Evaluation of clinical and radiological features of patients diagnosed with hypersensitivity pneumonia

Evaluation of clinical and radiological features of patients diagnosed with hypersensitivity pneumonia | 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 Research Article Evaluation of clinical and radiological features of patients diagnosed with hypersensitivity pneumonia ESMA SEVIL AKKURT, BERNA AKINCI OZYUREK, KEREM ENSARIOGLU, TUGCE SAHIN OZDEMIREL, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5418767/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 Background Hypersensitivity pneumonitis (HP) is an inflammatory fibrotic disease that affects the lung parenchyma and small airways. Aims Our study aimed to evaluate the clinical and radiological features of patients with an HP diagnosis in follow-up. Study Design: A retrospective cross-sectional study. Methods Our study included 100 patients diagnosed with HP who were diagnosed and managed in our clinic between 2020 and 2024. Clinical data, comorbidities, pulmonary function test-carbon monoxide diffusion capacity (PFT-DLCO) parameters, six-minute walk test results, high-resolution lung computed tomography (HRCT) patterns, prognosis, and mortality data were retrospectively documented. Results In our study, the male–female ratio was equal (50–50). The mean age was 63 (± 14). The majority of the patients were active smokers. While 65% of the patients were exposed to an organic or inorganic agent, 86.4% of all known exposures were caused by exposure to birds and bird products. A total of 29 patients (29%) were diagnosed by surgical sampling. The most common HRCT findings were reticulation (87%), ground-glass opacities (84.7%), and centrilobular nodules (75%). Fibrosis findings were seen in 40% of the patients. Glucocorticoids were the main treatment (77%), and 20 (20%) patients also required antifibrotic treatment. When correlation analyses were performed, the neutrophil count showed a negative correlation with the presence of a mosaic pattern, while a positive correlation was found with the presence of honeycombing. The basophil count had a positive correlation with exposure to birds and bird products. Conclusion There are no guidelines or consensus published in Turkiye regarding the diagnosis and treatment of HP. In our study, the positive correlation between the neutrophil count of the patients and the development of fibrosis in HRCT suggested that neutrophilia may also be a poor prognostic factor. The positive correlation between exposure to birds and bird products and basophilia was a striking finding. Basophilia Bird products Fibrotic disease Hypersensitivity pneumonitis 1. Introduction Hypersensitivity pneumonitis (HP) is an inflammatory fibrotic disease that affects the lung parenchyma and small airways. It is usually caused by an immune-mediated reaction triggered by the inhalation of a known or unknown antigen in susceptible individuals. HP is caused by many factors. Farmer’s lung and bird feeder’s lung are the most common causes of HP, and avian and animal antigens, microbial agents such as bacteria and fungi, plant proteins, low molecular weight chemicals, and metals have been identified as triggering factors ( 1 ). Since the presence of radiographic or histopathologic fibrosis is the primary determinant of prognosis, the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) guideline committee unanimously decided to classify HP as fibrotic or nonfibrotic ( 2 ). Common symptoms of HP in the fibrotic and nonfibrotic groups include dyspnoea and cough. Fever, chills, weight loss, and malaise are less common. In patients known to have been exposed to suspected HP triggers, HP should be suspected if there is clinical and radiographic imaging evidence of interstitial lung disease and alternative diagnoses can be excluded. The primary goal of evaluation is to identify the triggering agent ( 3 ). Other diagnostic steps include determining the severity of respiratory distress, evaluating characteristic radiographic imaging, and bronchoalveolar lavage features. When the diagnosis remains uncertain, a multidisciplinary evaluation with a decision to obtain tissue samples to confirm the diagnosis may be considered. Different HRCT patterns are applied depending on whether the patient has fibrotic or nonfibrotic HP. Nonfibrotic HP is typically associated with ground-glass opacification; however, HRCT may be normal because of the transient nature of the radiographic opacities. Air trapping, also known as mosaic attenuation, can be seen by comparing expiratory and inspiratory images. Patches of ground-glass opacification are present, usually few in number, and ranging in size from 3 to 25 mm. Bronchoalveolar lavage (BAL) is the most sensitive tool for detecting alveolitis in patients with suspected HP. When clinical and radiographic findings suggest subacute HP, significant BAL lymphocytosis (more than 20%) is a nonspecific but useful finding ( 4 ). Antigen avoidance and symptomatic treatment are the cornerstones of HP treatment, which usually results in disease regression. Additional treatment may be required for more severe or progressive diseases ( 5 ). The natural course of HP includes a variable clinical picture, ranging from resolution to gradual resolution or death due to respiratory failure. Nonfibrotic HP patients who avoid exposure to the triggering agent have a better prognosis. There is no published guideline or consensus regarding the diagnosis and treatment of HP in Turkiye. We aimed to contribute to the literature by evaluating the clinical features, radiological features, treatment approaches, treatment responses, and prognoses of the patients we followed in our clinic. 2. Materials and Methods Our study included 100 patients diagnosed with hypersensitivity pneumonia who were diagnosed and followed up in our diffuse parenchymal lung disease clinic between 2020 and 2024 and who met the inclusion criteria. Patients who refused medical treatment during the follow-up period and whose radiology, PFT-DLCO, and prognosis information could not be accessed from the hospital system or patient files were excluded from the study. The patients’ clinical information, additional diseases, PFT-DLCO parameters at the time of diagnosis, six-minute walking tests (6MWT), HRCT patterns, prognosis information, and mortality data were recorded retrospectively. The patients were diagnosed based on a combination of radiological images, exposure assessment, BAL lymphocytosis, and histopathological findings. The Ethics Committee (No:2024-BÇEK/96) approved the study. This research was conducted in conjunction with the Helsinki Declaration (revised in 2013). Inclusion Criteria : • Patients over the age of 18 • Patients followed up in our clinic with a diagnosis of hypersensitivity pneumonia between January 2020 and January 2024 • Patients whose demographic information, additional disease information, initial and follow-up PFT-DLCO data, HRCT findings taken at the time of diagnosis, and six-month prognosis information were accessible from the hospital system or patient files were included in the study. Exclusion Criteria : • Patients whose criteria could not be accessed from patient files or computer records • Patients who did not undergo HRCT at the time of diagnosis • Patients with less than six months of follow-up Statistical Analysis The patients’ results were put into a Microsoft Excel file for overall evaluation. After investigating any misinput and values, the data were moved to a statistics module (IBM Version 25th for Windows). The initial assessment was performed by descriptive analysis, for which values were given with mean and standard deviation or with median and percentiles, as required. Parametric distribution was evaluated by Q-Q plot analysis. Correlation analysis was performed by Pearson correlation after the confirmation of enough available data for a chi-square test if two nominal values were to be confirmed. A p-value below 0.05 was considered statistically significant. 3. Results A total of 100 patients were included in the study, with an equal male-to-female (50–50) ratio. The mean age was 63 (± 14) years old. The majority of the patients were either active smokers (n = 19, 21.3%) or ex-smokers (n = 30, 33.7%). Hypertension (n = 37, 37%) and diabetes mellitus (n = 23, 23%) were the most prevalent comorbidities observed. Among respiratory comorbidities, asthma (n = 10, 10%) and chronic obstructive pulmonary disease (n = 9, 9%) were predominantly seen, while coronary arterial disease (n = 16, 16%) was the most frequently observed cardiac comorbidity (Table 1 ). Table 1 Demographic Parameters and Comorbidities Parameters N(%) Gender Female 50 Male 50 Age (years, ±SD) 63 (± 14) Smoking Nonsmoker 51 (51) Exsmoker 30 (30) Active Smoker 19 ( 19 ) Smoking (Package/Year, ±SD) 24 ( 14 ) Chronic Obstructive Pulmonary Disease None 91 (91) Present 9 ( 9 ) Asthma None 90 (90) Present 10 ( 10 ) Coronary Arterial Disease None 84 (84) Present 16 ( 16 ) Diabetes Mellitus None 77 (77) Present 23 ( 23 ) Hypertension None 63 (63) Present 37 (37) SD : Standard Deviation, Diabetes Mellitus definition included both type 1 and type 2 diabetes, yet excluded treatment-related ones. Exposure to any known organic or inorganic agents was reported in 65% of patients, with exposure to bird and other avian products observed in 57 (87.7% of all known exposure causes) patients. The median exposure duration was 5 ( 4 – 15 ) years, with more than half of the patients who ceased exposure (n = 36, 57.1%). The BAL results had a median of 16% (10–32) lymphocyte ratio, with a median of 1.10 (0.71–1.55) CD4/CD8 ratio. The initial PFT results revealed a forced expiratory volume (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and DLCO results of 79% (± 23), 79% (± 20), 80% (± 11), and 68% (± 20) respectively. These results did not vary significantly at the third-month follow-up evaluation. However, 25 patients (33.3%) had a fall in either FVC or DLCO compared to the initial assessment. Overall, 29 patients (29%) required at least one surgical sampling for diagnostic confirmation during the HP evaluation (Table 2 ). Table 2 Exposure Evaluation, Laboratory Parameters, Bronchoalveolar Lavage and Pulmonary Function Test Results Parameters N (%) Exposure History None 35 (35) Present 65 (65) Exposure Type Bird 57 (87.7) Organic 6 (9.2) Nonorganic 2 (3.1) Exposure Duration (years, median, 25th-75th) 5 ( 4 – 15 ) Time to Last Exposure (years, median, 25th-75th) 5 ( 1 – 18 ) Cessation of Exposure Still Exposed 28 (43.1) Ceased 37 (56.9) BAL Lymphocyte Ratio (%, median, 25th-75th) 16 (10–32) Fibrotic HP 15 ( 10 – 20 ) Non-Fibrotic HP 16 (10–40) BAL CD4/CD8 Ratio (%, median, 25th-75th) 1.10 (0.71-.1.55) Fibrotic HP 1.21 (0.85–1.50) Non-Fibrotic HP 1.09 (0.68–1.60) White Blood Cell (x10^9/L) 8.9 (2.9) Lymphocytes (x10^9/L) 2.42 (0.87) Basophils (x10^9/L) 0.04 (0.02) Neutrophils (x10^9/L) 5.48 (2.53) Eosinophils (x10^9/L) 0.25 (0.21) Hemoglobin (g/L) 14.1 (1.7) Platelets (x10^9/L) 263 (77) Mean Platelet Volume (fl) 9.6 (1.2) Red Blood Cell Distribution Width (fl) 14.7 (22.2) FEV1 (%, ±SD) 79 ( 23 ) FVC (%, ±SD) 79 ( 20 ) FEV1/FVC Ratio (%, ±SD) 80 ( 11 ) DLCO (%, ±SD) 68 ( 20 ) DLCO/VA (%, ±SD) 94 ( 21 ) FVC Fall None 55 (77.5) Present 16 (22.5) DLCO Fall None 49 (75.4) Present 16 (24.6) 6MWT Distance (m) 404 (115) 6MWT Desaturation (%) No 36 (57.1) Present 27 (42.9) Surgical Sampling None 71 (71) Performed 29 (29) BAL : Bronchoalveolar lavage, FEV1 : Forced Expiratory Volume, FVC : Forced Vital Capacity, DLCO : Diffusing Capacity of the lung for Carbon Monoxide, VA : Alveolar Volume. HP : Hypersensitivity Pneumonitis 6MWT : Six-minute walking test. Survival was given with a period of three months after initial diagnosis. The cardiac evaluation showed a mean of 58% (± 4) ejection fraction and a mean of 33 (± 15) mmHg systolic pulmonary arterial pressure. Patients had walked an average distance of 404 (± 115) metres, and desaturation was reported in 27 (42.9%) patients. The initial total blood count test results were within normal parameters. Three patients (3%) were exitus during the three-month follow-up period, with an overall survival rate of 97%. Regarding radiological evaluation, HRCT results favoured the involvement of the lower lobes (n = 91, 9%), middle lobe, and lingula (n = 89, 89%), followed up with relatively spared upper lobes (n = 56, 56%). The majority of HRCT reports indicated HP (n = 73, 73%). The main reported pattern was reticulation (n = 87, 87%), followed by ground-glass opacities (GGO) (n = 83, 84.7%), and centrilobular nodules (n = 75, 75%). Fibrosis (n = 40, 40%) was identified in less than half of the patients (Table 3). Glucocorticoids were the mainstay treatment utilised (n = 77, 77%) among the patients, with additional immunosuppressive agents required in 13 (13%) patients and 20 (20%) patients requiring further antifibrotic treatment. Correlation analyses performed for parameters regarding their role in a radiological pattern showed that the cessation of exposure had a positive correlation with mosaic pattern and centrilobular opacity (correlation coefficient [CC]: 0.382, p: 0.02, and CC: 0.341, p: 0.006, respectively). Desaturation in a 6MWT positively correlated with middle lobe involvement (CC: 0.281, p: 0.026). The total distance walked in the 6MWT was also negatively correlated with traction bronchiectasis and fibrosis (CC: -0.292, p: 0.02 and CC: -0.270, p: 0.033, respectively). Honeycombing and fibrosis had a positive correlation with DLCO fall (CC: 0.262, p: 0.035 and CC: 0.277, p: 0.025, respectively), while DLCO at both diagnosis and follow-up had a negative correlation with reticular traction bronchiectasis. The neutrophil count was negatively correlated with a mosaic pattern (CC: -0.235, p: 0.019) and positively correlated with honeycombing (CC: 0.276, p: 005). A similar observation was present for haemoglobin levels, with a negative correlation for a mosaic pattern and a positive correlation for honeycombing (Table 4 ). Table 3 Radiological Pattern of Hypersensitivity Pneumonitis Parameters N (%) Tomography Findings Typical for HP 16 (16) Suggestive of HP 73 (73) Atypical of HP 11 (11) Ground Glass Opacity No 15 (15) Present 85 (85) Mosaic Attenuation No 41 (41) Present 59 (59) Centrilobular Nodules No 25 (25) Present 75 (75) Reticulation No 13 (13) Present 87 (87) Traction Bronchiectasis No 43 (43) Present 57 (57) Fibrosis No 60 (60) Present 40 (40) Honey Combing Pattern No 57 (57) Present 43 (43) Table 4 Correlation Between Radiological Findings and Functional Evaluation Middle Lobe Lower Lobe Mosaic Pattern Centrilobular Nodules Reticular Opacity Traction Bronchiectasis Fibrosis Honey Combing Exposure Cessation Correlation Coefficient -0.041 0.220 0.382 0.341 0.000 -0.244 -0.084 -0.037 P Value 0.748 0.083 0.002 0.006 1.000 0.054 0.511 0.775 DLCO Fall Correlation Coefficient 0.126 0.031 0.029 -0.125 0.199 0.199 0.262 0.277 P Value 0.319 0.807 0.818 0.320 0.113 0.112 0.035 0.025 6MWT Desaturation Correlation Coefficient 0.281 0.000 -0.065 -0.020 0.041 0.298 0.186 0.186 P Value 0.026 1.000 0.615 0.875 0.748 0.018 0.144 0.144 FEV1/FVC Ratio (Follow-up) (%) Correlation Coefficient 0.108 -0.058 -0.008 0.064 0.286 0.215 0.268 .304 P Value 0.351 0.616 0.946 0.578 0.012 0.061 0.019 0.007 DLCO (%) Correlation Coefficient -0.188 -0.286 0.012 -0.030 -0.228 -0.428 -0.099 -0.203 P Value 0.093 0.010 0.917 0.787 0.040 0.000 0.379 0.069 6MWT (m) Correlation Coefficient -0.229 0.047 0.195 0.143 -0.046 -0.292 -0.27 -0.170 Table 5 Correlation Between Exposure, Pulmonary Function Tests and Admission Laboratory Values Lymphocytes Basophils Neutrophils Hemoglobin Platelet Mean Platelet Volume RDW Exposure History Correlation Coefficient -0.060 -.211 * -0.067 -0.012 -0.106 0.000 -0.044 P Value 0.552 0.035 0.506 0.903 0.292 0.997 0.667 Exposure History (Bird Subtype) Correlation Coefficient 0.086 .260 * -0.001 -0.228 -0.118 0.058 0.166 P Value 0.495 0.035 0.997 0.066 0.346 0.646 0.183 FVC Fall Correlation Coefficient 0.003 -0.044 0.169 -0.128 0.077 .236 * 0.111 P Value 0.977 0.717 0.159 0.287 0.521 0.047 0.355 DLCO Fall Correlation Coefficient -0.183 0.175 .294 * -.266 * 0.004 -0.132 0.226 P Value 0.145 0.164 0.018 0.032 0.975 0.296 0.070 Antifibrotic treatment Correlation Coefficient 0.089 .340 ** 0.105 0.022 0.000 -0.112 0.060 P Value 0.379 0.001 0.297 0.831 0.998 0.265 0.556 6MWT (m) Correlation Coefficient .261 * 0.030 -0.104 0.094 0.147 -0.081 -.282 * P Value 0.039 0.818 0.418 0.464 0.251 0.526 0.025 Regarding laboratory result correlation, basophil count had a negative correlation with exposure history but a positive correlation with exposure to bird- and avian-related products (CC: -0.211, p: 0.035 and CC: 0.260 p: 0.035, respectively). An increase in basophil count also had a positive correlation with the antifibrotic requirement, with a higher correlation coefficient than the other variables (CC: 0.340 and p: 0.001). A drop in FVC positively correlated with the mean platelet volume (MPV), albeit at a threshold level (p: 0.047). Similarly, MPV was found to be negatively correlated with FEV1 and FVC values at the third month follow-up (CC: -0.347, p: 0.002, and CC :-0.348, p: 0.002). At the time of diagnosis, FVC had a negative correlation with basophil and neutrophil counts, an observation that was not present at the follow-up FVC and in the FVC fall comparison. Red blood cell distribution width was negatively correlated with DLCO/VA at follow-up and total 6WMT distance walked and positively correlated with higher systolic pulmonary arterial pressure (Table 5). 4. Discussion HP is difficult to diagnose and study due to the lack of a widely accepted definition. Recent articles have highlighted significant gaps in our understanding of the epidemiology, pathophysiology, best diagnostic strategy, classification, treatment, and follow-up of HP ( 6 – 7 ). In this study, we investigated HP cases diagnosed and followed at our institution and reported the etiologies, clinical features, and outcomes of HP. HP develops in susceptible individuals after repeated exposure to one or more triggering agents. The types and frequency of causative antigens of HP show demographic and geographic variations. These triggering agents are diverse, region-specific, and generally consist of protein antigens derived from fungi, animals, or microbes (e.g., bird antigens) ( 8 ). In a case series of 46 patients in Korea by Zo et al., the most common antigen was household mould, which accounted for almost half of the study patients (21%, 48.8%), followed by inorganic metals or chemicals ( 9 ). While bird antigens are thought to be the most common trigger in Western countries, numerous studies have shown that moulds are also common, particularly in Asian countries ( 10 – 11 ). This commonality is likely because many Asian countries have hot, humid climates ( 12 ). In another Korean case study, the most common trigger antigens were drugs. This discrepancy may be partially explained by the emphasis of case reports on presenting isolated or rare cases. In our study, 65% of patients reported exposure to any known organic or inorganic substance, while 57 patients (87.7% of all known exposures) had been exposed to birds and other bird products. The median duration of exposure to these agents was five (range 4–15) years, and more than half of the patients terminated exposure (n = 37, 56.9%). Antigen confirmation is widely accepted as crucial for the diagnosis and treatment of HP. Identification currently relies primarily on the history provided by clinicians because specific antibody or inhalation challenge tests are unproven alternative methods. Therefore, further studies are necessary to establish reliable tools, such as specific surveys based on antigen distribution in each region for antigen confirmation. In a Chinese study evaluating the clinical features of HP, the median age of patients was 60.5 (52.0–67.0) years. A total of 46.5% of the population were female (94/202). A total of 47 (22.8%) patients were former smokers, and 31 (15.4%) were current smokers, for a total of 78 (38.2%) smokers. Birds were the primary causative agent in 50.4% (68/135) of the cases with a recognised provoking antigen ( 13 ). In our study, the male–female ratio was equal (50–50), and the mean age was 63 (± 14). The majority of patients were current smokers (n = 19, 21.3%) or former smokers (n = 30, 33.7%). Hypertension (n = 37, 37%) and diabetes mellitus (n = 23, 23%) were the most common comorbidities. Among respiratory comorbidities, asthma (n = 10, 10%) and COPD (n = 9, 9%) were predominant, while CAD (n = 16, 16%) was the most common cardiac comorbidity. There are limited data on PFT in HP, and its role in diagnosis is controversial. In a retrospective study in India, 152 HP patients were analysed for defect type, lung volume, and DLCO. The PFT was abnormal in 118 (80%) cases. Among the abnormality patterns, the most common type was restrictive (74%), followed by mixed (15%) and obstructive (11%). DLCO data were available for 132 (87%) cases, and the levels were decreased by 67%. Isolated low DLCO levels were seen in 10% of cases ( 14 ). According to other studies, PFT is normal in 10–25% of cases. In these studies, restrictive abnormalities accounted for 53–77% of all abnormalities observed in HP patients. Obstructive and mixed defect types were seen in 5–15% and 4–12% of cases, respectively ( 15 , 17 ). According to our study’s initial PFT results, which differed from those of the literature, FEV1 was 79% (± 23), FVC was 79% (± 20), the FEV1/FVC ratio was 80% (± 11), and the DLCO was 68% (± 20). These results did not change significantly at the third-month follow-up evaluation. However, 25 patients (33.3%) showed a decrease in FVC or DLCO compared to the initial evaluation. Studies have found that a ≥ 10% decrease in FVC and a ≥ 15% decrease in DLCO within 12 months are poor prognostic factors in patients with chronic HP ( 18 – 19 ). Typical HRCT results for HP are consistent with bronchiolocentric inflammation observed on histopathology, which presents as small, ill-defined ground-glass nodules widely distributed throughout the lung fields. Lobular air trapping and small