Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
권호 표지
DOI QR코드

DOI QR Code

Current Diagnosis and Management of Hypersensitivity Pneumonitis

  • Received : 2020.02.14
  • Accepted : 2020.02.19
  • Published : 2020.04.30
Download PDF
⟨ Previous Next ⟩

Abstract

Hypersensitivity Pneumonitis (HP) one of the most common interstitial lung diseases (ILDs) is characterized by exposure to an inhaled inciting antigen that leads to a host immunologic reaction determining interstitial inflammation and architectural distortion. The underlying pathogenetic mechanisms are unclear. The absence of international shared diagnostic guidelines and the lack of a "gold-standard" test for HP combined with the presence of several clinical and radiologic overlapping features makes it particularly challenging to differentiate HP from other ILDs, also in expert contests. Radiology is playing a more crucial role in this process; recently the headcheese sign was recognized as a more specific for chronic-HP than the extensive mosaic attenuation. Several classification proposals and diagnostic models have been advanced by different groups, with no prospective validation. Therapeutic options for HP have been limited to antigen avoidance and immunosuppressant drugs over the last decades. Several questions about this condition remain unanswered and there is a need for more studies.

Keywords

References

  1. King TE Jr. Clinical advances in the diagnosis and therapy of the interstitial lung diseases. Am J Respir Crit Care Med 2005;172:268-79. https://doi.org/10.1164/rccm.200503-483OE
  2. Hyldgaard C, Hilberg O, Muller A, Bendstrup E. A cohort study of interstitial lung diseases in central Denmark. Respir Med 2014;108:793-9. https://doi.org/10.1016/j.rmed.2013.09.002
  3. Mohr LC. Hypersensitivity pneumonitis. Curr Opin Pulm Med 2004;10:401-11. https://doi.org/10.1097/01.mcp.0000135675.95674.29
  4. Johansson E, Boivin GP, Yadav JS. Early immunopathological events in acute model of mycobacterial hypersensitivity pneumonitis in mice. J Immunotoxicol 2017;14:77-88. https://doi.org/10.1080/1547691X.2016.1273284
  5. Okamoto T, Miyazaki Y, Ogura T, Chida K, Kohno N, Kohno S, et al. Nationwide epidemiological survey of chronic hypersensitivity pneumonitis in Japan. Respir Investig 2013;51:191-9. https://doi.org/10.1016/j.resinv.2013.03.004
  6. Fernandez Perez ER, Kong AM, Raimundo K, Koelsch TL, Kulkarni R, Cole AL. Epidemiology of hypersensitivity pneumonitis among an insured population in the United States: a claims-based cohort analysis. Ann Am Thorac Soc 2018;15:460-9. https://doi.org/10.1513/AnnalsATS.201704-288OC
  7. Ley B, Collard HR, King TE Jr. Clinical course and prediction of survival in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2011;183:431-40. https://doi.org/10.1164/rccm.201006-0894CI
  8. Martinez FJ, Collard HR, Pardo A, Raghu G, Richeldi L, Selman M, et al. Idiopathic pulmonary fibrosis. Nat Rev Dis Primers 2017;3:17074. https://doi.org/10.1038/nrdp.2017.74
  9. Noone A, Howlader N, Krapcho M, Miller D, Brest A, Yu M, et al. SEER cancer statistics review (CST) 1975-2015 [Internet]. Bethesda, MD: National Cancer Institute; 2018 [cited 2019 Dec 10]. Available from: https://seer.cancer.gov/csr/1975_2015/.
  10. Morell F, Villar A, Montero MA, Munoz X, Colby TV, Pipvath S, et al. Chronic hypersensitivity pneumonitis in patients diagnosed with idiopathic pulmonary fibrosis: a prospective casecohort study. Lancet Respir Med 2013;1:685-94. https://doi.org/10.1016/S2213-2600(13)70191-7
  11. Thomeer MJ, Costabe U, Rizzato G, Poletti V, Demedts M. Comparison of registries of interstitial lung diseases in three European countries. Eur Respir J Suppl 2001;32:114s-8s.
