Hypersensitivity Pneumonitis: Radiologic Phenotypes Are Associated With Distinct Survival Time and Pulmonary Function Trajectory

• Published in: Chest Vol. 155; no. 4; pp. 699 - 711
• Main Authors: Salisbury, Margaret L, Gu, Tian, Murray, Susan, Gross, Barry H, Chughtai, Aamer, Sayyouh, Mohamed, Kazerooni, Ella A, Myers, Jeffrey L, Lagstein, Amir, Konopka, Kristine E, Belloli, Elizabeth A, Sheth, Jamie S, White, Eric S, Holtze, Colin, Martinez, Fernando J, Flaherty, Kevin R
• Format: Journal Article
• Language: English
• Published: United States American College of Chest Physicians 01.04.2019
• Subjects: Alveolitis, Extrinsic Allergic - diagnosis; Alveolitis, Extrinsic Allergic - mortality; Biopsy; Diffuse Lung Disease; Female; Follow-Up Studies; Humans; Lung - diagnostic imaging; Male; Middle Aged; Phenotype; Prognosis; Radiography, Thoracic; Respiratory Function Tests - methods; Retrospective Studies; Survival Rate - trends; Tomography, X-Ray Computed; United States - epidemiology; United States; interstitial lung disease; prognostic model; pulmonary fibrosis
• DOI: 10.1016/j.chest.2018.08.1076
• ISSN: 1931-3543; 0012-3692

Hypersensitivity pneumonitis (HP) is an interstitial lung disease with a better prognosis, on average, than idiopathic pulmonary fibrosis (IPF). We compare survival time and pulmonary function trajectory in patients with HP and IPF by radiologic phenotype. HP (n = 117) was diagnosed if surgical/transbronchial lung biopsy, BAL, and exposure history results suggested this diagnosis. IPF (n = 152) was clinically and histopathologically diagnosed. All participants had a baseline high-resolution CT (HRCT) scan and FVC % predicted. Three thoracic radiologists documented radiologic features. Survival time is from HRCT scan to death or lung transplant. Cox proportional hazards models identify variables associated with survival time. Linear mixed models compare post-HRCT scan FVC % predicted trajectories. Subjects were grouped by clinical diagnosis and three mutually exclusive radiologic phenotypes: honeycomb present, non-honeycomb fibrosis (traction bronchiectasis and reticulation) present, and nonfibrotic. Nonfibrotic HP had the longest event-free median survival (> 14.73 years) and improving FVC % predicted (1.92%; 95% CI, 0.49-3.35; P = .009). HP with non-honeycomb fibrosis had longer survival than IPF (> 7.95 vs 5.20 years), and both groups experienced a significant decline in FVC % predicted. Subjects with HP and IPF with honeycombing had poor survival (2.76 and 2.81 years, respectively) and significant decline in FVC % predicted. Three prognostically distinct, radiologically defined phenotypes are identified among patients with HP. The importance of pursuing a specific diagnosis (eg, HP vs IPF) among patients with non-honeycomb fibrosis is highlighted. When radiologic honeycombing is present, invasive diagnostic testing directed at determining the diagnosis may be of limited value given a uniformly poor prognosis.