Hypersensitivity Pneumonitis Profile

CPT: 86331; 86602(x2); 86606; 86609; 86671
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Synonyms

  • Extrinsic Allergic Alveolitis Profile

Test Includes

Aspergillus fumigatus precipitating antibodies, IgG; Aureobasidium pullulans precipitating antibodies, IgG; Micropolyspora faeni precipitating antibodies, IgG; pigeon serum precipitating antibodies, IgG; Thermoactinomyces sacchari precipitating antibodies, IgG; Thermoactinomyces vulgaris precipitating antibodies, IgG


Expected Turnaround Time

4 - 5 days


Related Documents


Specimen Requirements


Specimen

Serum


Volume

1 mL


Container

Red-top tube or gel-barrier tube


Storage Instructions

Room temperature


Stability Requirements

Temperature

Period

Room temperature

7 days

Refrigerated

14 days

Frozen

14 days

Freeze/thaw cycles

Stable x2


Causes for Rejection

Excessive hemolysis


Test Details


Use

The test is used to detect the presence of precipitating antibodies associated with hypersensitivity pneumonitis.


Limitations

The presence of serum precipitins against suspected antigens indicates past exposure sufficient to elicit a humoral immunologic response but not necessarily sufficient to diagnose the disease.1,6 Moreover the specific antigen may not be represented in the testing panel.5,21 Hence, a positive test does not confirm and a negative test doesnot rule out a diagnosis of HP.


Methodology

Double diffusion (Ouchterlony)


Reference Interval

Normal: negative


Additional Information

Hypersensitivity pneumonitis (HP) is an interstitial lung disease that is characterized by a complex immunological reaction of the lung parenchyma in response to repetitive inhalation and subsequent sensitization to a wide variety of inhaled organic dusts.1-7 HP is associated with progressive pulmonary disability, irreversible lung damage, and mortality in some cases. HP can be classified as Acute/Inflammatory (symptoms less than six months) and Chronic/Fibrotic (symptoms more than six months) based on clinical, radiologic and pathologic characteristics.8 The name previously used for this condition, extrinsic allergic alveolitis, has been largely abandoned because inflammation involves more than just the alveoli and can extend to the bronchioles as well. The severity of the disease and clinical presentation varies depending on the quantity and type of inhaled antigen causing the condition. Numerous antigens have been found to cause HP.

Diagnosis of HP can be challenging and requires a combination of detailed history, radiologic evaluation, pathological examination and laboratory testing. Acute exposures to inciting antigens typically cause abrupt onset of nonproductive cough, dyspnea, and chills with arthralgias or malaise within a few hours of heavy exposure to a specific antigen.1-4,8 Symptoms usually resolve within a few days of avoiding exposure. Coughing is a predominant symptom due to airway-centered nature of inflammation.Patients also report shortness of breath, malaise, weight loss. No single laboratory testis diagnostic for hypersensitivity pneumonitis.1,6-8 Double diffusion (Ouchterlony) assays are used to determine antigen-specific IgG antibodies. The appearance of precipitin arcs confirms the presence of precipitating antibodies to specific antigens.

A number of antigens have been found to cause HP but only a small proportion of the people who are exposed to these antigens develop HP.1-6,8,9 Exposures to the causative antigens can be associated with specific occupations or hobbies but can also occur in the home and general environment.

Bird or Pigeon Fancier’s Lung: Globally, this is the most commonly reported form of HP and is caused by exposure to organic antigens in bird (particularly pigeon) excreta.1,10,11 Indirect exposure from feather bedding or down comforters have also been reported to cause disease. Avian antigen can exist in the indoor environment regardless of antigen avoidance.12 The presence of avian antigen in the indoor environment can be attributed to wild birds found outdoors.12

Farmer’s Lung: Caused by exposure to moldy hay, compost or grain stored in conditions of high humidity in the agricultural workplace.2,13 IgG precipitins commonly associated with Farmer’s Lung including Aspergillus fumigatus, Thermoactinomyces sacchari, Thermoactinomyces vulgaris and Saccharopolyspora rectivirgula (formerly called Micropolyspora faeni).

Humidifier/Sauna Taker’s Lung: HP secondary to occupational exposure to moldy water from heating/ventilation/air-conditioning systems has been described in adults.14-16 Non-occupational exposure to molds including Aspergillus fumigatus and aureobasidium pullulans via home saunas or water damage has also been shown to cause HP.17-20

Early diagnosis of HP is critical to avoid the development of extensive pulmonary fibrosis or restrictive lung disease has occurred.1 Identification of the offending agentis critical in diagnosing HP and implementing preventive measures.5,7 If diagnosed early enough, complete avoidance of inciting antigen results in total recovery of lung function in the majority of patients. If not promptly diagnosed and treated, HP can progress to pulmonary fibrosis and progressive respiratory failure. Presence of fibrosis and honeycombing have been associated with higher mortality. Primary prevention should aim to reduce exposure to known organic antigens.