  12. Solaymani-Dodaran M, West J, Smith C, Hubbard R. Extrinsic allergic alveolitis: incidence and mortality in the general population. QJM 2007;100:233-7. https://doi.org/10.1093/qjmed/hcm008
  13. Barber CM, Wiggans RE, Carder M, Agius R. Epidemiology of occupational hypersensitivity pneumonitis; reports from the SWORD scheme in the UK from 1996 to 2015. Occup Environ Med 2017;74:528-30. https://doi.org/10.1136/oemed-2016-103838
  14. Buchvald F, Petersen BL, Damgaard K, Deterding R, Langston C, Fan LL, et al. Frequency, treatment, and functional outcome in children with hypersensitivity pneumonitis. Pediatr Pulmonol 2011;46:1098-107. https://doi.org/10.1002/ppul.21479
  15. Sommerfeld CG, Weiner DJ, Nowalk A, Larkin A. Hypersensitivity pneumonitis and acute respiratory distress syndrome from E-cigarette use. Pediatrics 2018;141:e20163927. https://doi.org/10.1542/peds.2016-3927
  16. Selman M. Hypersensitivity pneumonitis. In: Schwarz M, King TE Jr, editors. Interstitial lung disease. 5th ed. Shelton, CT: People's Medical Publishing House-USA; 2011. p. 597-625.
  17. Ohtsuka Y, Munakata M, Tanimura K, Ukita H, Kusaka H, Masaki Y, et al. Smoking promotes insidious and chronic farmer's lung disease, and deteriorates the clinical outcome. Intern Med 1995;34:966-71. https://doi.org/10.2169/internalmedicine.34.966
  18. Camarena A, Aquino-Galvez A, Falfan-Valencia R, Sanchez G, Montano M, Ramos C, et al. PSMB8 (LMP7) but not PSMB9 (LMP2) gene polymorphisms are associated to pigeon breeder's hypersensitivity pneumonitis. Respir Med 2010;104:889-94. https://doi.org/10.1016/j.rmed.2010.01.014
  19. Aquino-Galvez A, Camarena A, Montano M, Juarez A, Zamora AC, Gonzalez-Avila G, et al. Transporter associated with antigen processing (TAP) 1 gene polymorphisms in patients with hypersensitivity pneumonitis. Exp Mol Pathol 2008;84:173-7. https://doi.org/10.1016/j.yexmp.2008.01.002
  20. Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ, et al. Needs and opportunities for research in hypersensitivity pneumonitis. Am J Respir Crit Care Med 2005;171:792-8. https://doi.org/10.1164/rccm.200409-1205WS
  21. Agostini C, Trentin L, Facco M, Semenzato G. New aspects of hypersensitivity pneumonitis. Curr Opin Pulm Med 2004;10:378-82. https://doi.org/10.1097/01.mcp.0000133067.71469.b2
  22. Lopez M, Salvaggio JE. Epidemiology of hypersensitivity pneumonitis/allergic alveolitis. Monogr Allergy 1987;21:70-86.
