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currently without directed therapy&#59; a previous hospital admission happened due to community-acquired pneumonia&#46; Chronic medications are an association of two anti-hypertensive drugs and atorvastatin&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up chest high-resolution CT scans showed progressive&#44; unspecific&#44; peripheral lower lung lobes intralobular reticulation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; as well as lymph node enlargement &#40;14<span class="elsevierStyleHsp" style=""></span>mm&#41; in the left paratracheal station &#40;4<span class="elsevierStyleHsp" style=""></span>L&#41;&#46; Endobronchial ultrasound-transbronchial needle aspiration &#40;EBUS-TBNA&#41; was performed&#59; the 4<span class="elsevierStyleHsp" style=""></span>L station was identified and sampled and its cytological analysis was unremarkable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Meanwhile&#44; the patient reported worsening exertional dyspnea&#46; Body plethysmography identified a mild obstructive ventilatory defect&#58; FEV1&#47;VC ratio equal to 64&#46;2&#37; and FEV1 equal to 2&#46;41<span class="elsevierStyleHsp" style=""></span>L &#40;86&#37; of the predicted value&#41;&#46; There was no lung diffusion impairment&#46; Fibreoptic bronchoscopy with bronchoalveolar lavage &#40;BAL&#41; in the middle lobe was performed&#46; BAL fluid cellular analysis showed a normal total cell count&#44; an intense lymphocytic alveolitis &#40;55&#46;6&#37;&#41; and a CD4&#47;CD8 ratio of 1&#46;87&#59; bronchial wash and BAL were negative for malignant cells or microbiological agents&#46; Serum immunological study was positive for anti-nuclear antibodies &#40;1&#47;1000 titer&#44; speckled pattern&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The decision to perform transbronchial lung cryobiopsy &#40;TBLC&#41; was made in ILD interdisciplinary meeting for diagnostic clarification&#46; Histological analysis of three samples from the right lower lobe showed features suggestive of both HP and autoimmunity &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A working diagnosis of HPAF was established in an ILD multidisciplinary meeting&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">This case report shows the diagnostic challenges of HPAF&#46; It is still unclear whether autoimmune features in HP are a distinct HP clinical phenotype or an unrelated finding&#46; However&#44; we think that both HPAF and non-HPAF HP patients deserve further study in future prospective studies&#44; specifically regarding immunosuppressive therapy outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; 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Letter to the Editor
Diagnostic challenges of hypersensitivity pneumonitis with autoimmune features: Dealing with more than a coincidence?
T. Oliveiraa,b,
Corresponding author
tiagooliveiramedico@gmail.com

Corresponding author at: Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal.
, N. Meloc, S. Guimarãesd,e, A. Moraisc,e
a Pulmonology Department, Centro Hospitalar Universitário do Porto – Hospital de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
b Abel Salazar Institute of Biomedical Sciences – University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
c Pulmonology Department, Centro Hospitalar Universitário de São João – Hospital de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
d Anatomic Pathology Department, Centro Hospitalar Universitário de São João – Hospital de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
e Faculty of Medicine – University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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currently without directed therapy&#59; a previous hospital admission happened due to community-acquired pneumonia&#46; Chronic medications are an association of two anti-hypertensive drugs and atorvastatin&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up chest high-resolution CT scans showed progressive&#44; unspecific&#44; peripheral lower lung lobes intralobular reticulation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; as well as lymph node enlargement &#40;14<span class="elsevierStyleHsp" style=""></span>mm&#41; in the left paratracheal station &#40;4<span class="elsevierStyleHsp" style=""></span>L&#41;&#46; Endobronchial ultrasound-transbronchial needle aspiration &#40;EBUS-TBNA&#41; was performed&#59; the 4<span class="elsevierStyleHsp" style=""></span>L station was identified and sampled and its cytological analysis was unremarkable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Meanwhile&#44; the patient reported worsening exertional dyspnea&#46; Body plethysmography identified a mild obstructive ventilatory defect&#58; FEV1&#47;VC ratio equal to 64&#46;2&#37; and FEV1 equal to 2&#46;41<span class="elsevierStyleHsp" style=""></span>L &#40;86&#37; of the predicted value&#41;&#46; There was no lung diffusion impairment&#46; Fibreoptic bronchoscopy with bronchoalveolar lavage &#40;BAL&#41; in the middle lobe was performed&#46; BAL fluid cellular analysis showed a normal total cell count&#44; an intense lymphocytic alveolitis &#40;55&#46;6&#37;&#41; and a CD4&#47;CD8 ratio of 1&#46;87&#59; bronchial wash and BAL were negative for malignant cells or microbiological agents&#46; Serum immunological study was positive for anti-nuclear antibodies &#40;1&#47;1000 titer&#44; speckled pattern&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The decision to perform transbronchial lung cryobiopsy &#40;TBLC&#41; was made in ILD interdisciplinary meeting for diagnostic