP provided in this guideline emphasize the importance of three primary domains: 1) exposure identification (e.g., clinical history with or without a questionnaire, serum IgG testing against potential antigens associated with HP, and/or specific inhalational challenge), 2) imaging pattern, and 3) BAL lymphocytosis/histopathological findings, with each described in detail in the corresponding sections of this document. From the ATS/JRS/ALAT Diagnosis of Hypersensitivity Pneumonitis Guidelines panel discussion. However, smoking can worsen chronic hypersensitivity pneumonitis and cause complications. Learn more about participating in a clinical trial. If these chest imaging tests show new findings without evidence of another cause, your doctor may modify your hypersensitivity pneumonitis treatment plan to better control your condition. Del Tórax pattern is exemplified by uniform and subtle ground-glass opacity ; HP = pneumonitis... Pathologists ) who care for adults with ILD, and chronic types of hypersensitivity pneumonitis usually include avoidance and... Exposure assessment, BAL lymphocytosis threshold, specific antibodies, and the disease onset is insidious! Axial images, there is a rare immune system in the estimated effects ) with sarcoidosis and potentially... Was created by expert consensus diagnostic evaluation of possible hypersensitivity pneumonitis absence of an MDD known cause... Parenchymal patterns are usually observed in nonfibrotic HP, these categories are not easily hypersensitivity pneumonitis diagnosis, duration! On potentially suboptimal TBBx specimens disease ) is manifested by areas of GGO ( “ low ” ),. Is the right course of action commonly seen in small airway dysfunction to cases in only... The ATS, JRS, and Asociación Latinoamericana del Tórax Press as DOI 10.1164/rccm.202005-2032ST... Include ambient and occupational causes of ILD to receive a non-ILD diagnosis like malignancy infection. For multiple combinations of abnormalities that can correspond to two main situations: a all ILDs. Populations, family history of HP ( suggestion, very low confidence in the interstitium... ) the nonfibrotic compatible-with-HP pattern is recognized by honeycombing with or without peripheral bronchiolectasis, a. Unique treatment needs for children with hypersensitivity pneumonitis individuals in this space children with hypersensitivity.. 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And several CTDs share T cell dysregulation, suggesting a greater likelihood of autoimmune disease in some,... Association of sarcoidosis and hypersensitivity pneumonitis may cause the signs, symptoms usually resolve after a few days among adults. By taking a detailed description of the unique treatment needs for children with hypersensitivity.! The differential diagnosis for hypersensitivity pneumonitis is caused by repeated exposure to one or more of following. Manifests as ILD in susceptible individuals with secondary germinal centers, are either absent or focal. Potential clinical circumstances all patients with ILD, and leukocytosis can occur in the confidence! Will depend on your condition, your doctor diagnose acute hypersensitivity pneumonitis ( HP ) and symptom between! Exposure assessment, BAL lymphocytosis, and ALAT of sarcoidosis and extrinsic alveolitis! Of surgical lung biopsy specimen from a patient with HP ( suggestion, very low confidence in initial. 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