airway restriction may also occur from this bronchiolocentric inflammation. The most specific CT pattern for HP, the triple-density pattern, consists of irregular distribution of ground-glass lobules with decreased lung density and vascular size and normal-appearing lobules. Reticular abnormalities, ground-glass opacities, bronchiectasis, traction bronchiolectasis, and honeycombing with lobar volume loss are signs of fibrosis ( 20 ). Regarding the radiological evaluation in our study, the results of the HRCT examination showed that the lower lobes (n = 91, 9%), middle lobe, and lingula (n = 89, 89%) were involved, while the upper lobes (n = 56, 56%) were relatively spared. Most HRCT reports (n = 73, 73%) identified HP. Reticular opacities (n = 87, 87%) were the most common pattern, followed by centrilobular nodules (n = 75, 75%) and ground-glass opacities (n = 83, 84.7%). Fibrosis (n = 40, 40%) and honeycombing (n = 43, 43%) were noted in less than half of the patients. In HP patients, traction bronchiectasis, honeycombing on HRCT, and the degree and presence of fibrosis were associated with mortality, but air trapping and mosaic attenuation were associated with increased survival. Decreased FVC or FVC decline, also known as DLCO, indicates the progression of interstitial lung disease (ILD) and has been associated with mortality in HP patients. In our study, honeycombing on HRCT and fibrosis were positively correlated with decreased DLCO. Desaturation in the six-minute walk test was positively correlated with middle lobe involvement, while total distance walked on the 6MWT was negatively correlated with traction bronchiectasis and fibrosis. Our study’s findings were consistent with the literature. More than 30% of BAL lymphocytes in fibrotic ILD patients are highly specific for HP; however, lymphocytosis does not exclude HP as a diagnosis, and a lung biopsy should be performed when necessary. While CHEST guidelines recommend a multidisciplinary discussion of exposures and HRCT pattern before considering BAL and not performing BAL in patients with HP-specific exposure history, clinical context, and HRCT pattern, ATS/JRS/ALAT guidelines recommend BAL with exposure history, an HRCT scan, and lymphocytosis assessment before multidisciplinary discussion ( 21 – 22 ). In our study, the median lymphocyte fraction of bronchoalveolar lavage results was 16% (10–32), and the median CD4/CD8 ratio was 1.10 (0.71–1.55). Unlike the literature, there was no difference in BAL lymphocytosis between fibrotic HP and nonfibrotic HP. This lack of difference may have occurred because patients are advised to stay away from the agent causing the disease until their bronchoscopy appointment, and the alveolitis may begin to improve during this period. A total of 29 patients (29%) required at least one surgical sampling for diagnostic confirmation during the evaluation of hypersensitivity pneumonitis. Although identifying and eliminating the triggering antigen is difficult to achieve in practice, improving outcomes in HP patients is essential. No protocol for treating HP pharmacologically has been established. Corticosteroids may initially help HP, but there is little evidence that they have long-term benefits or can halt the evolution of fibrotic HP ( 23 ). Whether antifibrotic drug therapy should be initiated in patients with fibrotic HP remains controversial. In the INBUILD study, nintedanib reduced the rate of FVC deterioration by 57% over 52 weeks compared with a placebo in 663 patients with fibrosing ILD other than idiopathic pulmonary fibrosis (IPF), who met the criteria for ILD progression in the past two years despite effective treatment in clinical practice. The nintedanib group also had a lower risk of acute exacerbation of ILD or mortality throughout the study ( 24 – 25 ). Randomised double-blind controlled trials have not been conducted to investigate pirfenidone as a treatment for HP. According to a retrospective analysis of the medical records of 23 HP patients, there was a significantly smaller decrease in vital capacity six months after the initiation of pirfenidone therapy than six months before initiation ( 26 ). The RELIEF study, which examined the effects of pirfenidone in patients with asbestosis, fibrotic nonspecific interstitial pneumonia, HP, or progressive pulmonary fibrosis caused by connective tissue disease, was terminated early because of low enrolment. However, an analysis of data from 127 patients, 57 of whom had HP, showed a smaller decrease in the percentage of predicted FVC in patients receiving pirfenidone than in patients receiving a placebo over a 48-week period ( 27 ). In our study, glucocorticoids were the main treatment for the patients (n = 77, 77%). A total of 13 (13%) patients required additional immunosuppressive agents, and 20 (20%) patients also required antifibrotic therapy. After exposure to an antigen, sensitised individuals’ immune responses may include humoral and cellular T-helper cell type 1 (Th1) immunological responses. Granulomatous inflammation and a mostly lymphocytic inflammatory pattern are the results of these reactions. Neutrophilic inflammation could contribute to the disease at the beginning and later stages of fibrosis, and T-regulatory cell dysfunction contributes to an overreaction to immunity. Evidence suggests that pulmonary fibrosis, which resembles the patterns of fibrotic ILD, most notably UIP, is caused by a relative shift from Th1 to Th2 activity, increased epithelial apoptosis, and aberrant fibroblast activity ( 2 ). In our study, the presence of neutrophilia correlated negatively with the mosaic pattern and positively with the honeycomb pattern. The positive correlation between the patients’ neutrophil counts and the development of fibrosis in HRCT suggested that neutrophilia may also be a poor prognostic factor. Regarding the correlation of laboratory results, basophil count was positively correlated with exposure to birds and bird products. The increase in basophil count was also positively correlated with antifibrotic requirements and had a higher correlation coefficient than other variables. Basophils play a crucial role in the immune response of the body, especially in cases of allergic reactions and parasite infections. Chronic myeloid leukaemia, myeloproliferative disorders, hypersensitivity reactions, inflammatory illnesses, and some infections are linked to basophilia. A number of temporary stimuli, including allergies or stress, can also cause a temporary rise in basophils. The membranes of mast cells and basophils are easily bound by immunoglobulin E. When a particular antigen binds to membrane-bound IgE, it causes degranulation by releasing mediators of acute hypersensitivity. Additionally, basophils are involved in a few delayed hypersensitivity events ( 28 ). We consider the positive correlation between exposure to birds and bird products and basophilia to be a remarkable finding. This study had several limitations. First, it was a retrospective study conducted in a single tertiary hospital. No sample size calculation was performed due to its retrospective nature. Additional methods for antigen identification, such as serum IgG antibody tests or challenge tests, were not used, but this has not been confirmed. 5. Conclusion There is no guideline or consensus published in Turkiye regarding the diagnosis and treatment of HP. In our study, the positive correlation between the patients’ neutrophil counts and the development of fibrosis in HRCT suggested that neutrophilia may be a poor prognostic factor. The positive correlation between exposure to birds and bird products and basophilia was a remarkable finding. The findings highlight the complexity of diagnosing and treating HP. Clinicians should conduct comprehensive patient histories and environmental assessments to identify potential triggers. The relationships between neutrophil and basophil counts should be explored as potential biomarkers for monitoring HP severity and treatment response. Declarations Acknowledgements The authors thank all the patients who participated in this study. Funding The present study was supported by the University of Health Sciences Atatürk Sanatorium Training and Research Hospital (Ankara, Turkey) Ethics Committee (No:2024-BÇEK/96). Availability of data and materials The data generated in the present study may be requested from the corresponding author. Ethical statement The writers are responsible for all aspects of the writing, including ensuring that any concerns about the work’s quality or credibility are thoroughly investigated and resolved. University of Health Sciences Atatürk Sanatorium Training and Research Hospital (Ankara, Turkey) Ethics Committee approved this study (No:2024-BÇEK/96). This research was carried out in conjunction with the Helsinki Declaration (as revised in 2013). Patient consent for publication Not applicable. Conflict of interest There are no conflicts of interest. Author contributions: Main idea/planning: Esma Sevil Akkurt, Berna Akıncı Ozyurek Data provision; Tunahan Dolmus Writing; Esma Sevil Akkurt, Özlem Düvenci Birben Statistical analysis: Kerem Ensarioglu Review and correction; Berna Akinci Ozyurek, Tugce Sahin Ozdemirel, Kerem Ensarioglu Confirmation; Berna Akinci Ozyurek, Hakan Erturk References Selman, M., Buendía-Roldán, I., Navarro, C., et al (2017). Hypersensitivity pneumonitis. In Pulmonary Hypertension and Interstitial Lung Disease (pp. 145-164). Springer, Cham . Raghu, G., Remy-Jardin, M., Ryerson, C. J., et al (2020). Diagnosis of hypersensitivity pneumonitis in adults. An official ATS/JRS/ALAT clinical practice guideline. American journal of respiratory and critical care medicine, 202(3), e36-e69. Quirce, S., Vandenplas, O., Campo, P., et al (2016).Occupational hypersensitivity pneumonitis: an EAACI position paper. Allergy , 71(6), 765-779. D’Ippolito, R., Chetta, A., Foresi, A., et al (2004).Induced sputum and bronchoalveolar lavage from patients with hypersensitivity pneumonitis. Respiratory medicine, 98(10), 977-983. Ejima, M., Okamoto, T., Suzuki, T., et al (2021). Efficacy of treatment with corticosteroids for fibrotic hypersensitivity pneumonitis: a propensity score-matched cohort analysis. BMC Pulmonary Medicine, 21(1), 1-12. Vasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity pneumonitis: perspectives in diagnosis and management. Am J Respir Crit Care Med 2017;196:680–689. 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;196:690–699. Vasakova M, Selman M, Morell F, Sterclova M, Molina-Molina M, Raghu G. Hypersensitivity pneumonitis: current concepts of pathogenesis and potential targets for treatment. Am J Respir Crit Care Med 2019;200:301–308. Zo S, Chung MP, Yoo HY, et al. Clinical characteristics and outcomes of hypersensitivity pneumonitis in South Korea. Ther Adv Respir Dis . 2023 Jan-Dec;17:17534666231212304. Fernández Pérez ER, Swigris JJ, Forssén AV , et al . Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. Chest 2013; 144: 1644–1651. Ando M, Arima K, Yoneda R , et al . Japanese summer-type hypersensitivity pneumonitis. Geographic distribution, home environment, and clinical characteristics of 621 cases. Am Rev Respir Dis 1991; 144: 765–769. Nishida T, Kawate E, Ishiguro T , et al . Antigen avoidance and outcome of nonfibrotic and fibrotic hypersensitivity pneumonitis. ERJ Open Res 2022; 8. . Chen X, Yang X, Ren Y, et al. Clinical characteristics of hypersensitivity pneumonitis: non-fibrotic and fibrotic subtypes. Chin Med J (Engl). 2023 Dec 5;136(23):2839-2846. Spalgais S, Mrigpuri P, Ravishankar N, Kumar R. Pulmonary Function and Diffusing Capacity of Carbon Monoxide in Hypersensitivity Pneumonitis: An Observational Study of 152 Patients. Thorac Res Pract. 2024 Mar;25(2):51-56. Kumar R, Spalgais S, Ranga V. Hypersensitivity pneumonitis: clinical, radiological and pathological profile of 103 patients from North India . Monaldi Arch Chest Dis . 2020;90(3):1307. Morais A, Winck JC, Delgado L et al. Suberosis and bird Fancier’s Disease: a comparative study of radiological, functional and bronchoalveolarlavage profiles. J Investig Allergol Clin Immunol .2004;14(1):26-33. Morell F, Roger À, Reyes L, Cruz MJ, Murio C, Muñoz X. Bird fancier’s lung: a series of 86 patients. Med (Baltim) . 2008;87(2):110-130. Gimenez A, Storrer K, Kuranishi L, et al. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. Thorax 2018;73:391-2. Horimasu Y, Ishikawa N, Iwamoto H, et al. Clinical and molecular features of rapidly progressive chronic hypersensitivity pneumonitis. Sarcoidosis Vasc Diffuse Lung Dis 2017;34:48-57. Kaburaki S, Okuda R, Takemura T, et al. Compatible with fibrotic hypersensitivity pneumonitis on high-resolution computed tomography: from the ATS/JRS/ALAT 2020 hypersensitivity pneumonitis guidelines . J Thorac Dis. 2024 Apr 30;16(4):2353-2364. doi: 10.21037/jtd-23-1845. Fernández Pérez ER, Travis WD, Lynch DA, et al. Executive summary diagnosis and evaluation of hypersensitivity pneumonitis: CHEST guideline and expert panel report. Chest 2021; 160: 595–615. 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 Me d 2020; 202: e36–e69. De Sadeleer LJ, Hermans F, De Dycker E, 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: 14. Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med 2019; 381: 1718–1727. Cottin V, Richeldi L, Rosas I, et al. Nintedanib and immunomodulatory therapies in progressive fibrosing interstitial lung diseases. Respir Res 2021; 22: 84. Shibata S, Furusawa H, Inase N. Pirfenidone in chronic hypersensitivity pneumonitis: a real-life experience. Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 139–142. Behr J, Prasse A, Kreuter M, et al. Pirfenidone in patients with progressive fibrotic interstitial lung diseases other than idiopathic pulmonary fibrosis (RELIEF): a double-blind, randomised, placebo-controlled, phase 2b trial. Lancet Respir Med 2021; 9: 476–486. Korošec P, Gibbs BF, Rijavec M, Custovic A, Turner PJ. Important and specific role for basophils in acute allergic reactions. Clin Exp Allergy . 2018 May;48(5):502-512. 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. 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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-5418767","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376424031,"identity":"c6ace9d5-c012-4e18-8c12-221f4ca95464","order_by":0,"name":"ESMA SEVIL AKKURT","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDADNnbmY1AG0VqY2dIYGBJADKKtYeYxA2thIKSFn/904geGPzaJfcw83x58/LFNno+ZgfHDxxzcWiRn5G6WYGxLS2xj5t1uOCPhtmEbMwOz5MxtuLUY3ODdIMHYcNiYjZl3mzRPwm1GoBYQG7cW+/NnN/9g+PMfqIXnGUiLPUEtBgy52yQY2A7IAbWwgbQkEtQicSN3m0ViWzJQC5uZ5Iy028ltzIzNeP3C3392840Pf+x45Nubn0l8sLltO7+9+eCHj3i0gEECKpexgYD6UTAKRsEoGAWEAADHo0S01KSOrgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"ESMA","middleName":"SEVIL","lastName":"AKKURT","suffix":""},{"id":376424032,"identity":"c38bbf95-7b3b-42c9-b280-c2f151ab0f1d","order_by":1,"name":"BERNA AKINCI OZYUREK","email":"","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"BERNA","middleName":"AKINCI","lastName":"OZYUREK","suffix":""},{"id":376424034,"identity":"bdf38df6-b27b-486f-87ac-5dc01c5b81ad","order_by":2,"name":"KEREM ENSARIOGLU","email":"","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"KEREM","middleName":"","lastName":"ENSARIOGLU","suffix":""},{"id":376424035,"identity":"09b50b7b-7901-484e-95aa-ec3b41c501d2","order_by":3,"name":"TUGCE SAHIN OZDEMIREL","email":"","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"TUGCE","middleName":"SAHIN","lastName":"OZDEMIREL","suffix":""},{"id":376424036,"identity":"9131abaa-42eb-4f8a-95da-0a66c372e1cc","order_by":4,"name":"OZLEM DUVENCI BIRBEN","email":"","orcid":"","institution":"University of Health Sciences, Ankara Oncology Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"OZLEM","middleName":"DUVENCI","lastName":"BIRBEN","suffix":""},{"id":376424037,"identity":"bca6960d-dffe-4e20-a16e-313a8f1e65e0","order_by":5,"name":"HAKAN ERTURK","email":"","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"HAKAN","middleName":"","lastName":"ERTURK","suffix":""},{"id":376424038,"identity":"167731a4-7f8c-46c6-b56c-e651dd226a87","order_by":6,"name":"TUNAHAN DOLMUS","email":"","orcid":"","institution":"University of Health Sciences, Atatürk Sanatorium Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"TUNAHAN","middleName":"","lastName":"DOLMUS","suffix":""}],"badges":[],"createdAt":"2024-11-08 21:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5418767/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5418767/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70853959,"identity":"6e173b49-61d7-46a6-9036-7c925ff692a0","added_by":"auto","created_at":"2024-12-08 06:31:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":939213,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5418767/v1/c260af0e-d7f0-4079-ae73-900dc74e6c9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of clinical and radiological features of patients diagnosed with hypersensitivity pneumonia","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHypersensitivity pneumonitis (HP) is an inflammatory fibrotic disease that affects the lung parenchyma and small airways. It is usually caused by an immune-mediated reaction triggered by the inhalation of a known or unknown antigen in susceptible individuals. HP is caused by many factors. Farmer\u0026rsquo;s lung and bird feeder\u0026rsquo;s lung are the most common causes of HP, and avian and animal antigens, microbial agents such as bacteria and fungi, plant proteins, low molecular weight chemicals, and metals have been identified as triggering factors (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Since the presence of radiographic or histopathologic fibrosis is the primary determinant of prognosis, the American Thoracic Society, Japanese Respiratory Society, and Asociaci\u0026oacute;n Latinoamericana del T\u0026oacute;rax (ATS/JRS/ALAT) guideline committee unanimously decided to classify HP as fibrotic or nonfibrotic (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCommon symptoms of HP in the fibrotic and nonfibrotic groups include dyspnoea and cough. Fever, chills, weight loss, and malaise are less common. In patients known to have been exposed to suspected HP triggers, HP should be suspected if there is clinical and radiographic imaging evidence of interstitial lung disease and alternative diagnoses can be excluded. The primary goal of evaluation is to identify the triggering agent (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Other diagnostic steps include determining the severity of respiratory distress, evaluating characteristic radiographic imaging, and bronchoalveolar lavage features. When the diagnosis remains uncertain, a multidisciplinary evaluation with a decision to obtain tissue samples to confirm the diagnosis may be considered.\u003c/p\u003e \u003cp\u003eDifferent HRCT patterns are applied depending on whether the patient has fibrotic or nonfibrotic HP. Nonfibrotic HP is typically associated with ground-glass opacification; however, HRCT may be normal because of the transient nature of the radiographic opacities. Air trapping, also known as mosaic attenuation, can be seen by comparing expiratory and inspiratory images. Patches of ground-glass opacification are present, usually few in number, and ranging in size from 3 to 25 mm. Bronchoalveolar lavage (BAL) is the most sensitive tool for detecting alveolitis in patients with suspected HP. When clinical and radiographic findings suggest subacute HP, significant BAL lymphocytosis (more than 20%) is a nonspecific but useful finding (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Antigen avoidance and symptomatic treatment are the cornerstones of HP treatment, which usually results in disease regression. Additional treatment may be required for more severe or progressive diseases (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe natural course of HP includes a variable clinical picture, ranging from resolution to gradual resolution or death due to respiratory failure. Nonfibrotic HP patients who avoid exposure to the triggering agent have a better prognosis.\u003c/p\u003e \u003cp\u003e There is no published guideline or consensus regarding the diagnosis and treatment of HP in Turkiye. We aimed to contribute to the literature by evaluating the clinical features, radiological features, treatment approaches, treatment responses, and prognoses of the patients we followed in our clinic.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eOur study included 100 patients diagnosed with hypersensitivity pneumonia who were diagnosed and followed up in our diffuse parenchymal lung disease clinic between 2020 and 2024 and who met the inclusion criteria. Patients who refused medical treatment during the follow-up period and whose radiology, PFT-DLCO, and prognosis information could not be accessed from the hospital system or patient files were excluded from the study. The patients\u0026rsquo; clinical information, additional diseases, PFT-DLCO parameters at the time of diagnosis, six-minute walking tests (6MWT), HRCT patterns, prognosis information, and mortality data were recorded retrospectively. The patients were diagnosed based on a combination of radiological images, exposure assessment, BAL lymphocytosis, and histopathological findings. The Ethics Committee (No:2024-B\u0026Ccedil;EK/96) approved the study. This research was conducted in conjunction with the Helsinki Declaration (revised in 2013).