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Published ahead of print on July 3, 2003, doi:10.1164/rccm.200301-137OC

Am. J. Respir. Crit. Care Med., Volume 168, Number 8, October 2003, 952-958

A more recent version of this article appeared on October 15, 2003
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Submitted on February 4, 2003
Accepted on June 27, 2003

CLINICAL DIAGNOSIS OF HYPERSENSITIVITY PNEUMONITIS

Yves Lacasse1*, Moises Selman2, Ulrich Costabel3, Jean-Charles Dalphin4, Masayuki Ando5, Ferran Morell6, Riitta Erkinjuntti-Pekkanen7, Nestor Muller8, Thomas V Colby9, Mark Schuyler10, and Yvon Cormier1

1 Pneumologie, Hopital Laval, Universite Laval, Ste-Foy, Quebec, Canada, 2 Instituto Nacional de Enfermedades Respiratorias, Mexico DF, Mexico, 3 Ruhrlandklinik, Essen, Germany, 4 Centre Hospitalier Universitaire de Besancon, Besancon, France, 5 Kumamoto University School of Medicine, Kumamoto, Japan, 6 Hospital Universitari Vall d'Hebron, Barcelona, Spain, 7 Kuopio University Hospital, Kuopio, Finland, 8 University of British Columbia, Vancouver, Canada, 9 Mayo Clinic Scottsdale, Scottsdale, AZ, USA, 10 University of New Mexico School of Medicine, Albuquerque, NM, USA

* To whom correspondence should be addressed. E-mail: yves.lacasse{at}med.ulaval.ca.

The diagnosis of hypersensitivity pneumonitis is difficult and often relies on histopathology. Our objective was to identify diagnostic criteria and to develop a clinical prediction rule for this disease. Consecutive patients presenting a condition for which hypersensitivity pneumonitis was considered in the differential diagnosis underwent a program of simple standardized diagnostic procedures. High-resolution CT scan and bronchoalveolar lavage defined the presence or absence of hypersensitivity pneumonitis. Patients underwent surgical lung biopsy when the CT scan, the lavage and other diagnostic procedures failed to yield a diagnosis. A cohort of 400 patients (116 hypersensitivity pneumonitis, 284 controls) provided data for the rule derivation. Six significant predictors of hypersensitivity pneumonitis were identified: exposure to a known offending antigen, positive precipitating antibodies to the offending antigen, recurrent episodes of symptoms, inspiratory crackles on physical examination, symptoms occurring 4-8 hours after exposure and weight loss. The area under the receiver operating characteristic curve was 0.93 (95% confidence interval: 0.90 - 0.95). The rule retained its accuracy when validated in a separate cohort of 261 patients. The diagnosis of hypersensitivity pneumonitis can often be made or rejected with confidence, especially in areas of high or low prevalence respectively, without bronchoalveolar lavage or biopsy.
Key words: lung diseases interstitial, decision support techniques, probability




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