Hypersensitivity Pneumonia Due to Resin Inhalation in a Violin Player

Hypersensitivity Pneumonia Due to Resin Inhalation in a Violin Player | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Hypersensitivity Pneumonia Due to Resin Inhalation in a Violin Player Tugba Onyilmaz, Elif Karasal Guliyev, Serap Argun Baris, Sevtap Dogan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6237984/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Respirable organic chemicals are known to cause respiratory conditions such as bronchial asthma and interstitial lung diseases. As well as occupational exposure, there is also the risk of inhalation during various hobbies. In the literature, there are cases of occupational asthma due to exposure to resin inhalation. Here, we present the first case of HP due to resin inhalation by a violinist, which is the first reported case in the literature. A 31-year-old female patient presented with complaints of exertional shortness of breath persisting for a year and a cough that had developed in the last three months. Approximately three months ago, the patient was admitted to a private hospital for a week due to suspected pneumonia, based on infiltrates observed on chest radiography. She was an active smoker. Her medical history revealed that she had no pets at home and no occupational exposure; however, she mentioned playing the violin as a hobby. Further questioning revealed that her shortness of breath worsened, particularly after resin was applied to the violin bow. Examination of the respiratory system revealed distinct bilateral inspiratory crackles, which were more pronounced on the left side. Thoracic computed tomography revealed widespread centrilobular ground-glass nodules, widespread thickening of the bronchial walls, and ground-glass opacities in all lobes, especially in the lower lobes. Fiberoptic bronchoscopy was performed. The lymphocyte rate in the bronchoalveolar lavage (BAL) was 9% and the CD4/CD8 ratio was 1.11. The council decided to proceed with wedge resection lung biopsy. Histopathological analysis of the lung specimen revealed extensive interstitial pigmented macrophages and foreign body giant cells. Interstitial fibrosis was observed in the parenchyma, which was reported to be pneumoconiosis or hypersensitivity pneumonia compatible with resin exposure. Methylprednisolone treatment was initiated for the patient who was diagnosed with fibrotic HP and the exposure was terminated. This case highlights the importance of considering occupational and hobby-related exposures in the diagnosis of interstitial lung diseases. We believe that using validated questionnaires in polyclinics for professionals and hobbies that are at risk for HP will contribute to the determination of exposure. Hypersensitivity pneumonia resin inhalation interstitial lung disease Figures Figure 1 Figure 2 Introduction Respirable organic chemicals are known to cause respiratory conditions such as bronchial asthma and interstitial lung diseases ( 1 ). As well as occupational exposure, there is also the risk of inhalation during various hobbies. Rosin, a resin derived from pine trees, is commonly used by musicians to create friction on the bow hairs, helping them to grip the violin strings. In the literature, there are cases of occupational asthma due to exposure to resin inhalation ( 2 ). Here, we present the first case of HP due to resin inhalation by a violinist, which is the first reported case in the literature. Case Report A 31-year-old female patient presented with complaints of exertional shortness of breath persisting for a year and a cough that had developed in the last three months. The patient's medical history revealed that she had been previously evaluated for exertional breathlessness at another medical center about nine months earlier. At that time, she was prescribed a short course of antibiotics and a salbutamol inhaler. More recently, approximately three months ago, the patient was admitted to a private hospital for a week due to suspected pneumonia, based on infiltrates observed on chest radiography. However, the patient's symptoms persisted despite these interventions, prompting her to seek further evaluation at our medical center. There were no other respiratory (phlegm, chest pain, or hemoptysis) or constitutional (fatigue, loss of appetite, weight loss, or fever) symptoms. She was an active smoker and had been smoking 5–6 cigarettes per day for 4 years. The patient's personal and family medical history were unremarkable. Her medical history revealed that she had no pets at home and no occupational exposure; however, she mentioned playing the violin as a hobby. Further questioning revealed that her shortness of breath worsened, particularly after resin was applied to the violin bow. Upon physical examination, the patient's vital signs were stable. No signs of cyanosis or clubbing are observed. Examination of the respiratory system revealed distinct bilateral inspiratory crackles, which were more pronounced on the left side. The posteroanterior chest radiograph demonstrated an interstitial