慢性過敏性肺炎の臨床的検討 - jrs.or.jp

1 732 40 9 2002 .. Chronic hypersensitivity pneumonitis CHP . CHP 6 4 1 1 . 4 2 HP . 1 5 . 2 10 CHP IPF! UIP.. CHP .. Chronic hypersensitivity pneumonitis CHP Environmental exposure IPF! UIP.. hypersensitivity pneumonitis HP . Table 1 . 4 1 3 1 . 1 .. 1 10 20.. 3 3 . chronic HP 4 . CHP Table 2 . 3 CRP .. CHP 6 VC . BALF 5 . 3 CD 4! 8 .. HRCT Table 3 . 3 4 . 1990 2 . 1 1 . CHP 6 Table 3 . 2 4 5 .. 431 3192 20 1 5 4 4 . 2 5 UIP . 14 1 29 . 733. Table 1 Characteristics of patients Case No. Sex Onset age yr Smoking history Type Subtype 1 F 63 never home-related acute onset 2 F 46 never home-related acute onset 3 M 51 current home-related acute onset 4 F 64 never home-related insidious 5 F 50 never bird fancier's lung insidious 6 M 46 ex flour-induced insidious M male; F female.

2 Never never a smoker; current current smoker; ex ex-smoker Table 2 Laboratory findings on diagnosis Case WBC CRT ESR PaO2 BAL. %VC. No. l mg/dl mm/h torr L/N/E. % CD4/8. 1 8,500 36 83 70 27/0/3 2 4,300 18 80 45 5/2/0 3 3,700 41 65 75 43/1/0 4 8,100 41 75 55 65/0/3 5 8,700 44 84 31 23/5/0 6 8,500 7 95 59 55/0/0 not examined L lymphocytes; N neutrophils; E eosinophils Table 3 Findings of HRCT and pathology on diagnosis HRCT Pathology Case No. Zonal Findings Lung biopsy Findings predominance 1 lower centrilobular OLB centrilobular nodules distribution GGO granuloma bronchiolitis alveolitis fibrosis 2 upper centrilobular OLB centrilobular nodules distribution GGO bronchiolitis alveolitis fibrosis 3 lower GGO VATS centrilobular distribution granuloma bronchiolitis alveolitis fibrosis 4 upper centrilobular OLB centrilobular nodules distribution GGO granuloma bronchiolitis alveolitis fibrosis 5 upper centrilobular TBLB granuloma nodules alveolitis GGO.

3 Traction BE. 6 lower GGO OLB centrilobular traction BE distribution honeycomb alveolitis fibrosis GGO ground glass opacity; BE bronchiectasis; TBLB transbronchial lung biopsy;. OLB open lung biopsy; VATS video assisted thoracic surgery 734 40 9 2002 . Table 4 Immunologic findings and provocation test Environmental Lymphocyte Provocation test Case Serum mycological stimulation Environmental No. precipitins Inhalation study test short/long 1 A. niger A. niger not examined negative/positive negative 2 negative negative not examined negative/positive not examined 3 negative A. nidulans not examined negative/positive not examined 4 C. acremonium C. acremonium not examined negative/positive not examined 5 pigeon serum not examined positive negative/positive positive 6 negative not examined positive negative/negative positive A.

4 Niger Aspergillus niger; C. acremonium Cephalosporium acremonium Table 5 Therapy and clinical course Therapy PaO2 %VC. Case Observation environmental im- Clinical course No. period yr % changes . provements/steroid 1 11 done/short course 12 28 death due to respiratory failure 2 7 done/long course 0 11 persistent P. aeruginosa infection 3 5 done/short course 15 13 occasional fever 4 10 done/long course 20 9 death due to exacerbation 5 3 done/long course 10 not exam'd. decreasing pulmonary function in tests 6 19 done/not done 6 0 stable Table 4 6 . 3 1 Aspergil- 19 . lus niger 4 Cephalosporium acremonium . 5 Pigeon serum 2 1 2 . 1 Aspergillus niger 3 As- 4 . pergillus nidulans 4 Cephalosporium acremo- HRCT Table 6 .. nium 2 HRCT 2 .. Table 4 Fig. 1 .. 2 . Yoshida 2 . HP.

5 1 5 . 2 1 2 . Table 5 . Fig. 2 . 4 . 1 . 11 Fig. 3 .. 2 .. CHP . 3 1990 . 2 HP . 4 . 10 CHP . 5 CHP 1 . 735. Table 6 Chest HRCT and pathological findings of cases 1 and 4. Case 1 Case 4. 70 yr 74 yr 64 yr 74 yr Chest HRCT. centrilobular nodules . GGO . traction BE . honeycombing . Pathology OLB VATS OLB Autopsy centrilobular . distribution . granuloma . bronchiolitis . alveolitis . fibrosis . honeycombing . GGO ground glass opacity; BE bronchiectasis;. OLB open lung biopsy; VATS video assisted surgery Fig. 1 Chest HRCT Cases 1, 4 showing increasing Fig. 2 Case 1 : Open lung biopsy specimen at 70 years ground-glass opacity, decreasing nodular opacity, and of age showing centrilobular distribution, fibrosis, and the presence of traction bronchiectasis and honey- the histologic triad of HP, including bronchiolitis, alve- combing for observation.