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients over the age of 18\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients followed up in our clinic with a diagnosis of hypersensitivity pneumonia between January 2020 and January 2024\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients whose demographic information, additional disease information, initial and follow-up PFT-DLCO data, HRCT findings taken at the time of diagnosis, and six-month prognosis information were accessible from the hospital system or patient files were included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients whose criteria could not be accessed from patient files or computer records\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients who did not undergo HRCT at the time of diagnosis\u003c/p\u003e\n\u003cp\u003e\u0026bull; Patients with less than six months of follow-up\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients\u0026rsquo; results were put into a Microsoft Excel file for overall evaluation. After investigating any misinput and values, the data were moved to a statistics module (IBM Version 25th for Windows). The initial assessment was performed by descriptive analysis, for which values were given with mean and standard deviation or with median and percentiles, as required. Parametric distribution was evaluated by Q-Q plot analysis. Correlation analysis was performed by Pearson correlation after the confirmation of enough available data for a chi-square test if two nominal values were to be confirmed. A p-value below 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 100 patients were included in the study, with an equal male-to-female (50\u0026ndash;50) ratio. The mean age was 63 (\u0026plusmn;\u0026thinsp;14) years old. The majority of the patients were either active smokers (n\u0026thinsp;=\u0026thinsp;19, 21.3%) or ex-smokers (n\u0026thinsp;=\u0026thinsp;30, 33.7%). Hypertension (n\u0026thinsp;=\u0026thinsp;37, 37%) and diabetes mellitus (n\u0026thinsp;=\u0026thinsp;23, 23%) were the most prevalent comorbidities observed. Among respiratory comorbidities, asthma (n\u0026thinsp;=\u0026thinsp;10, 10%) and chronic obstructive pulmonary disease (n\u0026thinsp;=\u0026thinsp;9, 9%) were predominantly seen, while coronary arterial disease (n\u0026thinsp;=\u0026thinsp;16, 16%) was the most frequently observed cardiac comorbidity (Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDemographic Parameters and Comorbidities\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eParameters\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eN(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e (years, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (\u0026plusmn;\u0026thinsp;14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNonsmoker\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eExsmoker\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eActive Smoker\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (\u003cspan\u003e19\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e (Package/Year, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (\u003cspan\u003e14\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic Obstructive Pulmonary Disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (\u003cspan\u003e9\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsthma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (\u003cspan\u003e10\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronary Arterial Disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (\u003cspan\u003e16\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes Mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (\u003cspan\u003e23\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e: Standard Deviation, Diabetes Mellitus definition included both type 1 and type 2 diabetes, yet excluded treatment-related ones.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eExposure to any known organic or inorganic agents was reported in 65% of patients, with exposure to bird and other avian products observed in 57 (87.7% of all known exposure causes) patients. The median exposure duration was 5 (\u003cspan\u003e4\u003c/span\u003e\u0026ndash;\u003cspan\u003e15\u003c/span\u003e) years, with more than half of the patients who ceased exposure (n\u0026thinsp;=\u0026thinsp;36, 57.1%). The BAL results had a median of 16% (10\u0026ndash;32) lymphocyte ratio, with a median of 1.10 (0.71\u0026ndash;1.55) CD4/CD8 ratio. The initial PFT results revealed a forced expiratory volume (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and DLCO results of 79% (\u0026plusmn;\u0026thinsp;23), 79% (\u0026plusmn;\u0026thinsp;20), 80% (\u0026plusmn;\u0026thinsp;11), and 68% (\u0026plusmn;\u0026thinsp;20) respectively. These results did not vary significantly at the third-month follow-up evaluation. However, 25 patients (33.3%) had a fall in either FVC or DLCO compared to the initial assessment. Overall, 29 patients (29%) required at least one surgical sampling for diagnostic confirmation during the HP evaluation (Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eExposure Evaluation, Laboratory Parameters, Bronchoalveolar Lavage and Pulmonary Function Test Results\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure History\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eBird\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (87.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eOrganic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNonorganic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure Duration\u003c/strong\u003e (years, median, 25th-75th)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (\u003cspan\u003e4\u003c/span\u003e\u0026ndash;\u003cspan\u003e15\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Last Exposure\u003c/strong\u003e (years, median, 25th-75th)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (\u003cspan\u003e1\u003c/span\u003e\u0026ndash;\u003cspan\u003e18\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCessation of Exposure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eStill Exposed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (43.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eCeased\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eBAL Lymphocyte Ratio\u003c/strong\u003e (%, median, 25th-75th)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (10\u0026ndash;32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eFibrotic HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (\u003cspan\u003e10\u003c/span\u003e\u0026ndash;\u003cspan\u003e20\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eNon-Fibrotic HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (10\u0026ndash;40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eBAL CD4/CD8 Ratio\u003c/strong\u003e (%, median, 25th-75th)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10 (0.71-.1.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eFibrotic HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.21 (0.85\u0026ndash;1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eNon-Fibrotic HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09 (0.68\u0026ndash;1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhite Blood Cell\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8.9 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymphocytes\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2.42 (0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eBasophils\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.04 (0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutrophils\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5.48 (2.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eEosinophils\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.25 (0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin\u003c/strong\u003e (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14.1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatelets\u003c/strong\u003e (x10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e263 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Platelet Volume\u003c/strong\u003e (fl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e9.6 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eRed Blood Cell Distribution Width\u003c/strong\u003e (fl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14.7 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eFEV1\u003c/strong\u003e (%, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (\u003cspan\u003e23\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eFVC\u003c/strong\u003e (%, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (\u003cspan\u003e20\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eFEV1/FVC Ratio\u003c/strong\u003e (%, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (\u003cspan\u003e11\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO\u003c/strong\u003e (%, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (\u003cspan\u003e20\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO/VA\u003c/strong\u003e (%, \u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (\u003cspan\u003e21\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFVC Fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (77.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO Fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (75.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e6MWT Distance\u003c/strong\u003e (m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e404 (115)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e6MWT Desaturation\u003c/strong\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e36 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Sampling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ePerformed\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eBAL\u003c/strong\u003e: Bronchoalveolar lavage, \u003cstrong\u003eFEV1\u003c/strong\u003e: Forced Expiratory Volume, \u003cstrong\u003eFVC\u003c/strong\u003e: Forced Vital Capacity, \u003cstrong\u003eDLCO\u003c/strong\u003e: Diffusing Capacity of the lung for Carbon Monoxide, \u003cstrong\u003eVA\u003c/strong\u003e: Alveolar Volume. \u003cstrong\u003eHP\u003c/strong\u003e: Hypersensitivity Pneumonitis \u003cstrong\u003e6MWT\u003c/strong\u003e: Six-minute walking test. Survival was given with a period of three months after initial diagnosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe cardiac evaluation showed a mean of 58% (\u0026plusmn;\u0026thinsp;4) ejection fraction and a mean of 33 (\u0026plusmn;\u0026thinsp;15) mmHg systolic pulmonary arterial pressure. Patients had walked an average distance of 404 (\u0026plusmn;\u0026thinsp;115) metres, and desaturation was reported in 27 (42.9%) patients. The initial total blood count test results were within normal parameters. Three patients (3%) were exitus during the three-month follow-up period, with an overall survival rate of 97%. Regarding radiological evaluation, HRCT results favoured the involvement of the lower lobes (n\u0026thinsp;=\u0026thinsp;91, 9%), middle lobe, and lingula (n\u0026thinsp;=\u0026thinsp;89, 89%), followed up with relatively spared upper lobes (n\u0026thinsp;=\u0026thinsp;56, 56%). The majority of HRCT reports indicated HP (n\u0026thinsp;=\u0026thinsp;73, 73%). The main reported pattern was reticulation (n\u0026thinsp;=\u0026thinsp;87, 87%), followed by ground-glass opacities (GGO) (n\u0026thinsp;=\u0026thinsp;83, 84.7%), and centrilobular nodules (n\u0026thinsp;=\u0026thinsp;75, 75%). Fibrosis (n\u0026thinsp;=\u0026thinsp;40, 40%) was identified in less than half of the patients (Table\u0026nbsp;3). Glucocorticoids were the mainstay treatment utilised (n\u0026thinsp;=\u0026thinsp;77, 77%) among the patients, with additional immunosuppressive agents required in 13 (13%) patients and 20 (20%) patients requiring further antifibrotic treatment.