Occupational Hypersensitivity Pneumonitis in a Baker: A New Cause

doi:10.1378/chest.13-1734

Chest

Volume 145, Issue 4, April 2014, Pages 856-858

https://doi.org/10.1378/chest.13-1734 Get rights and content

Bakers are exposed daily to flour and may be susceptible 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 diffusing 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 peribronchiolar interstitial inflammation by lung biopsy specimen. Cultures from flours isolated nine species, including Aspergillus fumigatus. Twenty-six antigens were tested. Serum-specific precipitins were found against A fumigatus, the flour mite Acarus siro, and total extracts from maize and oat. Outcome was favorable with cessation of occupational exposure to flours and transient therapy with prednisone and immunosuppressive agents. To our knowledge, this report is the first of a well-documented case of hypersensitivity pneumonitis due to sensitization to fungi-and mite-contaminated flours. Hypersensitivity pneumonitis—and not only asthma and allergic rhinitis—should be suspected in bakers with respiratory symptoms.

Section snippets

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 ventilated room. She had no other relevant history. Symptoms improved while she was away from work during

Discussion

To our knowledge, this is the first report of a well-documented case of HP due to sensitization to fungi-and mite-contaminated flours 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 confirmation of the diagnosis is not needed in the majority of cases of HP and would

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

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Cited by (20)

Assessment and Management of Occupational Hypersensitivity Pneumonitis
2020, Journal of Allergy and Clinical Immunology: In Practice
The diagnosis and treatment of occupational hypersensitivity pneumonitis (OHP) remain complex and challenging in the absence of diagnostic gold standards or clinical guidelines. This review provides an update of the recent literature regarding the different presentations of OHP and the diagnostic yield and value of the diagnostic tests currently available, which include occupational and medical history, laboratory tests (serum-specific immunoglobulins, environmental sampling), imaging, bronchoalveolar lavage, transbronchial biopsy, transbronchial cryobiopsy, surgical lung biopsy, and specific inhalation challenges. These tools provide a precise differential diagnosis within the framework of interstitial lung diseases. However, among the chronic fibrotic forms, distinguishing OHP from sarcoidosis, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis remains a diagnostic challenge. Avoidance of exposure is pivotal for OHP management, whereas corticosteroids are fundamental in the pharmacological approach to this disease. In addition, studies describing the long-term benefits of immunosuppressive and antifibrotic agents have increased the use of these treatments in OHP.
Diagnostic Pathology: Thoracic
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Citation Excerpt :
The first cases were reported when conventional outdoor drying of wood was replaced by indoor drying in special ovens, as well as in the indoors wood sorting and cutting, to improve working conditions in sawmills.37 Some cases have been reported in food industry workers, such as bakers who are exposed to flour on a daily basis, which can be contaminated with the fungi A. fumigatus;34 cheese producers can also develop cheese workers’ HP caused by Penicillium notatum, Penicillium viridicutum, A. fumigatus, Aspergillus niger, or A. pullulans35; in soy sauce brewer, where precipitin against Aspergillus oryzae was found (soya dust alveolitis);6,36 and even in salami factory workers due to inhalation of dried sausage dust. Morell et al.,33 for example, described five Spanish patients working in dry sausage production with Salami Brusher's disease, caused by P. glabrum and A. fumigatus.
Hypersensitivity pneumonitis (HP) is an immune-mediated syndrome triggered by inhalation of a wide variety of allergens, to which an individual has previously been sensitized. More than 200 agents responsible for the disease have already been identified; however, HP occurs only in a small number of individuals exposed to causal antigens. The present report provides an overview of the role of antigen role in HP, highlighting its diversity, research methods, and prevention strategies, as well as the impact on disease prognosis following elimination of antigen. HP is an underdiagnosed disease and, therefore, it is difficult to accurately estimate its incidence. Triggering antigens can be divided into six broad categories: bacteria, fungi, mycobacteria, animal and plant proteins, chemicals, and metals, represented by disease prototypes. The identification of causal antigen is a major challenge; it is impossible to obtain in about 30–60% of cases. The acute form of HP, with early detection and immediate eviction of causal antigen, tends to have an excellent prognosis. In the chronic form, partial recovery of disease is still possible; however, some cases tend to progress to fibrosis, even after removal from exposure. In conclusion, HP diagnosis should be based on a proactive search for potential antigen sources, although their identification is hampered by the lack of standardized methods of demonstrating the specific antigen sensitization. Antigen avoidance is a critical determinant in disease prognosis.
Aspergillus and the Lung
2024, Seminars in Respiratory and Critical Care Medicine
Clinical Manifestations of Human Exposure to Fungi
2023, Journal of Fungi
Hypersensitivity pneumonitis against the background of the use of organic substances, probably mustard powder (clinical case)
2023, Tuberculosis, Lung Diseases, HIV Infection

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Selected ReportsOccupational Hypersensitivity Pneumonitis in a Baker: A New Cause

Section snippets

Case Report

Discussion

Acknowledgments

Clin Chest Med

J Allergy Clin Immunol

Int J Food Microbiol

Baker's asthma

Curr Opin Allergy Clin Immunol

Non-neoplastic disorders of the lower respiratory tract

American Registry of Pathology and Armed Forces Institute of Pathology

Selected Reports
Occupational Hypersensitivity Pneumonitis in a Baker: A New Cause