6 Olitis and granuloma a, b .. HE stain . Video-assisted Case 1 : a 70-year-old patient b 74-year-old patient thoracic surgical biopsy specimen at 74 years of age . Case 4 : c 64-year-old patient d 74-year-old patient showing inconspicuous histologic triad findings and marked microscopic honeycombing c, d . HE stain . HP 2 . 3 CHP .. 3 CT honeycombing . 4 . 1 2 . 5 HP 6 CHP bird 6 fanchier'. s lung farmer's lung . 6 1 6 2 3 4 CHP summer-type . 5 3 home-related 3 . 736 40 9 2002 . CHP . IPF! UIP . fibroblastic foci . UIP HP . 6 .. 1 2 4.. NSIP . 4 . UIP .. IPF! UIP NSIP . Fig. 3 Case 4 : Open lung biopsy specimen at 64 years CHP . of age showing centrilobular distribution, fibrosis and . the histologic triad of HP a, b .. HE saein. Autopsy . revealed full extent honeycombing c, d.

7 HE stain . 4 1 Aspergillus niger 4 Cepha- losporium acremonium 5 6 .. CHP HP . CHP 6 6 . 4 1 1 . CHP . 5 . HP . CHP . PaO2 VC . BALF 6 5 CHP . CD 4! 8 1. BALF CHP . 7 . CHP . IPF . 4 HRCT 8 2 . Yoshizawa 3 36 Adler 5 68 HP 1 . 2 . 3 4 . 1 4 . 1 10 . IPF 9 . CHP CHP .. CHP . HRCT . CHP . 737. 5 Adler BD, Padley SPG, Muller NL, et al : Chronic hy- persensitivity pneumonitis : high-resolution CT and radiographic features in 16 patients. Radiology 1992 ; 185 : 91 95. 6 Coleman A, Colby TV : Histologic diagnosis of ex- trinsic allergic alveolitis. American J Surg Pathol 1 . 1988 ; 12 : 514 518. 1997 ; 180 : 24 28. 7 1 . 2 Yoshida K, Ando M, SaKata T, et al : Environmental . mycological studies on the casative agent of 1 1998 ; 36 : 627 632. summer-type hypersensitivity pneumonitis.

8 J Al- 8 Ohtani Y, Kojima K, Sumi Y, et al : Inhalation Provo- lergy Clin Immunol 1988 ; 81 : 475 483. cation Tests in Chronic Bird Fancier'. s Lung. Chest 3 Yoshizawa Y, Ohtani Y, Hayakawa H, et al : Chronic 2000 ; 118 : 1382 1389. hypersensitivity pneumonitis in Japan a nation- 9 Perez-Padilla R, Salas J, Chapela R, et al : Mortality wide epidemiologic survey J Allergy Clin Immu- in Mexican patients with chronic pigeon breeder'. s nol 1999 ; 103 : 315 320. lung compared with those with usual interstitial 4 Matar LD, McAdams HP, Sporn TA : Hypersensi- pneumonia. Am Rev Respir Dis 1993 ; 148 : 49 53. tivity pneumonitis. AJR 2000 ; 174 4 1061 1066. Abstract Clinical Analysis of Chronic Hypersensitivity Pneumonitis Seiichi Miwa, Kyoutarou Ide, Hideki Nakano, Hiroshi Kuwata, Kenichirou Suzuki, Hiroyuki Matsuda, Kouji Yokomura, Kazuhiro Asada, Yutaro Nakamura, Naoki Inui, Masahiro Shirai, Takafumi Suda, Kingo Chida and Hirotoshi Nakamura Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu-shi, Shzuoka, 431 3192, Japan Chronic hypersensitivity pneumonitis CHP has a poor prognosis because of the difficulties in its diagnosis and treatment.

9 Recently, we have encountered six cases of CHP 4 patients with the home-related type, a patient with bird fancier' s lung, and one with flour-induced CHP , and we examined the clinical characteristics of these cases. Environmental provocation testing has been considered useful for diagnosing HP, but all patients gave negative results in short-term environmental exposure tests performed routinely for the diagnosis of HP. How- ever, 5 patients had a positive response in long-term environmental exposure tests. Two patients died of respira- tory failure after ten years'observation despite improvement of the causative environment, and were given ster- oid therapy. Radiographically and pathologically, the process of progressive and irreversible lesions were recog- nized in our series of CHP patients.

10 The diagnosis of CHP should be carried out on the basis of the comprehensive findings including the detailed history, clinical course, radiography, and histology.