\u003c/p\u003e\n\u003cp\u003eCorrelation analyses performed for parameters regarding their role in a radiological pattern showed that the cessation of exposure had a positive correlation with mosaic pattern and centrilobular opacity (correlation coefficient [CC]: 0.382, p: 0.02, and CC: 0.341, p: 0.006, respectively). Desaturation in a 6MWT positively correlated with middle lobe involvement (CC: 0.281, p: 0.026). The total distance walked in the 6MWT was also negatively correlated with traction bronchiectasis and fibrosis (CC: -0.292, p: 0.02 and CC: -0.270, p: 0.033, respectively). Honeycombing and fibrosis had a positive correlation with DLCO fall (CC: 0.262, p: 0.035 and CC: 0.277, p: 0.025, respectively), while DLCO at both diagnosis and follow-up had a negative correlation with reticular traction bronchiectasis. The neutrophil count was negatively correlated with a mosaic pattern (CC: -0.235, p: 0.019) and positively correlated with honeycombing (CC: 0.276, p: 005). A similar observation was present for haemoglobin levels, with a negative correlation for a mosaic pattern and a positive correlation for honeycombing (Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eRadiological Pattern of Hypersensitivity Pneumonitis\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTomography Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eTypical for HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eSuggestive of HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73 (73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eAtypical of HP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGround Glass Opacity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMosaic Attenuation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCentrilobular Nodules\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eReticulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87 (87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraction Bronchiectasis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFibrosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHoney Combing Pattern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePresent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Correlation Between Radiological Findings and Functional Evaluation\u0026nbsp;\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"572\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMiddle Lobe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLower Lobe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMosaic Pattern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCentrilobular Nodules\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReticular Opacity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTraction Bronchiectasis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFibrosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHoney Combing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure Cessation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.382\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.341\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO Fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.262\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.277\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e6MWT Desaturation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.281\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.298\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFEV1/FVC Ratio (Follow-up) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.286\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.304\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.616\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.578\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-0.286\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-0.228\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-0.428\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.787\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.040\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e6MWT (m)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-0.292\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-0.27\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Correlation Between Exposure, Pulmonary Function Tests and Admission Laboratory Values\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"607\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLymphocytes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBasophils\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNeutrophils\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePlatelet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean Platelet Volume\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRDW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure History\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-.211\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.506\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.667\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure History (Bird Subtype)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.260\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFVC Fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.236\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.717\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDLCO Fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.294\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-.266\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntifibrotic treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.340\u003csup\u003e**\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e6MWT (m)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorrelation Coefficient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e.261\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e-.282\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cp\u003eRegarding laboratory result correlation, basophil count had a negative correlation with exposure history but a positive correlation with exposure to bird- and avian-related products (CC: -0.211, p: 0.035 and CC: 0.260 p: 0.035, respectively). An increase in basophil count also had a positive correlation with the antifibrotic requirement, with a higher correlation coefficient than the other variables (CC: 0.340 and p: 0.001). A drop in FVC positively correlated with the mean platelet volume (MPV), albeit at a threshold level (p: 0.047). Similarly, MPV was found to be negatively correlated with FEV1 and FVC values at the third month follow-up (CC: -0.347, p: 0.002, and CC :-0.348, p: 0.002). At the time of diagnosis, FVC had a negative correlation with basophil and neutrophil counts, an observation that was not present at the follow-up FVC and in the FVC fall comparison. Red blood cell distribution width was negatively correlated with DLCO/VA at follow-up and total 6WMT distance walked and positively correlated with higher systolic pulmonary arterial pressure (Table\u0026nbsp;5).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eHP is difficult to diagnose and study due to the lack of a widely accepted definition. Recent articles have highlighted significant gaps in our understanding of the epidemiology, pathophysiology, best diagnostic strategy, classification, treatment, and follow-up of HP (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In this study, we investigated HP cases diagnosed and followed at our institution and reported the etiologies, clinical features, and outcomes of HP.\u003c/p\u003e \u003cp\u003eHP develops in susceptible individuals after repeated exposure to one or more triggering agents. The types and frequency of causative antigens of HP show demographic and geographic variations. These triggering agents are diverse, region-specific, and generally consist of protein antigens derived from fungi, animals, or microbes (e.g., bird antigens) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In a case series of 46 patients in Korea by Zo et al., the most common antigen was household mould, which accounted for almost half of the study patients (21%, 48.8%), followed by inorganic metals or chemicals (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While bird antigens are thought to be the most common trigger in Western countries, numerous studies have shown that moulds are also common, particularly in Asian countries (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This commonality is likely because many Asian countries have hot, humid climates (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In another Korean case study, the most common trigger antigens were drugs. This discrepancy may be partially explained by the emphasis of case reports on presenting isolated or rare cases. In our study, 65% of patients reported exposure to any known organic or inorganic substance, while 57 patients (87.7% of all known exposures) had been exposed to birds and other bird products. The median duration of exposure to these agents was five (range 4\u0026ndash;15) years, and more than half of the patients terminated exposure (n\u0026thinsp;=\u0026thinsp;37, 56.9%). Antigen confirmation is widely accepted as crucial for the diagnosis and treatment of HP. Identification currently relies primarily on the history provided by clinicians because specific antibody or inhalation challenge tests are unproven alternative methods. Therefore, further studies are necessary to establish reliable tools, such as specific surveys based on antigen distribution in each region for antigen confirmation.