pattern in the middle and lower zones, with an increased density in the left lower zone (Fig. 1 ). Thoracic computed tomography revealed widespread centrilobular ground-glass nodules, widespread thickening of the bronchial walls, and ground-glass opacities in all lobes, especially in the lower lobes. First, thick-walled, millimetric cystic areas were thought to be dilated bronchioles. Focal consolidation was observed in the lower lobe of the left lung. No significant fibrosis was detected (Fig. 2 ). The described appearance was radiologically nonspecific and similar to the CT scan obtained three months previously. Radiological differential diagnoses included granulomatous inhalation disease, occupational disease, hypersensitivity pneumonia, granulomatous lymphocytic interstitial disease, and IGG4-related lung involvement. Laboratory tests revealed negative results for infection markers, autoantibodies, IG and IG G subpanel levels, and HIV test results. Fiberoptic bronchoscopy was performed because of a history of resin inhalation and radiological findings compatible with HP. Microbiological examination of the bronchial lavage revealed normal results. The lymphocyte rate in the bronchoalveolar lavage (BAL) was 9% and the CD4/CD8 ratio was 1.11. The case was presented to the multidisciplinary interstitial lung disease council because despite widespread radiological involvement in all lobes, the lower lobes were more affected, and the BAL lymphocyte ratio did not support HP. Following the council's recommendation, inspiratory and expiratory CT thorax scans were ordered. In addition to previous findings, expiratory imaging revealed predominantly focal air-trapping areas in the lower lobes. After reviewing the new CT results, the council decided to proceed with wedge resection lung biopsy. Histopathological analysis of the lung specimen (right lower lobe and upper lobe) revealed extensive interstitial pigmented macrophages and foreign body giant cells. Interstitial fibrosis was observed in the parenchyma, which was reported to be pneumoconiosis or hypersensitivity pneumonia compatible with resin exposure. The patient was informed of the relationship between her diagnosis and exposure, and the exposure was terminated. Methylprednisolone treatment was initiated for the patient who was diagnosed with fibrotic HP. Discussion In this case, a 31-year-old female violin player developed hypersensitivity pneumonitis after prolonged exposure to resin used for rosin application on the bow of her violin. Although cases of asthma due to resin inhalation have been reported in the literature, our case is the first case of HP due to resin inhalation. Hypersensitivity pneumonitis was previously thought to be less common, especially because antigen exposure was not adequately defined, and there was limited information about occupational groups in terms of exposure. However, over time, the awareness of antigen sources that can cause hypersensitivity pneumonia has increased. With the understanding of antigen sources, risky professions have also increased, and in addition to occupational exposure, agents to which our patient may be exposed as a hobby have also been listed. HP has two distinct phenotypes: fibrotic and non-fibrotic. The most important point in the diagnostic criteria for HP is the determination of exposure to anamnesis or a specific serum IgG. The ATS/JRS/ALAT guidelines recommend the development of a questionnaire to determine patient exposure. Radiologically, criteria are made separately for fibrotic and non-fibrotic HP patients, and classification is made as typical HP, compatible with HP or indeterminate HP. Generally, the identification of exposure and compatible radiological findings are sufficient for diagnosis. However, in rare cases, bronchoalveolar lavage and biopsy may be required to demonstrate lymphocyte dominance ( 3 ). For HP, a lymphocyte ratio > 20% in bronchoalveolar lavage is a supportive finding for diagnosis. In our case, the lymphocyte rate was 9%, and the patient was not supportive level in terms of HP. The absence of lymphocytosis in patients with HP has been associated with poor prognosis. In our case, it was radiologically compatible with HP and was classified as low-probability HP because the lymphocyte rate was not high in BAL findings. Biopsy was performed to confirm the diagnosis. The patient, who we thought radiologically had non-fibrotic HP, was evaluated as having fibrotic HP based on the pathology results. Patients' demographic data, smoking status, extent of antigen exposure and comorbidities, and physiological, radiological, and laboratory markers are important for prognosis ( 4 ). In a recent DELPHI survey, there was a consensus that a lymphocytosis rate of > 40% in BAL is an important diagnostic criterion ( 5 ). In another recent prospective cohort study, no correlation was found between BAL lymphocytosis and disease progression ( 6 ). In our case, patient’s smoking history and the absence of lymphocytosis in the BAL were the poor prognostic criteria. Hypersensitivity pneumonitis is a rare but potentially serious condition that can occur due to exposure to various allergens, including resins. Early recognition and removal of the triggering agent, along with appropriate treatment, can help prevent long-term lung damage. Musicians, particularly violin players, should be made aware of the potential risks of resin exposure and advised on appropriate preventive measures. Conclusion This case highlights the importance of considering occupational and hobby-related exposures in the diagnosis of interstitial lung diseases. We believe that using validated questionnaires in polyclinics for professionals and hobbies that are at risk for HP will contribute to the determination of exposure. Declarations Ethics Declarations Ethics approval and consent to participate Ethics approval was not required for this case report. Written informed consent for publication of this case and accompanying images was obtained from the patient. This study is not a clinical trial; therefore, trial registration is not applicable. Consent to publish Informed consent for publication was obtained from the patient. The patient gave written informed consent for her clinical details along with images to be published in this study by signing the consent form. Competing interests The authors declare no competing interests. Data availability This study is a case report and all analyzed data are presented within the manuscript. Images related to the case have been provided with the submission, and no additional datasets are available. References Morimoto Y, Nishida C, Tomonaga T, Izumi H, Yatera K, Sakurai K, Kim Y. Lung disorders induced by respirable organic chemicals. J Occup Health. 2021 Jan;63(1):e12240. doi: 10.1002/1348-9585.12240. Erratum in: J Occup Health. 2023 Jan;65(1):e12384. doi: 10.1002/1348-9585.12384. Hanon S, Rongé R, Potvin M, Schuermans D, Vincken W. Occupational asthma due to colophony in a violin player. J Allergy Clin Immunol Pract. 2014 Sep-Oct;2(5):624-5. doi: 10.1016/j.jaip.2014.06.018. Raghu G, Remy-Jardin M, Ryerson CJ, et al. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:36–69. Creamer A, Barratt S, et al. Prognostic factors in chronic hypersensitivity pneumonitis. European Respiratory Review 2020; 29(156): 190167; doi:https://doi.org/10.1183/16000617.0167-2019 Sterclova M, Smetakova M, Stehlik L, et al. Bronchoalveolar lavage cell profiles and proteins concentrations can be used to phenotype extrinsic allergic alveolitis patients. Multidiscip Respir Med 2019; 14: 13. doi:10.1186/s40248-019-0175-6 Morisset J, Johannson KA, Jones KD, et al. Identification of diagnostic criteria for chronic hypersensitivity pneumonitis: an International Modified Delphi Survey. Am J Respir Crit Care Med 2018; 197: 1036–1044. doi:10.1164/rccm.201710-1986OC Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6237984","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":440752020,"identity":"cc26e697-d270-4e87-8aee-ad716a38380d","order_by":0,"name":"Tugba Onyilmaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYDCCA0DM2ABiMTaC2HJgwQd4tTDDtTSAtBiDBROI0wKxMRHMxqeF7/b5Y5Jfd9jJmUskNxy6UVOXPj/s8EOgLXZyug3YtUieS2aTlj2TbGw5I7HhcM4xttyNt9MMgFqSjc0OYNdicIaZTVqyjTlxww2QFjae3I2zE0BaDiRuw6+lHqrln0S64ez0DwS1SH5sOwzRkttmkCAvnYPfFskzzMbWjGeOGxuceQjU0pdguEE6p+BAggFuv/CdYXx48+eOajmD4+kPH+d8q5OXn52++cOHCjs5XFpAgJkHRAokQJ0KVmmAWzkIMP4AkfxQQ+Ub8KseBaNgFIyCkQcAsVVq4E7OagcAAAAASUVORK5CYII=","orcid":"","institution":"Kocaeli University","correspondingAuthor":true,"prefix":"","firstName":"Tugba","middleName":"","lastName":"Onyilmaz","suffix":""},{"id":440752021,"identity":"78803d30-0f2a-4488-88e0-c0767c325c15","order_by":1,"name":"Elif Karasal Guliyev","email":"","orcid":"","institution":"Private Atakent Cihan Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Elif","middleName":"Karasal","lastName":"Guliyev","suffix":""},{"id":440752022,"identity":"b6657c47-4378-44cd-b81c-1d1b0c11fdaf","order_by":2,"name":"Serap Argun Baris","email":"","orcid":"","institution":"Kocaeli University","correspondingAuthor":false,"prefix":"","firstName":"Serap","middleName":"Argun","lastName":"Baris","suffix":""},{"id":440752023,"identity":"bb57d72e-3c91-4da5-9279-b85e4198d1c0","order_by":3,"name":"Sevtap Dogan","email":"","orcid":"","institution":"Kocaeli University","correspondingAuthor":false,"prefix":"","firstName":"Sevtap","middleName":"","lastName":"Dogan","suffix":""},{"id":440752025,"identity":"583880d0-fcb7-4242-a06b-bed07f0e74e4","order_by":4,"name":"Ilknur Basyigit","email":"","orcid":"","institution":"Kocaeli University","correspondingAuthor":false,"prefix":"","firstName":"Ilknur","middleName":"","lastName":"Basyigit","suffix":""}],"badges":[],"createdAt":"2025-03-16 14:08:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6237984/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6237984/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80583888,"identity":"a467f5e6-ab55-4f03-9622-6fde6091b539","added_by":"auto","created_at":"2025-04-15 00:14:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105742,"visible":true,"origin":"","legend":"\u003cp\u003eThe initial PA chest radiography