Non occupational chronic hypersensitivity pneumonitis due to Aspergillus fumigatus on leaky walls.

Aspergillus is a common fungus that causes variety of human diseases, depending on the host response. Hypersensitivity pneumonitis (HP) caused by Aspergillus is usually seen in an occupational setting, and case of farmer’s lung caused by Aspergillus fumigatus have also been reported.1-3 It is known that environmental A. fumigatus exposure rarely causes homerelated chronic HP. There are few case reports of nonoccupational chronic HP caused by A. fumigatus, the diagnosis of which was confirmed by a provocation test. A 74-year-old Japanese smoker presented with dry cough dating back 15 years. He lived in a 25-year-old reinforced concrete house. For 20 years, the house leaked when it rained, and the wallpapers of the hallway and bedroom became moldy. He first visited our hospital in November 2009, and high-resolution computed tomography (HRCT) demonstrated bilateral fibrotic shadows in the upper lobes but with poorly defined ground-glass opacity (GGO). Laboratory examinations at that time showed a surfactant protein D (SP-D) level of 167 ng ml and a KL6 level of 783 U ml. He has been seen in patients with idiopathic pulmonary fibrosis (IPF). He removed the moldy wallpaper in the rainy season, and during the next two months his shortness of breath and dry cough worsened. Laboratory examinations in October 2010 showed an SP-D level of 347 ng ml and a KL-6 level of 2390 U ml. Chest x-ray shows diffuse consolidation with small nodules in the bilateral lungs. HRCT showed GGO and fibrosis in the mid-to-lower lobes (Fig. 1). Spirometry revealed a forced vital capacity (FVC) 79.1% of predicted, a forced expiratory volume in 1 second (FEV1) 92.9% of predicted, a FEV1 FVC of 79.3%, and a diffusion capacity (DLCO) 70.9% of predicted. The bronchoalveolar lavage fluid (BALF) revealed lymphocytosis (62%) with a CD4+ CD8+ ratio of 6.01. A transbronchial lung biopsy showed lymphocytic alveolitis. Serum-precipitating antibodies to Aspergillus fumigatus and Aspergillus flavus were positive among 12 fungal species. The precipitate line of A. flavus overlapped with that of A. fumigatus, which indicated the cross reactivity of A. flavus with A. fumigatus. Latephase skin test reaction for A. fumigatus was positive. An allergen-specific lymphocyte stimulation test for the A. fumigatus antigen was performed using peripheral blood mononuclear cells. The stimulation index was 11.5. The IFN-γ, IL-5, and IL-13 concentrations in the culture supernatants were 725.7, 643.5, and 12108.6 pg ml, respectively, and in the absence of the antigen, their concentrations were 15.0, 1.3, and 5.8 pg ml, respectively. Samples from the wallpaper and bedroom-floor dust revealed contamination by A. fumigatus. Cultures of the indoor air obtained by volumetric air sampler in the house grew mainly A versicolor and Penicillium. Cladosporium was most frequently isolated from air samples collected from his house. Environmental sampling was performed using a volumetric air sampler and airborne particles were collected onto dichloran glycerol (DG-18) media.4 The diagnosis was definitively confirmed by performing a specific bronchial provocation test for A. fumigatus. He inhaled 1 ml of an A. fumigatus antigen solutions (10 mg ml) through a nebulizer for 2 minutes. Six hours after the challenge, the patient developed fever, hypoxemia (oxygen arterial pressure deAllergology International. 2012;61:501-502