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Allergic alveolitis

Essentials

  • Recurrent fever and dyspnoea may be caused by exposure to environmental organic particles or biological dusts, such as mould spores or bird droppings, in patients with allergic alveolitis.

Aetiology

  • Allergic alveolitis is caused by repeated or continuous exposure to organic particles or biological dusts. In some countries the condition is known as hypersensitivity pneumonitis. Several causative factors are known.
  • A common form of the disease is farmer's lung, which is caused by handling mouldy hay, litter or straw.
  • Allergic alveolitis may also be caused by exposure to mouldy sawdust, wood chippings or mushroom compost.
  • Cage bird droppings may cause allergic alveolitis known as bird fancier’s lung (bird breeder's lung).

Symptoms

  • The symptoms of acute allergic alveolitis develop about four to eight hours after exposure.
    • The most common symptoms are cough, dyspnoea and fever.
    • Muscle and joint pains, headache and nausea may also appear.
    • If the condition persists, loss of appetite and weight loss may occur.
  • The symptoms associated with farmer’s lung usually occur during the cattle indoor feeding season. The symptoms generally appear after the working day in the evening or at night, and they abate within a few days. With repeated exposure, the attacks recur.
  • The subacute form is the most common form of allergic alveolitis, and it may manifest as febrile episodes, bronchitic symptoms, malaise, loss of appetite, weight loss and exertional dyspnoea.
  • In cases where the symptoms are of a long duration a careful history should direct towards the possible diagnosis.

Clinical findings

  • Lung auscultation often reveals fine inspiratory crackles.

Imaging and laboratory tests

  • A chest x-ray may be normal or show an increased micronodular pattern, most prominent in the basal lobes, or more diffuse infiltrates.
  • Typical findings of high resolution CT scanning (HRCT) include air trapping and, in particular, centrilobular ground glass opacities. Reticular abnormalities are rarely seen in the acute and subacute phase, but they are common in the chronic phase. Honeycombing and traction bronchiectasis can also be encountered in the chronic phase. Abnormalities usually show diffuse distribution.
  • ESR and CRP may be elevated at the early stages. Leucocytosis may also be present.
  • The patient’s serum often contains allergen-specific IgG antibodies against mould dust or other antigens. The presence of antibodies indicates prior exposure but does not necessarily represent disease.
  • A bronchoalveolar lavage will show lymphocytosis and the T cell CD4/CD8 ratio may be reduced.

Pulmonary function tests

  • Oxygen saturation when measured with a pulse oximeter may be reduced.
  • The partial pressure of oxygen in an arterial sample is often reduced.
  • Diffusing capacity is usually reduced.
  • Restrictive changes are often evident on spirometry.

Diagnosis

  • Diagnosis is based on three major criteria:
    1. exposure to organic dust can be demonstrated
    2. symptoms compatible with allergic alveolitis
    3. radiological findings compatible with allergic alveolitis.
  • In addition to the major criteria two out of the six minor criteria should be fulfilled. The minor criteria are:
    • fine crackles on lung auscultation
    • reduced diffusing capacity
    • restrictive defect on spirometry
    • reduced partial pressure of oxygen in an arterial sample, and/or oxygen saturation, at rest or during exercise
    • lung biopsy compatible with the disease
    • positive provocation test.
  • If an acute case is suspected, expertise in pulmonary medicine should be sought immediately in order to arrange for diagnostic investigations as soon as possible. If these investigations are not done until, for example, after the sick leave period, the results may have returned back to normal.

Differential diagnoses

Treatment

  • Measures to eliminate allergen exposure and avoidance of further exposure are the cornerstones of treatment.
  • Glucocorticoids are used in severe cases to accelerate recovery, for example prednisolone with a starting dose of 30–60 mg a day followed by gradual dose reduction. The duration of drug treatment is usually about 2–4 weeks, and it does not alter long-term prognosis.
  • Exposure leading the recurrence of allergic alveolitis should be prevented, for example by using an air-supplied helmet respirator.
  • Allergic alveolitis due to occupational exposure, for example in farmers, may be considered an occupational disease entitling the patient to compensation.

Prognosis

  • Long-term, untreated illness can become chronic and may cause, for example, pulmonary fibrosis and emphysema.
  • Usually lung function will more or less normalise, provided that the disease is diagnosed and treated in time.

References

1. Spagnolo P, Rossi G, Cavazza A et al. Hypersensitivity Pneumonitis: A Comprehensive Review. J Investig Allergol Clin Immunol 2015;25(4):237-50; quiz follow 250.  [PMID:26310038]

2. Quirce S, Vandenplas O, Campo P et al. Occupational hypersensitivity pneumonitis: an EAACI position paper. Allergy 2016;71(6):765-79.  [PMID:26913451]


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Citation

"Allergic Alveolitis." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/455429/all/Allergic_alveolitis.
Allergic alveolitis. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/455429/all/Allergic_alveolitis. Accessed March 23, 2019.
Allergic alveolitis. (2019). In Evidence-Based Medicine Guidelines. Available from https://evidence.unboundmedicine.com/evidence/view/EBMG/455429/all/Allergic_alveolitis
Allergic Alveolitis [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2019 March 23]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/455429/all/Allergic_alveolitis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Allergic alveolitis ID - 455429 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/455429/all/Allergic_alveolitis PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -