Hypersensitivity pneumonitis: radiology and pathology aspect
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Hypersensitivity pneumonitis in the aspect of radiology and pathology: findings on imaging i.e. HRCT and pathologic characteristics and how to distinguish it from other differential diagnoses.
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Hypersensitivity pneumonitis: radiology and pathology aspect
- 1. PRESENTED IN RADIOLOGICAL-PATHOLOGICAL CONFERENCE 14 JULY 2015 BY T.CHAYOVAN Hypersensitivity Pneumonitis: Essential Radiologic and Pathologic Findings Teri J. Franks, MD, Jeffrey R. Galvin, MD Surgical Pathology Clinics Volume 3, Issue 1, Pages 187-198 (March 2010) DOI: 10.1016/j.path.2010.03.005
- 2. Hypersensitivity pneumonitis Diffuse granulomatous interstitial lung disease Caused by an immunologic response to repeated aerosol inhalation Clinical, radiologic, and histologic findings are quite variable Diagnosis depends on a constellation of findings rather than a single defining feature
- 4. Hypersensitivity pneumonitis Acute, subacute, or chronic Significant overlap Active versus residual
- 5. Hypersensitivity pneumonitis Radiologic triad Centrilobular nodules, multifocal ground glass opacities, air trapping Characteristic histologic triad Airway-centered chronic interstitial inflammation Interstitial poorly formed non-necrotizing granulomas Organizing pneumonia
- 6. The recommendation of Schulyer Symptoms compatible with hypersensitivity pneumonitis Evidence of exposure to appropriate antigen History or detection of serum and/or bronchoalveolar lavage (BAL) fluid antibody Findings compatible with hypersensitivity pneumonitis on chest radiograph or HRCT BAL fluid lymphocytosis Histologic lung changes compatible with hypersensitivity pneumonitis Positive natural challenge, which is reproduction of symptoms and laboratory abnormalities after exposure to the suspected environment
- 7. Gross features Gross specimens of large size are not often encountered BAL, transbronchial biopsy, or surgical lung biopsy Radiologic studies, particularly HRCT, as their in vivo gross lung examination Distribution of disease
- 8. Gross features HRCT > plain chest radiograph Sensitivity and specificity Small, indistinct, centrilobular nodules Multifocal ground glass opacities Air trapping in the expiratory phase of respiration Highly suggestive of hypersensitivity pneumonitis Not specific: respiratory bronchiolitis, follicular bronchitis, and asthma
- 9. Fig. 1 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 10. Fig. 3 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 11. Residual phase of hypersensitivity pneumonitis Fibrosis Reticular pattern, honeycombing, and traction bronchiectasis Associated with reduced survival These findings are most severe in the upper and middle lungs Fibrosis similar to idiopathic pulmonary fibrosis (IPF) Strikingly lower lobe predominance
- 12. Fig. 4 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 13. Fig. 5 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 14. Fig. 6 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 15. HP VS infection Care for an infectious etiology Focal or unilateral abnormalities
- 16. Fig. 7 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 17. Microscopic features Not an atopic disease and is not associated with increased eosinophils Surgical lung biopsy > transbronchial biopsy To appreciate the distribution of histologic findings of hypersensitivity pneumonitis
- 18. Microscopic features: Triad of active disease Airway-centered chronic interstitial inflammation Poorly circumscribed interstitial non-necrotizing granulomas Organizing pneumonia
- 19. Microscopic features: Triad of active disease Airway-centered chronic interstitial inflammation From an airway-centered to diffuse distribution Lymphocytes > plasma cells
- 20. Microscopic features: Triad of active disease Interstitial non-necrotizing granulomas Loose, poorly circumscribed interstitial collections of epithelioid histiocytes admixed with variable numbers of multinucleated giant cells and lymphocytes Epithelioid histiocytes often present in the peribronchiolar interstitium
