Fatal Hypersensitivity Pneumonitis from Exposure to <b><i>Fusarium vasinfectum</i></b> in a Home Environment: A Case Report

Abstract

Background: Hypersensitivity pneumonitis (HP) is a rare, non-IgE-mediated inflammatory lung disease caused by inhalational exposure to various antigens found in occupational, avocational and home environments. The prognosis is favorable with early detection and prompt removal of the causative agent, and fatalities are unusual. We present a fatal case of HP caused by chronic exposure to Fusarium vasinfectum mold in the home. Case Report: A 37-year-old white male presented with a 6-month history of progressively worsening dyspnea, cough, weight loss and fatigue associated with the self-renovation of his water-damaged, mold-infested mobile home. Evaluation included a physical examination (hypoxia, inspiratory crackles and expiratory rhonchi), baseline pulmonary function testing (mixed obstructive/restrictive pattern), chest computed tomography (bronchiectasis, fibrosis and diffuse interstitial involvement), bronchoalveolar lavage (macrophages 20%, lymphocytes 28% and neutrophils 52%) and transbronchial biopsy (interstitial fibrosis and chronic inflammatory infiltrate). Mold culture from the home grew out F. vasinfectum. An Ouchterlony double diffusion technique documented high antibody titer to F. vasinfectum. Despite aggressive intravenous corticosteroid treatment, the patient's lung function declined to the extent that he could not be removed from ventilator support following an open lung biopsy, eventually resulting in death. Conclusion: This is the first reported case of fatal HP related to an acute exacerbation of a chronic form of HP following continuous and intense exposure to F. vasinfectum. Although uncommon, a high index of suspicion for HP is necessary in patients with progressive respiratory symptoms and known environmental antigen exposure. With early detection and prompt removal of the causative antigen, HP prognosis is generally favorable, but can progress to fatal disease with continued exposure.

A Pigeon Fancier’s Lung; Subacute on Chronic Hypersensitivity Pneumonitis

“…HP can present in acute, subacute or chronic forms depending on the type, intensity and duration of exposure to the causative agent. 1 The disease is histologically characterized by a triad of non-necrotizing granulomas, chronic inflammatory changes in the small airways, and diffuse interstitial infiltrates of the chronic inflammatory cells. 2 Pigeon fancier's lungis caused by exposure to airborne avian antigen which provokes a hypersensitivity reaction in a susceptible host.…”

“…The prevalence depends on the intensity, duration of exposure and individual host factors. 1 Studies document 6000-21,000 cases per 100,000 persons per year for pigeon breeders in U.S but the incidence in Sri Lanka is unknown. Early diagnosis of this entity is important as it may reverse the disease and if unchecked can lead to irreversible lung damage, respiratory insufficiency and even death.…”

“…The prognosis is generally favorable with early identification, prompt removal of the offending antigen and symptomatic treatment with corticosteroids. 1 A continued antigen exposure can lead to a permanent loss in lung function, irreversible pulmonary fibrosis and even premature death. 1 In our patient the disease has progressed to chronic state.…”

Exposure assessment in hypersensitivity pneumonitis: a comprehensive review and proposed screening questionnaire

“…T. asahii spores are often released more intensely in the summer months, causing seasonal outbreaks and the descriptive diagnosis of "summer-type HP". Outside of Japan, a variety of other fungal species have been reported in contaminated homes, including more commonly Aspergillus and Fusarium from Europe and North America, followed by Penicillium, Cladosporium, Cryptococcus, Aureobasidium pullulans, Peziza domiciliana and Cephalosporium acremonium [21,[26][27][28][29][30][31][32]. Fungal contamination may also occur through a variety of moisture containing or trapping domestic items, including humidifiers, air purifiers, heating units, air conditioners and ventilation ducts [33][34][35][36][37].…”

Musical Instrument-Associated Health Issues and Their Management

“…This condition is triggered by an excessive immune response that induces acute infection-like symptoms and increasingly severe lung damage (Girard et al 2009). While fatalities due to HP are rare, the continuous and intense exposure to HP antigens may lead to death in some cases (Dickson and Tankersley 2015). In Japan, there have been several reports of HP associated with home ultrasonic humidifiers (Nakagawa et al 1995;Higuchi et al 2011;Takagi et al 2012).…”