Cladosporium herbarum Hot-Tub Lung Hypersensitivity Pneumoni
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Enquiring about environmental and occupational exposure during anamnesis is fundamental, particularly when addressing respiratory tract symptoms. The mainstay management of hypersensitivity pneumonitis is based on the eviction of the offending agent and control of inflammation, currently with corticosteroids. Antigen source removal may entail important psychological, social and economic consequences for the patient and will need a multidisciplinary approach.

This report presents the case of a 39-year-old non-smoker female who was a floriculture greenhouse worker, with an unremarkable medical history. She was admitted to the emergency department with recent irritative cough, dyspnoea on moderate effort and pleuritic chest pain. A chest X-ray showed bilateral reticular interstitial opacities. The patient was treated with inhaled LABA/ICS and discharged home. Ten days later, with no clinical improvement, the patient was evaluated in a private clinic, where a course of macrolide antibiotics was started. During the next 9 days, the symptoms worsened and the patient returned to our emergency department. Physical examination showed no major abnormalities, except for inspiratory fine crackles in both lung bases. A repeat chest X-ray showed diffuse fine nodular opacities.

The patient was then admitted to the internal medicine department. Blood workup showed no relevant changes. Autoimmune disease screening was negative and sputum and blood cultures were sterile. A Mantoux test was anergic. A high-resolution computed tomography (HRCT) lung scan showed a diffuse micronodular pattern, suggesting atypical alveolar interstitial disease. Bronchoalveolar lavage analysis showed intense lymphocytic alveolitis; low CD4/CD8 ratio; polymerase chain reaction for Pneumocystis jirovecii, respiratory syncytial virus, adenovirus, influenza A and B virus, parainfluenza virus types 1, 2 and 3, cytomegalovirus and herpes simplex virus 1 and 2 were all negative; Mycobacterium smears and cultures were also negative.

Give the high suspicion for hypersensitivity pneumonitis (HP) and inconclusive other tests, we carried out a precipitin assay that revealed positive precipitins against Cladosporium herbarum A lung biopsy showed a pattern of extrinsic allergic alveolitis, associated with well-defined granulomas suggesting hot-tub lung disease. Pulmonary function tests showed a mild restrictive defect and a severe decrease in carbon monoxide diffusion capacity (57% of predicted). Taking into account the epidemiologic background, all the findings in the evaluation and in the absence of pulmonary fibrosis, a diagnosis of subacute hot-tub lung HP was made.

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