  23. Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Am J Respir Crit Care Med 2012;186:314-24. https://doi.org/10.1164/rccm.201203-0513CI
  24. Salisbury ML, Myers JL, Belloli EA, Kazerooni EA, Martinez FJ, Flaherty KR. Diagnosis and treatment of fibrotic hypersensitivity pneumonia: where we stand and where we need to go. Am J Respir Crit Care Med 2017;196:690-9. https://doi.org/10.1164/rccm.201608-1675PP
  25. Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity pneumonitis: perspectives in diagnosis and management. Am J Respir Crit Care Med 2017;196:680-9. https://doi.org/10.1164/rccm.201611-2201PP
  26. Cottin V, Hirani NA, Hotchkin DL, Nambiar AM, Ogura T, Otaola M, et al. Presentation, diagnosis and clinical course of the spectrum of progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018;27:180076. https://doi.org/10.1183/16000617.0076-2018
  27. Fernandez Perez ER, Swigris JJ, Forssen AV, Tourin O, Solomon JJ, Huie TJ, et al. Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. Chest 2013;144:1644-51. https://doi.org/10.1378/chest.12-2685
  28. Morisset J, Johannson KA, Jones KD, Wolters PJ, Collard HR, Walsh SL, et al. Identification of diagnostic criteria for chronic hypersensitivity pneumonitis: an international modified Delphi survey. Am J Respir Crit Care Med 2018;197:1036-44. https://doi.org/10.1164/rccm.201710-1986OC
  29. Ojanguren I, Morell F, Ramon MA, Villar A, Romero C, Cruz MJ, et al. Long-term outcomes in chronic hypersensitivity pneumonitis. Allergy 2019;74:944-52. https://doi.org/10.1111/all.13692
  30. Soumagne T, Dalphin JC. Current and emerging techniques for the diagnosis of hypersensitivity pneumonitis. Expert Rev Respir Med 2018;12:493-507. https://doi.org/10.1080/17476348.2018.1473036
  31. Cormier Y, Belanger J, Tardif A, Leblanc P, Laviolette M. Relationships between radiographic change, pulmonary function, and bronchoalveolar lavage fluid lymphocytes in farmer's lung disease. Thorax 1986;41:28-33. https://doi.org/10.1136/thx.41.1.28
  32. Kokkarinen JI, Tukiainen HO, Terho EO. Recovery of pulmonary function in farmer's lung: a five-year follow-up study. Am Rev Respir Dis 1993;147:793-6. https://doi.org/10.1164/ajrccm/147.4.793
  33. Gimenez A, Storrer K, Kuranishi L, Soares MR, Ferreira RG, Pereira CA. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. Thorax 2018;73:391-2. https://doi.org/10.1136/thoraxjnl-2017-210035
  34. Dias OM, Baldi BG, Pennati F, Aliverti A, Chate RC, Sawamura MV, et al. Computed tomography in hypersensitivity pneumonitis: main findings, differential diagnosis and pitfalls. Expert Rev Respir Med 2018;12:5-13. https://doi.org/10.1080/17476348.2018.1395282
  35. Schwaiblmair M, Beinert T, Vogelmeier C, Fruhmann G. Cardiopulmonary exercise testing following hay exposure challenge in farmer's lung. Eur Respir J 1997;10:2360-5. https://doi.org/10.1183/09031936.97.10102360
  36. Dias OM, Baldi BG, Ferreira JG, Cardenas LZ, Pennati F, Salito C, et al. Mechanisms of exercise limitation in patients with chronic hypersensitivity pneumonitis. ERJ Open Res 2018;4:00043-2018.
  37. Lacasse Y, Selman M, Costabel U, Dalphin JC, Ando M, Morell F, et al. Clinical diagnosis of hypersensitivity pneumonitis. Am J Respir Crit Care Med 2003;168:952-8. https://doi.org/10.1164/rccm.200301-137OC
  38. Chong BJ, Kanne JP, Chung JH. Headcheese sign. J Thorac Imaging 2014;29:W13. https://doi.org/10.1097/RTI.0000000000000067
  39. Kligerman SJ, Henry T, Lin CT, Franks TJ, Galvin JR. Mosaic attenuation: etiology, methods of differentiation, and pitfalls. Radiographics 2015;35:1360-80. https://doi.org/10.1148/rg.2015140308
  40. Lynch DA, Newell JD, Logan PM, King TE Jr, Muller NL. Can CT distinguish hypersensitivity pneumonitis from idiopathic pulmonary fibrosis? AJR Am J Roentgenol 1995;165:807-11. https://doi.org/10.2214/ajr.165.4.7676971