\u003c/p\u003e \u003cp\u003eIn a Chinese study evaluating the clinical features of HP, the median age of patients was 60.5 (52.0\u0026ndash;67.0) years. A total of 46.5% of the population were female (94/202). A total of 47 (22.8%) patients were former smokers, and 31 (15.4%) were current smokers, for a total of 78 (38.2%) smokers. Birds were the primary causative agent in 50.4% (68/135) of the cases with a recognised provoking antigen (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In our study, the male\u0026ndash;female ratio was equal (50\u0026ndash;50), and the mean age was 63 (\u0026plusmn;\u0026thinsp;14). The majority of patients were current smokers (n\u0026thinsp;=\u0026thinsp;19, 21.3%) or former smokers (n\u0026thinsp;=\u0026thinsp;30, 33.7%). Hypertension (n\u0026thinsp;=\u0026thinsp;37, 37%) and diabetes mellitus (n\u0026thinsp;=\u0026thinsp;23, 23%) were the most common comorbidities. Among respiratory comorbidities, asthma (n\u0026thinsp;=\u0026thinsp;10, 10%) and COPD (n\u0026thinsp;=\u0026thinsp;9, 9%) were predominant, while CAD (n\u0026thinsp;=\u0026thinsp;16, 16%) was the most common cardiac comorbidity. There are limited data on PFT in HP, and its role in diagnosis is controversial. In a retrospective study in India, 152 HP patients were analysed for defect type, lung volume, and DLCO. The PFT was abnormal in 118 (80%) cases. Among the abnormality patterns, the most common type was restrictive (74%), followed by mixed (15%) and obstructive (11%). DLCO data were available for 132 (87%) cases, and the levels were decreased by 67%. Isolated low DLCO levels were seen in 10% of cases (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). According to other studies, PFT is normal in 10\u0026ndash;25% of cases. In these studies, restrictive abnormalities accounted for 53\u0026ndash;77% of all abnormalities observed in HP patients. Obstructive and mixed defect types were seen in 5\u0026ndash;15% and 4\u0026ndash;12% of cases, respectively (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). According to our study\u0026rsquo;s initial PFT results, which differed from those of the literature, FEV1 was 79% (\u0026plusmn;\u0026thinsp;23), FVC was 79% (\u0026plusmn;\u0026thinsp;20), the FEV1/FVC ratio was 80% (\u0026plusmn;\u0026thinsp;11), and the DLCO was 68% (\u0026plusmn;\u0026thinsp;20). These results did not change significantly at the third-month follow-up evaluation. However, 25 patients (33.3%) showed a decrease in FVC or DLCO compared to the initial evaluation. Studies have found that a\u0026thinsp;\u0026ge;\u0026thinsp;10% decrease in FVC and a\u0026thinsp;\u0026ge;\u0026thinsp;15% decrease in DLCO within 12 months are poor prognostic factors in patients with chronic HP (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTypical HRCT results for HP are consistent with bronchiolocentric inflammation observed on histopathology, which presents as small, ill-defined ground-glass nodules widely distributed throughout the lung fields. Lobular air trapping and small airway restriction may also occur from this bronchiolocentric inflammation. The most specific CT pattern for HP, the triple-density pattern, consists of irregular distribution of ground-glass lobules with decreased lung density and vascular size and normal-appearing lobules. Reticular abnormalities, ground-glass opacities, bronchiectasis, traction bronchiolectasis, and honeycombing with lobar volume loss are signs of fibrosis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Regarding the radiological evaluation in our study, the results of the HRCT examination showed that the lower lobes (n\u0026thinsp;=\u0026thinsp;91, 9%), middle lobe, and lingula (n\u0026thinsp;=\u0026thinsp;89, 89%) were involved, while the upper lobes (n\u0026thinsp;=\u0026thinsp;56, 56%) were relatively spared. Most HRCT reports (n\u0026thinsp;=\u0026thinsp;73, 73%) identified HP. Reticular opacities (n\u0026thinsp;=\u0026thinsp;87, 87%) were the most common pattern, followed by centrilobular nodules (n\u0026thinsp;=\u0026thinsp;75, 75%) and ground-glass opacities (n\u0026thinsp;=\u0026thinsp;83, 84.7%). Fibrosis (n\u0026thinsp;=\u0026thinsp;40, 40%) and honeycombing (n\u0026thinsp;=\u0026thinsp;43, 43%) were noted in less than half of the patients.\u003c/p\u003e \u003cp\u003eIn HP patients, traction bronchiectasis, honeycombing on HRCT, and the degree and presence of fibrosis were associated with mortality, but air trapping and mosaic attenuation were associated with increased survival. Decreased FVC or FVC decline, also known as DLCO, indicates the progression of interstitial lung disease (ILD) and has been associated with mortality in HP patients. In our study, honeycombing on HRCT and fibrosis were positively correlated with decreased DLCO. Desaturation in the six-minute walk test was positively correlated with middle lobe involvement, while total distance walked on the 6MWT was negatively correlated with traction bronchiectasis and fibrosis. Our study\u0026rsquo;s findings were consistent with the literature.\u003c/p\u003e \u003cp\u003eMore than 30% of BAL lymphocytes in fibrotic ILD patients are highly specific for HP; however, lymphocytosis does not exclude HP as a diagnosis, and a lung biopsy should be performed when necessary. While CHEST guidelines recommend a multidisciplinary discussion of exposures and HRCT pattern before considering BAL and not performing BAL in patients with HP-specific exposure history, clinical context, and HRCT pattern, ATS/JRS/ALAT guidelines recommend BAL with exposure history, an HRCT scan, and lymphocytosis assessment before multidisciplinary discussion (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In our study, the median lymphocyte fraction of bronchoalveolar lavage results was 16% (10\u0026ndash;32), and the median CD4/CD8 ratio was 1.10 (0.71\u0026ndash;1.55). Unlike the literature, there was no difference in BAL lymphocytosis between fibrotic HP and nonfibrotic HP. This lack of difference may have occurred because patients are advised to stay away from the agent causing the disease until their bronchoscopy appointment, and the alveolitis may begin to improve during this period. A total of 29 patients (29%) required at least one surgical sampling for diagnostic confirmation during the evaluation of hypersensitivity pneumonitis.\u003c/p\u003e \u003cp\u003eAlthough identifying and eliminating the triggering antigen is difficult to achieve in practice, improving outcomes in HP patients is essential. No protocol for treating HP pharmacologically has been established. Corticosteroids may initially help HP, but there is little evidence that they have long-term benefits or can halt the evolution of fibrotic HP (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Whether antifibrotic drug therapy should be initiated in patients with fibrotic HP remains controversial. In the INBUILD study, nintedanib reduced the rate of FVC deterioration by 57% over 52 weeks compared with a placebo in 663 patients with fibrosing ILD other than idiopathic pulmonary fibrosis (IPF), who met the criteria for ILD progression in the past two years despite effective treatment in clinical practice. The nintedanib group also had a lower risk of acute exacerbation of ILD or mortality throughout the study (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Randomised double-blind controlled trials have not been conducted to investigate pirfenidone as a treatment for HP. According to a retrospective analysis of the medical records of 23 HP patients, there was a significantly smaller decrease in vital capacity six months after the initiation of pirfenidone therapy than six months before initiation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The RELIEF study, which examined the effects of pirfenidone in patients with asbestosis, fibrotic nonspecific interstitial pneumonia, HP, or progressive pulmonary fibrosis caused by connective tissue disease, was terminated early because of low enrolment. However, an analysis of data from 127 patients, 57 of whom had HP, showed a smaller decrease in the percentage of predicted FVC in patients receiving pirfenidone than in patients receiving a placebo over a 48-week period (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In our study, glucocorticoids were the main treatment for the patients (n\u0026thinsp;=\u0026thinsp;77, 77%). A total of 13 (13%) patients required additional immunosuppressive agents, and 20 (20%) patients also required antifibrotic therapy.\u003c/p\u003e \u003cp\u003eAfter exposure to an antigen, sensitised individuals\u0026rsquo; immune responses may include humoral and cellular T-helper cell type 1 (Th1) immunological responses. Granulomatous inflammation and a mostly lymphocytic inflammatory pattern are the results of these reactions. Neutrophilic inflammation could contribute to the disease at the beginning and later stages of fibrosis, and T-regulatory cell dysfunction contributes to an overreaction to immunity. Evidence suggests that pulmonary fibrosis, which resembles the patterns of fibrotic ILD, most notably UIP, is caused by a relative shift from Th1 to Th2 activity, increased epithelial apoptosis, and aberrant fibroblast activity (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In our study, the presence of neutrophilia correlated negatively with the mosaic pattern and positively with the honeycomb pattern. The positive correlation between the patients\u0026rsquo; neutrophil counts and the development of fibrosis in HRCT suggested that neutrophilia may also be a poor prognostic factor.\u003c/p\u003e \u003cp\u003eRegarding the correlation of laboratory results, basophil count was positively correlated with exposure to birds and bird products. The increase in basophil count was also positively correlated with antifibrotic requirements and had a higher correlation coefficient than other variables. Basophils play a crucial role in the immune response of the body, especially in cases of allergic reactions and parasite infections. Chronic myeloid leukaemia, myeloproliferative disorders, hypersensitivity reactions, inflammatory illnesses, and some infections are linked to basophilia. A number of temporary stimuli, including allergies or stress, can also cause a temporary rise in basophils. The membranes of mast cells and basophils are easily bound by immunoglobulin E. When a particular antigen binds to membrane-bound IgE, it causes degranulation by releasing mediators of acute hypersensitivity. Additionally, basophils are involved in a few delayed hypersensitivity events (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). We consider the positive correlation between exposure to birds and bird products and basophilia to be a remarkable finding.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, it was a retrospective study conducted in a single tertiary hospital. No sample size calculation was performed due to its retrospective nature. Additional methods for antigen identification, such as serum IgG antibody tests or challenge tests, were not used, but this has not been confirmed.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e There is no guideline or consensus published in Turkiye regarding the diagnosis and treatment of HP. In our study, the positive correlation between the patients\u0026rsquo; neutrophil counts and the development of fibrosis in HRCT suggested that neutrophilia may be a poor prognostic factor. The positive correlation between exposure to birds and bird products and basophilia was a remarkable finding. The findings highlight the complexity of diagnosing and treating HP. Clinicians should conduct comprehensive patient histories and environmental assessments to identify potential triggers. The relationships between neutrophil and basophil counts should be explored as potential biomarkers for monitoring HP severity and treatment response.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the patients who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was supported by the University of Health Sciences Atat\u0026uuml;rk Sanatorium Training and Research Hospital (Ankara, Turkey) Ethics Committee (No:2024-B\u0026Ccedil;EK/96).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated in the present study may be requested from the corresponding author.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Ethical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe writers are responsible for all aspects of the writing, including ensuring that any concerns about the work\u0026rsquo;s quality or credibility are thoroughly investigated and resolved. University of Health Sciences Atat\u0026uuml;rk Sanatorium Training and Research Hospital (Ankara, Turkey) Ethics Committee approved this study\u0026nbsp;(No:2024-B\u0026Ccedil;EK/96). This research was carried out in conjunction with the Helsinki Declaration (as revised in 2013).