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CHEST Selected Reports

856 Selected Reports


Occupational Hypersensitivity
Pneumonitis in a Baker
A New Cause
Mathieu Gerfaud-Valentin , MD ; Gabriel Reboux , PhD ;
Julie Traclet , MD ; Franoise Thivolet-Bjui , MD ;
Jean-Franois Cordier , MD ; and Vincent Cottin , MD
Bakers are exposed daily to our and may be suscep-
tible to immunologic occupational diseases. A 30-year-
old, nonsmoking, female baker was referred for
progressive dyspnea on exertion, basal crackles on
auscultation, restrictive lung function, decreased dif-
fusing capacity of the lung for carbon monoxide,
ground glass hyperdensities with a mosaic pattern on
high-resolution CT scan, 25% lymphocytosis by BAL,
and cellular chronic bronchiolitis with peribronchio-
lar interstitial inammation by lung biopsy specimen.
Cultures from ours isolated nine species, including
Aspergillus fumigatus . Twenty-six antigens were tested.
Serum-specic precipitins were found against A fumig-
atus , the our mite Acarus siro, and total extracts from
maize and oat. Outcome was favorable with cessation
of occupational exposure to ours and transient ther-
apy with prednisone and immunosuppressive agents.
To our knowledge, this report is the rst of a well-
documented case of hypersensitivity pneumonitis due
to sensitization to fungi- and mite-contaminated ours.
Hypersensitivity pneumonitisand not only asthma
and allergic rhinitisshould be suspected in bakers
with respiratory symptoms.
CHEST 2014; 145 ( 4 ): 856 858
Abbreviations : HP 5 hypersensitivity pneumonitis ; HRCT 5
high-resolution CT
H
ypersensitivity pneumonitis (HP) is an immunologi-
cally mediated diffuse lung disease caused by repeated
inhalation of organic agents in sensitized individuals. Causal
antigens are largely microbiologic in nature
1
and often
occupational. Bakers are exposed daily to our and may
develop occupational asthma and atopic rhinitis,
2
but, to
our knowledge, HP has not been reported previously in
bakers.
Case Report
A 30-year-old female nonsmoker who had been working
as a baker for 8 months presented with progressive dyspnea
on exertion and dry cough for 3 months. She was exposed
daily to wheat and oat flours while making bread from
5:00 pm to 4:00 am and reported morning cough, dyspnea,
fever, and chills. She worked in an artisanal family-owned
bakery while not wearing a mask in a moderately venti-
lated room. She had no other relevant history. Symptoms
improved while she was away from work during vacations.
The patients husband also worked in the same bakery but
had no symptoms.
Basal inspiratory crackles were present on auscultation.
Pulmonary function tests showed the following: total lung
capacity, 3.40 L (64% predicted); vital capacity, 2.15 L
(61%); FEV
1
, 2.1 L (60%); diffusing capacity of the lung
for carbon monoxide, 33%; and transfer coefcient for car-
bon monoxide, 60%. Pa o
2
was 67 mm Hg on room air. Six-
minute walk distance was 435 m, with desaturation from
96% to 88%. High-resolution CT (HRCT) scan demon-
strated diffuse bilateral ground glass patchy hyperdensi-
ties with a mosaic pattern ( Fig 1 ). Laboratory tests showed
peripheral blood lymphocytosis (4,510 3 10
9
/L) and mod-
erate polyclonal hypergammaglobulinemia. BAL differen-
tial count demonstrated 25% lymphocytes, 5% neutrophils,
3% eosinophils, and 67% macrophages. Antinuclear and
anticyclic citrullinated peptide antibodies were absent. A
specimen taken from video-assisted lung biopsy of the left
lower lobe revealed marked interstitial and bronchiolocen-
tric lymphocytic inltrates with mild macrophagic alveolitis
but without granuloma or brosis ( Fig 2 ).
The patient was referred for further etiologic investiga-
tions and management. Microbiologic cultures from 10 ours
that the patient used isolated nine species, including Asper-
gillus fumigatus . Weevils were not found. Twenty-six anti-
gens issued from fungi, actinomycetes, mites, and total
flour extracts were tested. Electrosyneresis testing for
serum-specic precipitins against A fumigatus and the
our mite Acarus siro were strongly positive, with 4 and
Manuscript received July 25 , 2013 ; revision accepted October 4 ,
2013 .
Afliations: From the Hospices Civils de Lyon (Drs Gerfaud-
Valentin, Traclet, Cordier, and Cottin), Hpital Louis Pradel, Ser-
vice de Pneumologie-Centre de rfrence national des maladies
pulmonaires rares, Universit Claude Bernard Lyon 1, Lyon;
Laboratoire de parasitologie et mycologie (Dr Reboux), Centre
hospitalier universitaire Jean Minjoz, Besanon; and Hospices
Civils de Lyon (Dr Thivolet-Bjui), Groupe hospi talier est, Centre
de biologie et pathologie est, Universit Claude Bernard Lyon 1,
Lyon, France.
Correspondence to: Vincent Cottin, MD, Hospices Civils de Lyon,
Hpital Louis Pradel, Service de Pneumologie-Centre de rfrence
national des maladies pulmonaires rares, Universit Claude Bernard
Lyon 1, 28 avenue Doyen Lepine, f-69677 Lyon, France; e-mail:
vincent.cottin@chu-lyon.fr
2014 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.13-1734
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CHEST / 145 / 4 / APRIL 2014 857 journal.publications.chestnet.org
(60%); diffusing capacity of the lung for carbon monoxide,
50%; and transfer coefcient for carbon monoxide, 90%.
Discussion
To our knowledge, this is the first report of a well-
documented case of HP due to sensitization to fungi- and
mite-contaminated ours in a baker. The diagnosis of HP
was based on a combination of features, including a clinical
presentation compatible with subacute HP,
3
lymphocytic
alveolitis on BAL, and a typical imaging pattern with ground
glass hyperdensities and mosaic pattern on chest HRCT
scan. Histologic conrmation of the diagnosis is not needed
in the majority of cases of HP and would not have been
mandatory in the present case. The most consistent histo-
logic feature is a cellular chronic bronchiolitis with peribron-
chiolar interstitial inammation; poorly formed granulomas
(not found in the present case) are present in only two-thirds
of cases.
4
The diagnosis was further conrmed by strongly
positive precipitins against various ours, specically against
molds ( Aspergillus ) and mites ( Acarus ) isolated from the
ours of the patients bakery, and by the dramatic improve-
ment observed after cessation of occupational exposure.
A siro, a storage mite, has been shown to be involved in
allergic manifestations in millworkers
5
and bakers
6
yet has
not been previously reported as a cause of HP. Aspergillus
is a classic contaminant of ours
7 , 8
that may cause HP in
other circumstances, especially in farmers.
9

