Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, MD 21201, USA.
Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Occup Med (Lond). 2017 Jun 1;67(4):311-313. doi: 10.1093/occmed/kqx030.
This case highlights the importance of considering hypersensitivity pneumonitis (HP) in the differential diagnosis of interstitial lung disease (ILD) and of obtaining an occupational history so that remediable risk factors may be identified and managed.
To report a case of a chicken sexer with severe rheumatoid arthritis (RA) who developed progressively worsening dyspnoea and restrictive lung disease associated with pulmonary fibrosis.
Clinical investigation included physical examination, occupational history, pulmonary function tests (PFTs), chest imaging and bronchoalveolar lavage (BAL), as well as serological tests including standard IgE bird feather mixture and local IgG precipitin preparation to chicken excrement. Lung histopathology was examined post-mortem.
The patient had worked as a chicken sexer for 29 years with limited control of exposure to chicken bioaerosols. PFTs initially showed mild restriction with a moderate gas transfer defect and computerized tomography of the chest exhibited extensive interstitial infiltrates throughout with severe honeycombing at the bases. Cytology from a BAL revealed multinucleated giant cells (MNGs). Specific serologic tests for bird antigens were negative. Histopathology demonstrated diffuse interstitial fibrosis with honeycombing, poorly formed granulomas and MNGs.
Findings were consistent with a diagnosis of HP with RA-associated ILD. The patient's history of severe RA biased the diagnosis to one of RA-associated ILD and her occupational risk had been less emphatically addressed. Obtaining a thorough occupational history can uncover exposures to workplace respiratory hazards and may create opportunities for intervention to limit morbidity from chronic lung disease.
本病例强调了在鉴别诊断间质性肺疾病（ILD）时考虑过敏性肺炎（HP）的重要性，并强调获取职业史以便识别和处理可纠正的危险因素的重要性。
报告一例患有严重类风湿关节炎（RA）的肉鸡性别鉴定员，其逐渐出现进行性呼吸困难和与肺纤维化相关的限制性肺病。
临床调查包括体格检查、职业史、肺功能检查（PFT）、胸部影像学和支气管肺泡灌洗（BAL），以及血清学检查，包括标准 IgE 鸟羽混合物和鸡粪便的局部 IgG 沉淀素制备。肺组织病理学检查在死后进行。
该患者从事肉鸡性别鉴定工作 29 年，对接触鸡生物气溶胶的控制有限。PFT 最初显示轻度受限，伴有中度气体转移缺陷，胸部计算机断层扫描显示广泛的间质浸润，基底有严重的蜂巢状改变。BAL 的细胞学检查显示多核巨细胞（MNG）。针对鸟类抗原的特异性血清学检查呈阴性。组织病理学显示弥漫性间质纤维化伴蜂窝状改变、未形成的肉芽肿和 MNG。
这些发现与 HP 合并 RA 相关的 ILD 诊断一致。患者严重 RA 的病史使诊断偏向于 RA 相关的 ILD，而她的职业风险则被较少关注。获取详细的职业史可以发现工作场所呼吸危害的暴露，并为干预提供机会，以限制慢性肺病的发病率。