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMain idea/planning: Esma Sevil Akkurt, Berna Akıncı Ozyurek\u003c/p\u003e\n\u003cp\u003eData provision; Tunahan Dolmus\u003c/p\u003e\n\u003cp\u003eWriting; Esma Sevil Akkurt, \u0026Ouml;zlem D\u0026uuml;venci Birben\u003c/p\u003e\n\u003cp\u003eStatistical analysis: Kerem Ensarioglu\u003c/p\u003e\n\u003cp\u003eReview and correction; Berna Akinci Ozyurek, Tugce Sahin Ozdemirel, Kerem Ensarioglu\u003c/p\u003e\n\u003cp\u003eConfirmation; Berna Akinci Ozyurek, Hakan Erturk\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSelman, M., Buend\u0026iacute;a-Rold\u0026aacute;n, I., Navarro, C., et al (2017). Hypersensitivity pneumonitis. In Pulmonary Hypertension and Interstitial Lung Disease (pp. 145-164). \u003cem\u003eSpringer, Cham\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eRaghu, G., Remy-Jardin, M., Ryerson, C. J., et al (2020). Diagnosis of hypersensitivity pneumonitis in adults. An official ATS/JRS/ALAT clinical practice guideline. \u003cem\u003eAmerican journal of respiratory and critical care medicine,\u003c/em\u003e 202(3), e36-e69.\u003c/li\u003e\n\u003cli\u003eQuirce, S., Vandenplas, O., Campo, P., et al (2016).Occupational hypersensitivity pneumonitis: an EAACI position paper. \u003cem\u003eAllergy\u003c/em\u003e, 71(6), 765-779.\u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Ippolito, R., Chetta, A., Foresi, A., et al (2004).Induced sputum and bronchoalveolar lavage from patients with hypersensitivity pneumonitis. Respiratory medicine, 98(10), 977-983.\u003c/li\u003e\n\u003cli\u003eEjima, M., Okamoto, T., Suzuki, T., et al (2021). Efficacy of treatment with corticosteroids for fibrotic hypersensitivity pneumonitis: a propensity score-matched cohort analysis. \u003cem\u003eBMC Pulmonary Medicine,\u003c/em\u003e 21(1), 1-12.\u003c/li\u003e\n\u003cli\u003eVasakova M, Morell F, Walsh S, Leslie K, Raghu G. Hypersensitivity pneumonitis: perspectives in diagnosis and management. \u003cem\u003eAm J\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003eRespir Crit Care Med\u003c/em\u003e 2017;196:680\u0026ndash;689.\u003c/li\u003e\n\u003cli\u003eSalisbury 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. \u003cem\u003eAm J Respir Crit Care Med\u003c/em\u003e 2017;196:690\u0026ndash;699.\u003c/li\u003e\n\u003cli\u003eVasakova M, Selman M, Morell F, Sterclova M, Molina-Molina M, Raghu G. Hypersensitivity pneumonitis: current concepts of pathogenesis and potential targets for treatment. \u003cem\u003eAm J Respir Crit Care Med\u003c/em\u003e 2019;200:301\u0026ndash;308.\u003c/li\u003e\n\u003cli\u003eZo S, Chung MP, Yoo HY, et al. Clinical characteristics and outcomes of hypersensitivity pneumonitis in South Korea. \u003cem\u003eTher Adv Respir Dis\u003c/em\u003e. 2023 Jan-Dec;17:17534666231212304. \u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez P\u0026eacute;rez ER, Swigris JJ, Forss\u0026eacute;n AV\u003cem\u003e, et al\u003c/em\u003e. Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. \u003cem\u003eChest \u003c/em\u003e2013; 144: 1644\u0026ndash;1651.\u003c/li\u003e\n\u003cli\u003eAndo M, Arima K, Yoneda R\u003cem\u003e, et al\u003c/em\u003e. Japanese summer-type hypersensitivity pneumonitis. Geographic distribution, home environment, and clinical characteristics of 621 cases. \u003cem\u003eAm Rev Respir Dis \u003c/em\u003e1991; 144: 765\u0026ndash;769.\u003c/li\u003e\n\u003cli\u003eNishida T, Kawate E, Ishiguro T\u003cem\u003e, et al\u003c/em\u003e. Antigen\u003cem\u003e \u003c/em\u003eavoidance and outcome of nonfibrotic and\u003cem\u003e \u003c/em\u003efibrotic hypersensitivity pneumonitis. \u003cem\u003eERJ Open Res \u003c/em\u003e2022; 8.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003e. \u003c/strong\u003eChen X, Yang X, Ren Y, et al. Clinical characteristics of hypersensitivity pneumonitis: non-fibrotic and fibrotic subtypes. \u003cem\u003eChin Med J (Engl).\u003c/em\u003e 2023 Dec 5;136(23):2839-2846. \u003c/li\u003e\n\u003cli\u003eSpalgais S, Mrigpuri P, Ravishankar N, Kumar R. Pulmonary Function and Diffusing Capacity of Carbon Monoxide in Hypersensitivity Pneumonitis: An Observational Study of 152 Patients. \u003cem\u003eThorac Res Pract. \u003c/em\u003e2024 Mar;25(2):51-56. \u003c/li\u003e\n\u003cli\u003eKumar R, Spalgais S, Ranga V. Hypersensitivity pneumonitis: clinical, radiological and pathological profile of 103 patients from North India\u003cem\u003e. Monaldi Arch Chest Dis\u003c/em\u003e. 2020;90(3):1307.\u003c/li\u003e\n\u003cli\u003eMorais A, Winck JC, Delgado L et al. Suberosis and bird Fancier\u0026rsquo;s Disease: a comparative study of radiological, functional and bronchoalveolarlavage profiles. \u003cem\u003eJ Investig Allergol Clin Immunol\u003c/em\u003e.2004;14(1):26-33.\u003c/li\u003e\n\u003cli\u003eMorell F, Roger \u0026Agrave;, Reyes L, Cruz MJ, Murio C, Mu\u0026ntilde;oz X. Bird fancier\u0026rsquo;s lung: a series of 86 patients. \u003cem\u003eMed (Baltim)\u003c/em\u003e. 2008;87(2):110-130.\u003c/li\u003e\n\u003cli\u003eGimenez A, Storrer K, Kuranishi L, et al. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. \u003cem\u003eThorax \u003c/em\u003e2018;73:391-2.\u003c/li\u003e\n\u003cli\u003eHorimasu Y, Ishikawa N, Iwamoto H, et al. Clinical and molecular features of rapidly progressive chronic hypersensitivity pneumonitis. \u003cem\u003eSarcoidosis Vasc Diffuse Lung Dis \u003c/em\u003e2017;34:48-57.\u003c/li\u003e\n\u003cli\u003eKaburaki S, Okuda R, Takemura T, et al. Compatible with fibrotic hypersensitivity pneumonitis on high-resolution computed tomography: from the ATS/JRS/ALAT 2020 hypersensitivity pneumonitis guidelines\u003cem\u003e. J Thorac Dis.\u003c/em\u003e 2024 Apr 30;16(4):2353-2364. doi: 10.21037/jtd-23-1845. \u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez P\u0026eacute;rez ER, Travis WD, Lynch DA, et al. Executive summary diagnosis and evaluation of hypersensitivity pneumonitis: CHEST guideline and expert panel report. \u003cem\u003eChest\u003c/em\u003e 2021; 160: 595\u0026ndash;615.\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. \u003cem\u003eAm J Respir Crit Care Me\u003c/em\u003ed 2020; 202: e36\u0026ndash;e69.\u003c/li\u003e\n\u003cli\u003eDe Sadeleer LJ, Hermans F, De Dycker E, et al. Effects of corticosteroid treatment and antigen avoidance in a large hypersensitivity pneumonitis cohort: a single-centre cohort study\u003cem\u003e. J Clin Med\u003c/em\u003e 2018; 8: 14.\u003c/li\u003e\n\u003cli\u003eFlaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. \u003cem\u003eN Engl J Med\u003c/em\u003e 2019; 381: 1718\u0026ndash;1727.\u003c/li\u003e\n\u003cli\u003eCottin V, Richeldi L, Rosas I, et al. Nintedanib and immunomodulatory therapies in progressive fibrosing interstitial lung diseases. \u003cem\u003eRespir Res\u003c/em\u003e 2021; 22: 84.\u003c/li\u003e\n\u003cli\u003eShibata S, Furusawa H, Inase N. Pirfenidone in chronic hypersensitivity pneumonitis: a real-life experience. \u003cem\u003eSarcoidosis Vasc Diffuse Lung Dis\u003c/em\u003e 2018; 35: 139\u0026ndash;142.\u003c/li\u003e\n\u003cli\u003eBehr J, Prasse A, Kreuter M, et al. Pirfenidone in patients with progressive fibrotic interstitial lung diseases other than idiopathic pulmonary fibrosis (RELIEF): a double-blind, randomised, placebo-controlled, phase 2b trial. \u003cem\u003eLancet Respir Med\u003c/em\u003e 2021; 9: 476\u0026ndash;486.\u003c/li\u003e\n\u003cli\u003eKoro\u0026scaron;ec P, Gibbs BF, Rijavec M, Custovic A, Turner PJ. Important and specific role for basophils in acute allergic reactions. \u003cem\u003eClin Exp Allergy\u003c/em\u003e. 2018 May;48(5):502-512.\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":"Basophilia, Bird products, Fibrotic disease, Hypersensitivity pneumonitis","lastPublishedDoi":"10.21203/rs.3.rs-5418767/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5418767/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypersensitivity pneumonitis (HP) is an inflammatory fibrotic disease that affects the lung parenchyma and small airways.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eOur study aimed to evaluate the clinical and radiological features of patients with an HP diagnosis in follow-up.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e \u003cp\u003eA retrospective cross-sectional study.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eOur study included 100 patients diagnosed with HP who were diagnosed and managed in our clinic between 2020 and 2024. Clinical data, comorbidities, pulmonary function test-carbon monoxide diffusion capacity (PFT-DLCO) parameters, six-minute walk test results, high-resolution lung computed tomography (HRCT) patterns, prognosis, and mortality data were retrospectively documented.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn our study, the male\u0026ndash;female ratio was equal (50\u0026ndash;50). The mean age was 63 (\u0026plusmn;\u0026thinsp;14). The majority of the patients were active smokers. While 65% of the patients were exposed to an organic or inorganic agent, 86.4% of all known exposures were caused by exposure to birds and bird products. A total of 29 patients (29%) were diagnosed by surgical sampling. The most common HRCT findings were reticulation (87%), ground-glass opacities (84.7%), and centrilobular nodules (75%). Fibrosis findings were seen in 40% of the patients. Glucocorticoids were the main treatment (77%), and 20 (20%) patients also required antifibrotic treatment. When correlation analyses were performed, the neutrophil count showed a negative correlation with the presence of a mosaic pattern, while a positive correlation was found with the presence of honeycombing. The basophil count had a positive correlation with exposure to birds and bird products.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e There are no guidelines or consensus published in Turkiye regarding the diagnosis and treatment of HP. In our study, the positive correlation between the neutrophil count of the patients and the development of fibrosis in HRCT suggested that neutrophilia may also be a poor prognostic factor. The positive correlation between exposure to birds and bird products and basophilia was a striking finding.\u003c/p\u003e","manuscriptTitle":"Evaluation of clinical and radiological features of patients diagnosed with hypersensitivity pneumonia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-28 11:21:29","doi":"10.21203/rs.3.rs-5418767/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":"dc39ff38-173a-4d41-b6a5-3e44d209865e","owner":[],"postedDate":"November 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-08T06:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-28 11:21:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5418767","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5418767","identity":"rs-5418767","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}