- 21. Microscopic features: Triad of active disease Organizing pneumonia Plugs of pale staining, loose fibroblastic tissue filling Distal bronchioles (bronchiolitis obliterans) Alveolar ducts Contiguous alveolar spaces Foamy macrophages, fibrinous exudate, and neutrophils in alveolar spaces secondary to bronchiolar obstruction
- 22. Microscopic features Continued exposure can lead to fibrotic residua in the histologic patterns of fibrotic NSIP or UIP Absent lymphoid follicles with germinal centers, interstitial eosinophils and neutrophils, and vasculitis
- 23. Fig. 9 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 24. Fig. 10 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 25. Fig. 11 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 26. Fig. 12 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 27. Differential diagnosis Organized into two groups: Noninfectious interstitial lung disease, primarily sarcoidosis, lymphoid interstitial pneumonia (LIP), NSIP, and UIP Granulomatous infection
- 28. Sarcoidosis Morphology and distribution of the granulomas Degree and distribution of the chronic interstitial inflammation. Sarcoidosis HP Granulomas compact, well circumscribed, sometimes hyalinized, distributed in a lymphangitic pattern along bronchovascular bundles, pleura, and interlobular septae Loose, poorly circumscribed, lack hyalinization, confined to a peribronchiolar distribution Chronic interstitial inflammation accompanies the distribution of granulomas without significant extension into the adjacent parenchyma greater degree of interstitial inflammation with more extensive involvement of the surrounding parenchyma Organizing pneumonia - +
- 29. Fig. 13 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 30. Fig. 11 Surgical Pathology Clinics 2010 3, 187-198DOI: (10.1016/j.path.2010.03.005) Copyright © 2010 Elsevier Inc. Terms and Conditions
- 31. LIP Densely cellular interstitial infiltrates of lymphocytes, plasma cells, and histiocytes that markedly expand and distort alveolar walls. LIP diffusely involves the lung parenchyma and lacks airway- centered distribution Lymphoid aggregates with reactive germinal centers
- 33. Residual HP VS UIP VS Fibrotic NSIP HP UIP NSIP upper lobe lower lobe lower lobe airway- centered subpleural airway- centered
- 34. Granulomatous infections Special stains for microorganisms in all biopsies with granulomas Culture correlation
- 35. Hot tub lung Controversially represents a hypersensitivity reaction or infection Characterized by airway-centered non-necrotizing granulomas, organizing pneumonia, and chronic interstitial inflammation Hot tub lung HP Granulomas well-formed distributed in both the interstitium and alveolar spaces Loose, poorly circumscribed, confined to a peribronchiolar distribution Chronic interstitial inflammation Tends to associated with the granulomas More diffusely distributed in the lung parenchyma Organizing pneumonia ++ +
- 36. An approach to biopsy diagnosis Interpretation of biopsies in this setting is difficult since granulomas occur in a wide array of disease processes Multidisciplinary triangle of clinical, radiologic, and pathologic information
- 37. An approach to biopsy diagnosis Active disease Airway-centered chronic interstitial inflammation, poorly-formed granulomas, and organizing pneumonia on biopsy Widespread mosaic ground glass attenuation and centrilobular nodules on chest CT Rresidual disease Presence of epithelioid histocytes and granulomas
- 38. An approach to biopsy diagnosis Lung injury caused by infection > HP Chest CT plays a critical role in identifying esp. mycobacterial infections
- 39. Treatment Avoiding contact with the offending antigen is the cornerstone of hypersensitivity pneumonitis treatment Active disease typically resolves without sequelae Oral corticosteroids serve to control symptoms but do not appear to effect long-term outcome The presence of fibrosis on histology or CT portents a poor prognosis
- 40. Points in Histologic Evaluation of Hypersensitivity Pneumonitis Interpreting biopsies with clinical and radiologic findings Perform special stains for microorganisms and correlate with cultures when granulomas are present on biopsy Negative special stains do not exclude infection