  41. Silva CI, Muller NL, Lynch DA, Curran-Everett D, Brown KK, Lee KS, et al. Chronic hypersensitivity pneumonitis: differentiation from idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia by using thin-section CT. Radiology 2008;246:288-97. https://doi.org/10.1148/radiol.2453061881
  42. Barnett J, Molyneaux PL, Rawal B, Abdullah R, Hare SS, Vancheeswaran R, et al. Variable utility of mosaic attenuation to distinguish fibrotic hypersensitivity pneumonitis from idiopathic pulmonary fibrosis. Eur Respir J 2019;54:1900531. https://doi.org/10.1183/13993003.00531-2019
  43. Soumagne T, Chardon ML, Dournes G, Laurent L, Degano B, Laurent F, et al. Emphysema in active farmer's lung disease. PLoS One 2017;12:e0178263. https://doi.org/10.1371/journal.pone.0178263
  44. Franquet T, Hansell DM, Senbanjo T, Remy-Jardin M, Muller NL. Lung cysts in subacute hypersensitivity pneumonitis. J Comput Assist Tomogr 2003;27:475-8. https://doi.org/10.1097/00004728-200307000-00003
  45. Salisbury ML, Gross BH, Chughtai A, Sayyouh M, Kazerooni EA, Bartholmai BJ, et al. Development and validation of a radiological diagnosis model for hypersensitivity pneumonitis. Eur Respir J 2018;52:1800443. https://doi.org/10.1183/13993003.00443-2018
  46. Walsh SL, Richeldi L. Demystifying fibrotic hypersensitivity pneumonitis diagnosis: it's all about shades of grey. Eur Respir J 2019;54:1900906. https://doi.org/10.1183/13993003.00906-2019
  47. Chung JH, Zhan X, Cao M, Koelsch TL, Manjarres DC, Brown KK, et al. Presence of air trapping and mosaic attenuation on chest computed tomography predicts survival in chronic hypersensitivity pneumonitis. Ann Am Thorac Soc 2017;14:1533-8. https://doi.org/10.1513/AnnalsATS.201701-035OC
  48. Salisbury ML, Gu T, Murray S, Gross BH, Chughtai A, Sayyouh M, et al. Hypersensitivity pneumonitis: radiologic phenotypes are associated with distinct survival time and pulmonary function trajectory. Chest 2019;155:699-711. https://doi.org/10.1016/j.chest.2018.08.1076
  49. Lynch DA. CT phenotypes in hpersensitivity pneumonitis. Chest 2019;155:655-6. https://doi.org/10.1016/j.chest.2018.10.048
  50. Jacob J, Bartholmai BJ, Egashira R, Brun AL, Rajagopalan S, Karwoski R, et al. Chronic hypersensitivity pneumonitis: identification of key prognostic determinants using automated CT analysis. BMC Pulm Med 2017;17:81. https://doi.org/10.1186/s12890-017-0418-2
  51. Raghu G, Remy-Jardin M, Myers JL, Richeldi L, Ryerson CJ, Lederer DJ, et al. Diagnosis of idiopathic pulmonary fibrosis: an oficial ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 2018;198:e44-68. https://doi.org/10.1164/rccm.201807-1255ST
  52. Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM, et al. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 2012;185:1004-14. https://doi.org/10.1164/rccm.201202-0320ST
  53. Ohtani Y, Saiki S, Kitaichi M, Usui Y, Inase N, Costabel U, et al. Chronic bird fancier's lung: histopathological and clinical correlation: an application of the 2002 ATS/ERS consensus classification of the idiopathic interstitial pneumonias. Thorax 2005;60:665-71. https://doi.org/10.1136/thx.2004.027326
  54. Santos V, Martins N, Sousa C, Jacob M, Padrao E, Melo N, et al. Hypersensitivity pneumonitis: main features characterization in a Portuguese cohort. Pulmonology 2019 Oct 29 [Epub]. https://doi.org/10.1016/j.pulmoe.2019.09.004.
  55. Vourlekis JS, Schwarz MI, Cherniack RM, Curran-Everett D, Cool CD, Tuder RM, et al. The effect of pulmonary fibrosis on survival in patients with hypersensitivity pneumonitis. Am J Med 2004;116:662-8. https://doi.org/10.1016/j.amjmed.2003.12.030
  56. Fireman E, Vardinon N, Burke M, Spizer S, Levin S, Endler A, et al. Predictive value of response to treatment of T-lymphocyte subpopulations in idiopathic pulmonary fibrosis. Eur Respir J 1998;11:706-11.