Footnotes

1. Greenberger PA. Hypersensitivity pneumonitis: A fibrosing alveolitis produced by inhalation of diverse antigens. J Allergy Clin Immunol. 2019 Apr;143(4):1295-1301. Epub 2018 Nov 15.30448501
2. Costabel U, Bonella F, Guzman J. Chronic hypersensitivity pneumonitis. Clin Chest Med. 2012 Mar;33(1):151-163.22365252
3. Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest. 2012 Jul;142(1):208-217.22796841
4. Ohshimo S, Bonella F, Guzman J, Costabel U. Hypersensitivity pneumonitis. Immunol Allergy Clin North Am. 2012 Nov;32(4):537-556.23102065
5. Patel AM, Ryu JH, Reed CE. Hypersensitivity pneumonitis: current concepts and future questions. J Allergy Clin Immunol. 2001 Nov;108(5):661-670.11692086
6. Spagnolo P, Rossi G, Cavazza A, et al. Hypersensitivity Pneumonitis: A Comprehensive Review. J Investig Allergol Clin Immunol. 2015;25(4):237-250; quiz follow 250.26310038
7. Jacobs RL, Andrews CP, Coalson JJ. Hypersensitivity pneumonitis: beyond classic occupational disease-changing concepts of diagnosis and management. Ann Allergy Asthma Immunol. 2005 Aug;95(2):115-128.16136760
8. Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity Pneumonitis: Perspectives in Diagnosis and Management. Am J Respir Crit Care Med. 2017 Sep 15;196(6):680-689.28598197
9. Quirce S, Vandenplas O, Campo P. et al. Occupational hypersensitivity pneumonitis: an EAACI position paper. Allergy. 2016 Jun;71(6):765-779.26913451
10. Woge MJ, Ryu JH, Moua T. Diagnostic implications of positive avian serology in suspected hypersensitivity pneumonitis. Respir Med. 2017 Aug;129:173-178.28732828
11. Chan AL, Juarez MM, Leslie KO, Ismail HA, Albertson TE. Bird fancier's lung: a state-of-the-art review. Clin Rev Allergy Immunol. 2012 Aug;43(1-2):69-83.21870048
12. Sema M, Miyazaki Y, Tsutsui T, Tomita M, Eishi Y, Inase N. Environmental levels of avian antigen are relevant to the progression of chronic hypersensitivity pneumonitis during antigen avoidance. Immun Inflamm Dis. 2018 Mar;6(1):154-162.29168324
13. Cano-Jiménez E, Acuña A, Botana MI, et al. Farmer's Lung Disease. A Review. Arch Bronconeumol. 2016 Jun;52(6):321-328.26874898
14. Woodard ED, Friedlander B, Lesher RJ, Font W, Kinsey R, Hearne FT. Outbreak of hypersensitivity pneumonitis in an industrial setting. JAMA. 1988 Apr 1;259(13):1965-1969.3346977
15. Storms WW. Occupational hypersensitivity lung disease. J Occup Med. 1978 Dec;20(12):823-824.569690
16. Baur X, Richter G, Pethran A, Czuppon AB, Schwaiblmair M. Increased prevalence of IgG-induced sensitization and hypersensitivity pneumonitis (humidifier lung) in nonsmokers exposed to aerosols of a contaminated air conditioner. Respiration. 1992;59(4):211-214.1485005
17. Engelhart S, Rietschel E, Exner M, Lange L. Childhood hypersensitivity pneumonitis associated with fungal contamination of indoor hydroponics. Int J Hyg Environ Health. 2009 Jan;212(1):18-20.18375180
18. Metzger WJ, Patterson R, Fink J, Semerdijan R, Roberts M. Sauna-takers disease. Hypersensitivity pneumonitis due to contaminated water in a home sauna. JAMA. 1976 Nov 8;236(19):2209-2211.989816
19. Temprano J, Becker BA, Hutcheson PS, Knutsen AP, Dixit A, Slavin RG. Hypersensitivity pneumonitis secondary to residential exposure to Aureobasidium pullulans in 2 siblings. Ann Allergy Asthma Immunol. 2007 Dec;99(6):562-566.18219839
20. Apostolakos MJ, Rossmoore H, Beckett WS. Hypersensitivity pneumonitis from ordinary residential exposures. Environ Health Perspect. 2001 Sep;109(9):979-981.11673130
21. Krasnick J, Meuwissen HJ, Nakao MA, Yeldandi A, Patterson R. Hypersensitivity pneumonitis: problems in diagnosis. J Allergy Clin Immunol. 1996 Apr;97(4):1027-1030.8655880

References

Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008 Sep;63 Suppl 5:v1-58.18757459
Churg A, Ryerson CJ. The Many Faces of Hypersensitivity Pneumonitis. Chest. 2017 Sep;152(3):458-460.28889874
Hirschmann JV, Pipavath SN, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics. 2009 Nov;29(7):1921-1938.19926754

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
660670 Hypersensitivity Pneumonitis 660092 Aspergillus fumigatus IgG 19726-9
660670 Hypersensitivity Pneumonitis 660100 Micropolyspora faeni IgG 34410-1
660670 Hypersensitivity Pneumonitis 660118 Thermoactinomyces vulgaris IgG 19761-6
660670 Hypersensitivity Pneumonitis 660084 Aureobasidium pullulans IgG 33572-9
660670 Hypersensitivity Pneumonitis 660027 Thermoactinomyces sacchari IgG 35318-5
660670 Hypersensitivity Pneumonitis 660076 Pigeon Serum IgG 19752-5

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