at the time of admission\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6237984/v1/d86d5c37f021d7052d02a611.png"},{"id":80583349,"identity":"b34fd4e2-8e6a-489b-8a1f-1327d7173cfd","added_by":"auto","created_at":"2025-04-15 00:06:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":322186,"visible":true,"origin":"","legend":"\u003cp\u003eThe initial thoracic CT at the time of admission\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6237984/v1/89db51400e103aef79b23ebc.png"},{"id":80584239,"identity":"e512bc4d-5583-46d3-b537-2c5fa25465ec","added_by":"auto","created_at":"2025-04-15 00:22:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":820663,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6237984/v1/63a2bd90-6dcd-456f-9dd5-5525fd17597c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHypersensitivity Pneumonia Due to Resin Inhalation in a Violin Player\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRespirable organic chemicals are known to cause respiratory conditions such as bronchial asthma and interstitial lung diseases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). As well as occupational exposure, there is also the risk of inhalation during various hobbies. Rosin, a resin derived from pine trees, is commonly used by musicians to create friction on the bow hairs, helping them to grip the violin strings. In the literature, there are cases of occupational asthma due to exposure to resin inhalation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHere, we present the first case of HP due to resin inhalation by a violinist, which is the first reported case in the literature.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 31-year-old female patient presented with complaints of exertional shortness of breath persisting for a year and a cough that had developed in the last three months. The patient's medical history revealed that she had been previously evaluated for exertional breathlessness at another medical center about nine months earlier. At that time, she was prescribed a short course of antibiotics and a salbutamol inhaler. More recently, approximately three months ago, the patient was admitted to a private hospital for a week due to suspected pneumonia, based on infiltrates observed on chest radiography. However, the patient's symptoms persisted despite these interventions, prompting her to seek further evaluation at our medical center.\u003c/p\u003e \u003cp\u003eThere were no other respiratory (phlegm, chest pain, or hemoptysis) or constitutional (fatigue, loss of appetite, weight loss, or fever) symptoms. She was an active smoker and had been smoking 5\u0026ndash;6 cigarettes per day for 4 years. The patient's personal and family medical history were unremarkable. Her medical history revealed that she had no pets at home and no occupational exposure; however, she mentioned playing the violin as a hobby. Further questioning revealed that her shortness of breath worsened, particularly after resin was applied to the violin bow.\u003c/p\u003e \u003cp\u003eUpon physical examination, the patient's vital signs were stable. No signs of cyanosis or clubbing are observed. Examination of the respiratory system revealed distinct bilateral inspiratory crackles, which were more pronounced on the left side. The posteroanterior chest radiograph demonstrated an interstitial pattern in the middle and lower zones, with an increased density in the left lower zone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thoracic computed tomography revealed widespread centrilobular ground-glass nodules, widespread thickening of the bronchial walls, and ground-glass opacities in all lobes, especially in the lower lobes. First, thick-walled, millimetric cystic areas were thought to be dilated bronchioles. Focal consolidation was observed in the lower lobe of the left lung. No significant fibrosis was detected (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The described appearance was radiologically nonspecific and similar to the CT scan obtained three months previously. Radiological differential diagnoses included granulomatous inhalation disease, occupational disease, hypersensitivity pneumonia, granulomatous lymphocytic interstitial disease, and IGG4-related lung involvement. Laboratory tests revealed negative results for infection markers, autoantibodies, IG and IG G subpanel levels, and HIV test results.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFiberoptic bronchoscopy was performed because of a history of resin inhalation and radiological findings compatible with HP. Microbiological examination of the bronchial lavage revealed normal results. The lymphocyte rate in the bronchoalveolar lavage (BAL) was 9% and the CD4/CD8 ratio was 1.11. The case was presented to the multidisciplinary interstitial lung disease council because despite widespread radiological involvement in all lobes, the lower lobes were more affected, and the BAL lymphocyte ratio did not support HP. Following the council's recommendation, inspiratory and expiratory CT thorax scans were ordered. In addition to previous findings, expiratory imaging revealed predominantly focal air-trapping areas in the lower lobes. After reviewing the new CT results, the council decided to proceed with wedge resection lung biopsy. Histopathological analysis of the lung specimen (right lower lobe and upper lobe) revealed extensive interstitial pigmented macrophages and foreign body giant cells. Interstitial fibrosis was observed in the parenchyma, which was reported to be pneumoconiosis or hypersensitivity pneumonia compatible with resin exposure.