clarification&#46; Histological analysis of three samples from the right lower lobe showed features suggestive of both HP and autoimmunity &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A working diagnosis of HPAF was established in an ILD multidisciplinary meeting&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">This case report shows the diagnostic challenges of HPAF&#46; It is still unclear whether autoimmune features in HP are a distinct HP clinical phenotype or an unrelated finding&#46; However&#44; we think that both HPAF and non-HPAF HP patients deserve further study in future prospective studies&#44; specifically regarding immunosuppressive therapy outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; 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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">TBLC histopathology findings in HPAF&#46; There are expressive peribronchiolar and subpleural changes&#44; typical of HP and CTDs&#44; respectively&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;A&#41;</span> A prominent&#44; dense interstitial chronic inflammatory infiltrate without lymphoid follicles with a predominantly bronchiolocentric distribution is seen&#46; There are extensive lesions of peribronchiolar metaplasia &#40;white - - - - -&#41; and loose aggregates of epithelioid histiocytes &#8211; epithelioid granulomas &#40;white &#42;&#41;&#46; A centrilobular region is marked with white &#35; &#8211; hematoxylin and eosin &#40;H&#38;E&#41; staining&#44; 40&#215; magnification&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;B&#41;</span> Detail of a lesion of peribronchiolar metaplasia &#40;white - - - - -&#41;&#44; adjacent to the centrilobular region &#40;white &#35;&#41; &#8211; H&#38;E staining&#44; 200&#215; magnification&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;C&#41;</span> Detail of an epithelioid granuloma &#40;white &#42;&#41; &#8211; H&#38;E staining&#44; 200&#215; magnification&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;D&#41;</span> A moderate cellular chronic inflammatory infiltrate&#44; extensively involving subpleural areas &#40;<elsevierMultimedia ident="202009020806347101"></elsevierMultimedia>&#41;&#44; as well as alveolar septa&#44; is also seen &#8211; H&#38;E staining&#44; 40&#215; magnification&#46;</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;E&#41;</span> Detail of organizing pneumonia lesion &#40;&#8594;&#41; &#8211; H&#38;E staining&#44; 200&#215; magnification&#46;</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;F&#41;</span> Detail of a multinucleated giant cell &#40;&#9655; and &#8226;&#8226;&#8226;&#8226;&#8226;&#8226;&#8226;&#41; adjacent to the visceral pleura &#40;<elsevierMultimedia ident="202009020806347102"></elsevierMultimedia>&#41; &#8211; H&#38;E staining&#44; 400&#215; magnification&#46;</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">&#40;G&#41;</span> Detail of a pleura-centered epithelioid granuloma &#40;white &#42;&#41; and focal mesothelial reactivity &#40;&#9658;&#41; interspersed with normal pleural mesothelium &#40;<elsevierMultimedia ident="202009020806347103"></elsevierMultimedia>&#41; &#8211; H&#38;E staining&#44; 200&#215; magnification&#46;</p>"
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                      "titulo" => "An official European Respiratory Society&#47;American Thoracic Society research statement&#58; interstitial pneumonia with autoimmune features"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Fischer"
                            1 => "K&#46;M&#46; Antoniou"
                            2 => "K&#46;K&#46; Brown"
                            3 => "J&#46; Cadranel"
                            4 => "T&#46;J&#46; Corte"
                            5 => "R&#46;M&#46; du Bois"
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                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2015"
                        "volumen" => "46"
                        "numero" => "4"
                        "paginaInicial" => "976"
                        "paginaFinal" => "987"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of survival in coexistent hypersensitivity pneumonitis with autoimmune features"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Adegunsoye"
                            1 => "J&#46;M&#46; Oldham"
                            2 => "C&#46; Demchuk"
                            3 => "S&#46; Montner"
                            4 => "R&#46; Vij"
                            5 => "M&#46;E&#46; Strek"
                          ]
                        ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.rmed.2016.03.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2016"
                        "volumen" => "114"
                        "paginaInicial" => "53"
                        "paginaFinal" => "60"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27109811"
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">We would like to thank all the remaining elements of the ILD interdisciplinary meeting for the decisive contributions to the diagnosis of the patient&#58; Andr&#233; Carvalho&#44; MD &#40;Radiology&#41;&#44; Concei&#231;&#227;o Souto Moura&#44; MD &#40;Anatomic Pathology&#41;&#44; H&#233;lder Novais e Bastos&#44; MD&#44; PhD &#40;Pulmonology&#41;&#44; Jos&#233; Miguel Pereira&#44; MD &#40;Radiology&#41;&#44; Patr&#237;cia Mota&#44; MD &#40;Pulmonology&#41; and Rui Cunha&#44; MD &#40;Radiology&#41;&#46;</p>"
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Article information
ISSN: 25310437
Original language: English
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