  57. Ohshimo S, Bonella F, Cui A, Beume M, Kohno N, Guzman J, et al. Significance of bronchoalveolar lavage for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2009;179:1043-7. https://doi.org/10.1164/rccm.200808-1313OC
  58. Patel AM, Ryu JH, Reed CE. Hypersensitivity pneumonitis: current concepts and future questions. J Allergy Clin Immunol 2001;108:661-70. https://doi.org/10.1067/mai.2001.119570
  59. Barrera L, Mendoza F, Zuniga J, Estrada A, Zamora AC, Melendro EI, et al. Functional diversity of T-cell subpopulations in subacute and chronic hypersensitivity pneumonitis. Am J Respir Crit Care Med 2008;177:44-55. https://doi.org/10.1164/rccm.200701-093OC
  60. Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol 2012;25 Suppl 1:S58-67. https://doi.org/10.1038/modpathol.2011.152
  61. Sharp C, McCabe M, Adamali H, Medford AR. Use of transbronchial cryobiopsy in the diagnosis of interstitial lung disease: a systematic review and cost analysis. QJM 2017;110:207-14.
  62. Iftikhar IH, Alghothani L, Sardi A, Berkowitz D, Musani AI. Transbronchial lung cryobiopsy and video-assisted thoracoscopic lung biopsy in the diagnosis of diffuse parenchymal lung disease: a meta-analysis of diagnostic test accuracy. Ann Am Thorac Soc 2017;14:1197-211.
  63. Grunes D, Beasley MB. Hypersensitivity pneumonitis: a review and update of histologic findings. J Clin Pathol 2013;66:888-95. https://doi.org/10.1136/jclinpath-2012-201337
  64. Miller R, Allen TC, Barrios RJ, Beasley MB, Burke L, Cagle PT, et al. Hypersensitivity pneumonitis A perspective from members of the Pulmonary Pathology Society. Arch Pathol Lab Med 2018;142:120-6. https://doi.org/10.5858/arpa.2017-0138-SA
  65. Castonguay MC, Ryu JH, Yi ES, Tazelaar HD. Granulomas and giant cells in hypersensitivity pneumonitis. Hum Pathol 2015;46:607-13. https://doi.org/10.1016/j.humpath.2014.12.017
  66. Wang P, Jones KD, Urisman A, Elicker BM, Urbania T, Johannson KA, et al. Pathologic findings and prognosis in a large prospective cohort of chronic hypersensitivity pneumonitis. Chest 2017;152:502-9. https://doi.org/10.1016/j.chest.2017.02.011
  67. Johannson KA, Elicker BM, Vittinghoff E, Assayag D, de Boer K, Golden JA, et al. A diagnostic model for chronic hypersensitivity pneumonitis. Thorax 2016;71:951-4. https://doi.org/10.1136/thoraxjnl-2016-208286
  68. Molyneaux PL, Maher TM. Time for an international consensus on hypersensitivity pneumonitis. A Call to Arms. Am J Respir Crit Care Med 2017;196:665-6. https://doi.org/10.1164/rccm.201707-1439ED
  69. Swigris J. DELPHIning diagnostic criteria for chronic hypersensitivity pneumonitis. Am J Respir Crit Care Med 2018;197:980-1. https://doi.org/10.1164/rccm.201712-2403ED
  70. Fernandez Perez ER. Diagnostic decision-making in hypersensitivity pneumonitis: toward a consensus statement. Am J Respir Crit Care Med 2018;197:1646-7. https://doi.org/10.1164/rccm.201711-2358LE
  71. Takei R, Yamano Y, Kataoka K, Yokoyama T, Matsuda T, Kimura T, et al. Usefulness of new diagnostic criteria for chronic hypersensitivity pneumonitis established on the basis of a Delphi survey: a Japanese cohort study. Respir Investig 2020;58:52-8. https://doi.org/10.1016/j.resinv.2019.10.001
  72. Walsh SL, Wells AU, Desai SR, Poletti V, Piciucchi S, Dubini A, et al. Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. Lancet Respir Med 2016;4:557-65. https://doi.org/10.1016/S2213-2600(16)30033-9