Occupational asthma is known to develop in bakers,
2

but surprisingly, occupational HP seems to be exceedingly
rare, with no case report found in the medical literature
through MEDLINE using hypersensitivity pneumonitis
OR extrinsic allergic alveolitis AND baker as search
terms. Isolated cases of HP due to sensitization to antigens
from weevils (beetles that contaminate grains and ours)
have been reported
10
; however, the presence of weevils was
denitely ruled out in the present case.
In conclusion, we describe a case of HP due to the inha-
lation of a variety of ours and their contaminant molds.

Figure 1. High-resolution CT scan showing diffuse bilateral
ground glass patchy hyperdensities with a mosaic pattern.
A, Inspiration. B, Expiration .

Figure 2. Lung biopsy specimen demonstrating bronchiolocen-
tric lymphocytic inltrates (hematoxylin-eosin, magnication 3 250).
5 arcs, respectively. Moreover, serum testing with total
extracts from maize and oat was strongly positive, with
7 and 6 arcs, respectively. IgE specic for Aspergillus was
negative.
A diagnosis of HP related to molds and mites contami-
nating cereal storages and bakers ours was made. Treat-
ment with 0.5 mg/kg/d po prednisone was initiated with
gradual tapering, and the patient was instructed to stop
occupational exposure to ours. Clinical symptoms and
pulmonary function tests improved initially, but occupa-
tional exposure continued, and the patients condition
deteriorated further. Mycophenolate mofetil was added to
corticosteroids with some improvement. The patient even-
tually avoided persistent exposure to our, and all drug
therapy could then be stopped. Three years later, only
functional class 1 dyspnea is present. Mild ground glass
hyperdensities are still present on HRCT scan. Pulmonary
function tests are as follows: total lung capacity, 3.58 L
(71% predicted); vital capacity, 2.0 L (66%); FEV
1
, 1.54 L
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858 Selected Reports
HP in addition to asthma and allergic rhinitis should be
suspected in bakers with respiratory symptoms.
Acknowledgments
Financial/nonnancial disclosures: The authors have reported
to CHEST that no potential conicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
Other contributions: CHEST worked with the authors to ensure
that the Journal policies on patient consent to report information
were met.
References
1. Fishwick D . New occupational and environmental causes of
asthma and extrinsic allergic alveolitis . Clin Chest Med . 2012 ;
33 ( 4 ): 605 - 616 .
2. Brant A . Bakers asthma . Curr Opin Allergy Clin Immunol .
2007 ; 7 ( 2 ): 152 - 155 .
3. Richerson HB , Bernstein IL , Fink JN , et al ; Guidelines for the
clinical evaluation of hypersensitivity pneumonitis: report of
the Subcommittee on Hypersensitivity Pneumonitis . J Allergy
Clin Immunol . 1989 ; 84 ( 5 pt 2 ): 839 - 844 .
4. Travis WD , Colby TV, Koss MN , Rosado-de-Christenson ML ,
Mueller NL , Kinh TE . Non-neoplastic disorders of the lower
respiratory tract . In: King DW , ed. American Registry of
Pathology and Armed Forces Institute of Pathology . Washington,
DC : 2002 .
5. Revsbech P , Andersen G . Storage mite allergy among grain
elevator workers . Allergy . 1987 ; 42 ( 6 ): 423 - 429 .
6. Revsbech P , Dueholm M . Storage mite allergy among bakers .
Allergy . 1990 ; 45 ( 3 ): 204 - 208 .
7. Berghofer LK , Hocking AD , Miskelly D , Jansson E . Micro-
biology of wheat and our milling in Australia . Int J Food
Microbiol . 2003 ; 85 ( 1-2 ): 137 - 149 .
8. Bosly HA , Kawanna MA . Fungi species and red our beetle in
stored wheat our under Jazan region conditions [published
online ahead of print August 17, 2012] . Toxicol Ind Health .
doi:10.1177/0748233712457449 .
9. Kaukonen K , Savolainen J , Viander M , Terho EO . Avidity of