\u003c/p\u003e \u003cp\u003eThe patient was informed of the relationship between her diagnosis and exposure, and the exposure was terminated. Methylprednisolone treatment was initiated for the patient who was diagnosed with fibrotic HP.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this case, a 31-year-old female violin player developed hypersensitivity pneumonitis after prolonged exposure to resin used for rosin application on the bow of her violin. Although cases of asthma due to resin inhalation have been reported in the literature, our case is the first case of HP due to resin inhalation.\u003c/p\u003e \u003cp\u003eHypersensitivity pneumonitis was previously thought to be less common, especially because antigen exposure was not adequately defined, and there was limited information about occupational groups in terms of exposure. However, over time, the awareness of antigen sources that can cause hypersensitivity pneumonia has increased. With the understanding of antigen sources, risky professions have also increased, and in addition to occupational exposure, agents to which our patient may be exposed as a hobby have also been listed.\u003c/p\u003e \u003cp\u003eHP has two distinct phenotypes: fibrotic and non-fibrotic. The most important point in the diagnostic criteria for HP is the determination of exposure to anamnesis or a specific serum IgG. The ATS/JRS/ALAT guidelines recommend the development of a questionnaire to determine patient exposure. Radiologically, criteria are made separately for fibrotic and non-fibrotic HP patients, and classification is made as typical HP, compatible with HP or indeterminate HP. Generally, the identification of exposure and compatible radiological findings are sufficient for diagnosis. However, in rare cases, bronchoalveolar lavage and biopsy may be required to demonstrate lymphocyte dominance (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor HP, a lymphocyte ratio\u0026thinsp;\u0026gt;\u0026thinsp;20% in bronchoalveolar lavage is a supportive finding for diagnosis. In our case, the lymphocyte rate was 9%, and the patient was not supportive level in terms of HP. The absence of lymphocytosis in patients with HP has been associated with poor prognosis.\u003c/p\u003e \u003cp\u003eIn our case, it was radiologically compatible with HP and was classified as low-probability HP because the lymphocyte rate was not high in BAL findings. Biopsy was performed to confirm the diagnosis. The patient, who we thought radiologically had non-fibrotic HP, was evaluated as having fibrotic HP based on the pathology results.\u003c/p\u003e \u003cp\u003ePatients' demographic data, smoking status, extent of antigen exposure and comorbidities, and physiological, radiological, and laboratory markers are important for prognosis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In a recent DELPHI survey, there was a consensus that a lymphocytosis rate of \u0026gt;\u0026thinsp;40% in BAL is an important diagnostic criterion (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In another recent prospective cohort study, no correlation was found between BAL lymphocytosis and disease progression (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In our case, patient\u0026rsquo;s smoking history and the absence of lymphocytosis in the BAL were the poor prognostic criteria.\u003c/p\u003e \u003cp\u003eHypersensitivity pneumonitis is a rare but potentially serious condition that can occur due to exposure to various allergens, including resins. Early recognition and removal of the triggering agent, along with appropriate treatment, can help prevent long-term lung damage. Musicians, particularly violin players, should be made aware of the potential risks of resin exposure and advised on appropriate preventive measures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the importance of considering occupational and hobby-related exposures in the diagnosis of interstitial lung diseases. We believe that using validated questionnaires in polyclinics for professionals and hobbies that are at risk for HP will contribute to the determination of exposure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was not required for this case report. Written informed consent for publication of this case and accompanying images was obtained from the patient. This study is not a clinical trial; therefore, trial registration is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained from the patient. The patient gave written informed consent for her clinical details along with images to be published in this study by signing the consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a case report and all analyzed data are presented within the manuscript. Images related to the case have been provided with the submission, and no additional datasets are available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMorimoto Y, Nishida C, Tomonaga T, Izumi H, Yatera K, Sakurai K, Kim Y. Lung disorders induced by respirable organic chemicals. J Occup Health. 