  73. Lynch DA, Sverzellati N, Travis WD, Brown KK, Colby TV, Galvin JR, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. Lancet Respir Med 2018;6:138-53. https://doi.org/10.1016/S2213-2600(17)30433-2
  74. Vasakova M, Morell F, Raghu G. Reply to Fernandez Perez: diagnostic decision-making in hypersensitivity pneumonitis: toward a consensus statement. Am J Respir Crit Care Med 2018;197:1648. https://doi.org/10.1164/rccm.201802-0314LE
  75. Cormier Y, Desmeule M. Treatment of hypersensitivity pneumonitis: contact avoidance versus corticosteroid treatment. Can Respir J 1994;1:223-8. https://doi.org/10.1155/1994/643515
  76. De Sadeleer LJ, Hermans F, De Dycker E, Yserbyt J, Verschakelen JA, Verbeken EK, et al. Effects of corticosteroid treatment and antigen avoidance in a large hypersensitivity pneumonitis cohort: a single-centre cohort study. J Clin Med 2018;8:E14. https://doi.org/10.3390/jcm8010014
  77. Kokkarinen JI, Tukiainen HO, Terho EO. Effect of corticosteroid treatment on the recovery of pulmonary function in farmer's lung. Am Rev Respir Dis 1992;145:3-5. https://doi.org/10.1164/ajrccm/145.1.3
  78. Morisset J, Johannson KA, Vittinghoff E, Aravena C, Elicker BM, Jones KD, et al. Use of mycophenolate mofetil or azathioprine for the management of chronic hypersensitivity pneumonitis. Chest 2017;151:619-25. https://doi.org/10.1016/j.chest.2016.10.029
  79. Adegunsoye A, Oldham JM, Fernandez Perez ER, Hamblin M, Patel N, Tener M, et al. Outcomes of immunosuppressive therapy in chronic hypersensitivity pneumonitis. ERJ Open Res 2017;3:00016-2017.
  80. Morell F, Ojanguren I, Villar A, Ramon MA, Munoz X, Cruz MJ. Addition of rituximab to oral corticosteroids in the treatment of chronic hypersensitivity pneumonitis. Arch Bronconeumol 2019 Sep 7 [Epub]. https://doi.org/10.1016/j.arbres.2019.07.013.
  81. Carlsen KH, Leegaard J, Lund OD, Skjaervik H. Allergic alveolitis in a 12-year-old boy: treatment with budesonide nebulizing solution. Pediatr Pulmonol 1992;12:257-9. https://doi.org/10.1002/ppul.1950120411
  82. Wuyts WA, Agostini C, Antoniou KM, Bouros D, Chambers RC, Cottin V, et al. The pathogenesis of pulmonary fibrosis: a moving target. Eur Respir J 2013;41:1207-18. https://doi.org/10.1183/09031936.00073012
  83. Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SL, Inoue Y, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med 2019;381:1718-27. https://doi.org/10.1056/NEJMoa1908681
  84. Mateos-Toledo H, Mejia-Avila M, Rodriguez-Barreto O, Mejia-Hurtado JG, Rojas-Serrano J, Estrada A, et al. An open-label study with pirfenidone on chronic hypersensitivity pneumonitis. Arch Bronconeumol 2019 Nov 26 [Epub]. https://doi.org/10.1016/j.arbres.2019.08.019.
  85. Richeldi L, Varone F, Bergna M, de Andrade J, Falk J, Hallowell R, et al. Pharmacological management of progressive-fibrosing interstitial lung diseases: a review of the current evidence. Eur Respir Rev 2018;27:180074. https://doi.org/10.1183/16000617.0074-2018

Cited by

  1. Pharmacological treatment of idiopathic pulmonary fibrosis and fibrosing interstitial lung diseases: current trends and future directions vol.5, pp.1, 2021, https://doi.org/10.23838/pfm.2020.00205
  2. Nouveautés dans la prise en charge des pneumopathies d’hypersensibilité vol.38, pp.6, 2020, https://doi.org/10.1016/j.rmr.2021.04.006
  3. Sooty bark disease of maples: the risk for hypersensitivity pneumonitis by fungal spores not only for woodman vol.16, pp.1, 2020, https://doi.org/10.1186/s12995-021-00292-5