Aspergillus umbrosus IgG antibodies in farmers lung disease .
Clin Exp Immunol . 1994 ; 95 ( 1 ): 162 - 165 .
10. Lunn JA , Hughes DT . Pulmonary hypersensitivity to the grain
weevil . Br J Ind Med . 1967 ; 24 ( 2 ): 158 - 161 .
Mycobacterium Brisbanense
Species Nova Isolated From a
Patient With Chronic Cavitary
Lung Infection
Mau-Ern Poh , MBBS ; Chong-Kin Liam , MBBS, FCCP ;
Kee-Peng Ng , PhD ; and Ruixin Tan , MBBCh, BAO
We describe the rst case, to our knowledge, of Myco-
bacterium brisbanense species nova with the type
strain W6743T ( 5 ATCC 49938T 5 DSM 44680T) iso-
lated from the lungs of a man with a 6-month history
of productive cough and intermittent fever pre-
senting with acute hypoglycemia. A CT scan of the
thorax revealed multiple small nodules and consoli-
Manuscript received August 20 , 2013 ; revision accepted
November 4 , 2013 .
Afliations: From the Division of Respiratory Medicine (Drs Poh
and Liam), Department of Medicine, and Department of Medical
Microbiology (Drs Ng and Tan), Faculty of Medicine, University
of Malaya, Kuala Lumpur, Malaysia.
Correspondence to: Mau-Ern Poh, MBBS, Department of Medi-
cine, Faculty of Medicine, University of Malaya, Lembah Pantai,
50603 Kuala Lumpur, Malaysia; e-mail: ernestpoh@gmail.com
2014 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.13-1952
dation over both lungs with cavitation. Sputum cul-
ture repeatedly grew M brisbanense species nova, a
novel species never before isolated in Malaysia. The
case met the American Thoracic Society criteria for the
diagnosis of nontuberculous mycobacterial infection.
There was dramatic clinical and radiologic response
to treatment with an empirical combination of rifam-
picin, etham butol, and levooxacin and subsequently
clarithro mycin and levooxacin once sensitivity was
known. This report is the rst, to our knowledge, of
the pathogen isolated in a patient with chronic cavitary
lung infection since it was rst identied from an antral
sinus in Brisbane, Queensland, Australia, and the rst
time it is isolated from a human subject in Malaysia.
CHEST 2014; 145 ( 4 ): 858 860
Abbreviations : LJ 5 Lowenstein-Jensen ; MGIT 5 Mycobacteria
Growth Indicator Tube
M
ycobacterium brisbanense species nova isolated from
patients with lower respiratory tract infections has not
been reported to date. We report a case of M brisbanense
species nova isolated from a patient with extensive cavitary
pneumonia with his written consent. This is the rst time,
to our knowledge, the organism was isolated from a patient
in Malaysia after it was rst identied from an antral sinus
in Brisbane, Queensland, Australia.
1

Case Report
A 62-year-old man with type 2 diabetes mellitus and
hyper tension was found unconscious at home. He regained
consciousness after correction of hypoglycemia at the ED.
He had a 6-month history of a cough productive of clear
sputum, intermittent fever, night sweats, anorexia, and sig-
nicant weight loss. There was no history of contact with
pulmonary TB or travel outside the country. The patient
underwent a right-side nephrectomy 12 years previously for
renal cell carcinoma. He was not on immunosuppressive
therapy and had never smoked.
The patient was febrile with a respiratory rate of
30 breaths/min and oxygen saturation of 94% on room air,
but chest auscultation ndings were unremarkable. There
was no blood leukocytosis, and blood cultures were nega-
tive. A chest radiograph showed patchy, ill-dened airspace
opacities over both lung elds ( Fig 1 ). A CT scan of the
thorax revealed multiple areas of consolidation with cavita-
tion in both lungs ( Fig 2 ). The Mantoux tuberculin skin
test was nonreactive. Three good-quality sputum samples
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