2021 Jan;63(1):e12240. doi: 10.1002/1348-9585.12240. Erratum in: J Occup Health. 2023 Jan;65(1):e12384. doi: 10.1002/1348-9585.12384.\u003c/li\u003e\n\u003cli\u003eHanon S, Rong\u0026eacute; R, Potvin M, Schuermans D, Vincken W. Occupational asthma due to colophony in a violin player. J Allergy Clin Immunol Pract. 2014 Sep-Oct;2(5):624-5. doi: 10.1016/j.jaip.2014.06.018. \u003c/li\u003e\n\u003cli\u003eRaghu G, Remy-Jardin M, Ryerson CJ, et al. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:36\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eCreamer A, Barratt S, et al. Prognostic factors in chronic hypersensitivity pneumonitis. European Respiratory Review 2020; 29(156): 190167; doi:https://doi.org/10.1183/16000617.0167-2019\u003c/li\u003e\n\u003cli\u003eSterclova M, Smetakova M, Stehlik L, et al. Bronchoalveolar lavage cell profiles and proteins concentrations can be used to phenotype extrinsic allergic alveolitis patients. Multidiscip Respir Med 2019; 14: 13. doi:10.1186/s40248-019-0175-6\u003c/li\u003e\n\u003cli\u003eMorisset J, Johannson KA, Jones KD, et al. Identification of diagnostic criteria for chronic hypersensitivity pneumonitis: an International Modified Delphi Survey. Am J Respir Crit Care Med 2018; 197: 1036\u0026ndash;1044. doi:10.1164/rccm.201710-1986OC\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hypersensitivity pneumonia, resin inhalation, interstitial lung disease","lastPublishedDoi":"10.21203/rs.3.rs-6237984/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6237984/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRespirable organic chemicals are known to cause respiratory conditions such as bronchial asthma and interstitial lung diseases. As well as occupational exposure, there is also the risk of inhalation during various hobbies. In the literature, there are cases of occupational asthma due to exposure to resin inhalation. Here, we present the first case of HP due to resin inhalation by a violinist, which is the first reported case in the literature.\u003c/p\u003e \u003cp\u003eA 31-year-old female patient presented with complaints of exertional shortness of breath persisting for a year and a cough that had developed in the last three months. Approximately three months ago, the patient was admitted to a private hospital for a week due to suspected pneumonia, based on infiltrates observed on chest radiography. She was an active smoker. Her medical history revealed that she had no pets at home and no occupational exposure; however, she mentioned playing the violin as a hobby. Further questioning revealed that her shortness of breath worsened, particularly after resin was applied to the violin bow. Examination of the respiratory system revealed distinct bilateral inspiratory crackles, which were more pronounced on the left side. Thoracic computed tomography revealed widespread centrilobular ground-glass nodules, widespread thickening of the bronchial walls, and ground-glass opacities in all lobes, especially in the lower lobes.\u003c/p\u003e \u003cp\u003eFiberoptic bronchoscopy was performed. The lymphocyte rate in the bronchoalveolar lavage (BAL) was 9% and the CD4/CD8 ratio was 1.11. The council decided to proceed with wedge resection lung biopsy. Histopathological analysis of the lung specimen revealed extensive interstitial pigmented macrophages and foreign body giant cells. Interstitial fibrosis was observed in the parenchyma, which was reported to be pneumoconiosis or hypersensitivity pneumonia compatible with resin exposure.\u003c/p\u003e \u003cp\u003eMethylprednisolone treatment was initiated for the patient who was diagnosed with fibrotic HP and the exposure was terminated.\u003c/p\u003e \u003cp\u003eThis case highlights the importance of considering occupational and hobby-related exposures in the diagnosis of interstitial lung diseases. We believe that using validated questionnaires in polyclinics for professionals and hobbies that are at risk for HP will contribute to the determination of exposure.\u003c/p\u003e","manuscriptTitle":"Hypersensitivity Pneumonia Due to Resin Inhalation in a Violin Player","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-15 00:06:16","doi":"10.21203/rs.3.rs-6237984/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"feb09268-acc1-418a-b326-02e5e9b58bf8","owner":[],"postedDate":"April 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-15T00:06:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-15 00:06:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6237984","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6237984","identity":"rs-6237984","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}