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Hypersensitivity Pneumonitis: Spectrum of High-Resolution CT and Pathologic Findings

C. Isabela S. Silva1, Andrew Churg2 and Nestor L. Müller1

1 Department of Radiology, Vancouver General Hospital, University of British Columbia, 899 W 12th Ave., Vancouver, BC, Canada V5Z 1M9.
2 Department of Pathology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada V5Z 1M9.


Figure 1
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  		Fig. 1A —35-year-old woman with subacute hypersensitivity pneumonitis (bird fancier's lung). Photomicrograph of histopathologic specimen obtained at surgical lung biopsy shows moderate, diffuse, bronchiolocentric chronic lymphocytic inflammatory infiltrate. (H and E, x60)

 

Figure 2
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  		Fig. 1B —35-year-old woman with subacute hypersensitivity pneumonitis (bird fancier's lung). Magnified view of different area from A shows poorly formed granuloma (arrows) and chronic interstitial inflammatory infiltrate. (H and E, x200)

 

Figure 3
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  		Fig. 2A —41-year-old man with subacute hypersensitivity pneumonitis. High-resolution CT image shows bilateral poorly defined centrilobular nodules and ground-glass opacities. Also evident are lobular areas (arrows) of decreased attenuation.

 

Figure 4
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  		Fig. 2B —41-year-old man with subacute hypersensitivity pneumonitis. Expiratory high-resolution CT scan at same level as A shows air trapping in lobules (curved arrows) that had decreased attenuation on inspiratory CT and in other lung regions (straight arrow).

 

Figure 5
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  		Fig. 3 —36-year-old woman with hypersensitivity pneumonitis caused by selective serotonin reuptake inhibitor sertraline. High-resolution CT image shows bilateral ground-glass opacities and lobular areas (arrows) of decreased attenuation and vascularity. Patient was taking oral sertraline for management of depressive illness.

 

Figure 6
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  		Fig. 4 —74-year-old man with hypersensitivity pneumonitis (bird fancier's lung). Lowpower view of surgical lung biopsy specimen shows mild interstitial mononuclear cell infiltrate that correlates with areas of ground-glass opacities seen on highresolution CT. (H and E, x60)

 

Figure 7
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  		Fig. 5 —65-year-old man with hypersensitivity pneumonitis (bird fancier's lung). Photomicrograph of surgical lung biopsy specimen shows chronic inflammatory infiltrate with focal area (arrows) of organizing pneumonia. (H and E, x60)

 

Figure 8
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  		Fig. 6A —65-year-old man with chronic and subacute hypersensitivity pneumonitis due to exposure to red cedar. High-resolution CT image at level of left upper bronchus shows bilateral patchy areas of ground-glass opacities, fine reticulation, and traction bronchiectasis (arrow). Bilateral centrilobular nodules (circles) also are evident.

 

Figure 9
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  		Fig. 6B —65-year-old man with chronic and subacute hypersensitivity pneumonitis due to exposure to red cedar. High-resolution CT image at level of lung bases shows relative sparing with minimal reticulation. Lobules (arrows) with decreased attenuation and vascularity are evident in lower lobes.

 

Figure 10
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  		Fig. 6C (continued) —65-year-old man with chronic and subacute hypersensitivity pneumonitis due to exposure to red cedar. Low-power view of surgical lung biopsy specimen shows areas of subacute (curved arrows) and chronic (straight arrows) changes of hypersensitivity pneumonitis. (H and E, x40)

 

Figure 11
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  		Fig. 6D (continued) —65-year-old man with chronic and subacute hypersensitivity pneumonitis due to exposure to red cedar. Higher-power view shows chronic interstitial inflammatory infiltrate and interstitial fibrosis. Also evident are giant cell (curved arrow) and fibroblast focus (straight arrows). (H and E, x400)

 

Figure 12
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  		Fig. 7A —56-year-old man with chronic hypersensitivity pneumonitis due to occupational exposure to isocyanate compounds in paint. High-resolution CT scan shows bilateral reticulation, traction bronchiectasis (curved arrow), and traction bronchiolectasis (straight arrows). Also evident are subpleural cysts consistent with mild honeycombing (arrowheads). Area of ground-glass opacity with superimposed reticulation is present in right middle lobe. These high-resolution CT findings resemble those of nonspecific interstitial pneumonia.

 

Figure 13
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  		Fig. 7B —56-year-old man with chronic hypersensitivity pneumonitis due to occupational exposure to isocyanate compounds in paint. Coronal reformatted image shows predominance of abnormalities in subpleural and basal regions.

 

Figure 14
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  		Fig. 7C (continued) —56-year-old man with chronic hypersensitivity pneumonitis due to occupational exposure to isocyanate compounds in paint. Photomicrograph of surgical lung biopsy specimen shows nondiagnostic honeycombing and moderate mononuclear interstitial infiltrate. (H and E, x20)

 

Figure 15
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  		Fig. 8A —80-year-old woman with hypersensitivity pneumonitis due to exposure to mold. High-resolution CT scan shows subtle ground-glass opacities and minimal subpleural reticulation in dorsal regions of lower lobes that can be interpreted as normal dependent density.

 

Figure 16
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  		Fig. 8B —80-year-old woman with hypersensitivity pneumonitis due to exposure to mold. Prone high-resolution CT scan at same level as A shows persistent abnormalities in dorsal regions of lower lobes. Diagnosis of hypersensitivity pneumonitis was made clinically. Samples of air in patient's apartment grew Penicillium organisms.

 

Figure 17
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  		Fig. 9 —47-year-old man with subacute hypersensitivity pneumonitis (bird fancier's lung). High-resolution CT image shows patchy ground-glass opacities in right lower lobe and lingula.

 

Figure 18
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  		Fig. 10A —53-year-old man with hypersensitivity pneumonitis. High-resolution CT image shows extensive bilateral ground-glass opacities, poorly defined small centrilobular nodules (straight arrows), and lobular areas (curved arrows) of decreased attenuation and vascularity in right middle lobe. These findings are characteristic of subacute hypersensitivity pneumonitis.

 

Figure 19
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  		Fig. 10B —53-year-old man with hypersensitivity pneumonitis. Surgical lung biopsy specimen of right lower lobe shows thickening of alveolar wall by mild to moderate inflammation consisting mostly of lymphocytes and plasma cells. Histologic findings are those of nonspecific interstitial pneumonitis. Diagnosis of hypersensitivity pneumonitis was based on radiologic and clinical findings. Patient had positive results for Aspergillus precipitins, but specific etiologic agent for hypersensitivity pneumonitis was not identified. (H and E, x40)

 

Figure 20
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  		Fig. 11 —45-year-old woman with subacute hypersensitivity pneumonitis (winemaker's lung). High-resolution CT image at level of right upper bronchus shows bilateral small centrilobular nodules (arrows).

 

Figure 21
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  		Fig. 12 —77-year-old man with chronic hypersensitivity pneumonitis (bird fancier's lung). High-resolution CT image shows mild reticulation and micronodules (arrows) in peripheral lung regions.

 

Figure 22
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  		Fig. 13 —55-year-old man with hypersensitivity pneumonitis due to exposure to mold. High-resolution CT image of upper lobes shows patchy bilateral ground-glass opacities, nodular areas of consolidation (straight arrows), and perilobular opacities (curved arrows). These high-resolution CT findings resemble those of organizing pneumonia (bronchiolitis obliterans organizing pneumonia).

 

Figure 23
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  		Fig. 14A —74-year-old man with chronic and subacute hypersensitivity pneumonitis (bird fancier's lung). High-resolution CT image shows mild reticulation and extensive bilateral ground-glass opacities. Also evident are bilateral centrilobular nodules (straight arrows) and localized areas (curved arrows) of decreased attenuation and vascularity.

 

Figure 24
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  		Fig. 14B —74-year-old man with chronic and subacute hypersensitivity pneumonitis (bird fancier's lung). Surgical lung biopsy specimen shows cellular bronchiolitis with infiltrate of chronic inflammatory cells (straight arrows), thickening wall (curved arrows), and narrowing lumen. This type of bronchiolitis presumably accounts for lobular areas of decreased attenuation and vascularity seen on high-resolution CT. (H and E, x160)

 

Figure 25
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  		Fig. 15A —70-year-old woman with acute exacerbation of biopsy-proven chronic hypersensitivity pneumonitis. High-resolution CT image at level of right upper lobe shows patchy bilateral ground-glass opacities and peripheral reticulation.

 

Figure 26
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  		Fig. 15B —70-year-old woman with acute exacerbation of biopsy-proven chronic hypersensitivity pneumonitis. High-resolution CT image at same level as A obtained 7 years after A when patient developed acute exacerbation shows extensive bilateral ground-glass opacities.

 

Figure 27
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  		Fig. 16 —45-year-old woman with subacute hypersensitivity pneumonitis. Highresolution CT image shows bilateral ground-glass opacities, poorly defined centrilobular nodules (straight arrows), and thin-walled cysts. Also evident is lobular area (curved arrow) of decreased attenuation in left upper lobe. Patient was lifelong nonsmoker. (Reprinted with permission from [9])

 

Figure 28
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  		Fig. 17 —44-year-old man with chronic hypersensitivity pneumonitis (farmer's lung). High-resolution CT image shows bilateral ground-glass opacities and centrilobular emphysema. Patient was lifelong nonsmoker. (Courtesy of Dr. Yvon Cormier, Quebec, Canada)

 

Figure 29
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  		Fig. 18A —35-year-old man with hot tub lung. High-resolution CT image shows diffuse bilateral poorly defined small nodules.

 

Figure 30
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  		Fig. 18B —35-year-old man with hot tub lung. Low-power view of surgical lung biopsy specimen shows numerous nonnecrotizing granulomas (arrows) accompanied by chronic interstitial inflammatory infiltrate. Histologic findings are characteristic of hot tub lung. (H and E, x40)

 

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