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Semin Respir Crit Care Med 2020; 41(02): 214-228
DOI: 10.1055/s-0040-1701250
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Clinical Decision-Making in Hypersensitivity Pneumonitis: Diagnosis and Management

Evans R. Fernández Pérez
1   Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
,
Tilman L. Koelsch
2   Division of Radiology, National Jewish Health, Denver, Colorado
,
Paolo M. Leone
3   Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
,
Steve D. Groshong
4   Division of Pathology, Department of Medicine, National Jewish Health, Denver, Colorado
,
David A. Lynch
2   Division of Radiology, National Jewish Health, Denver, Colorado
,
Kevin K. Brown
1   Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
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Publikationsverlauf

Publikationsdatum:
12. April 2020 (online)

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Abstract

This review provides an updated approach to the diagnosis and management of hypersensitivity pneumonitis (HP). The importance of using a multidisciplinary discussion to increase diagnostic and treatment confidence is emphasized. The role of Bayesian reasoning is highlighted throughout, underscoring the importance of hypothesis generation (differential diagnosis) and diagnostic test interpretation based on the probability of HP. Probability estimates of diagnostic certainty (i.e., a confident versus a working diagnosis) and treatment thresholds are carefully examined.

Therapeutically, beyond antigen avoidance and newly available antifibrotic therapy for patients with a progressive fibrosing phenotype; the role, timing, and expected response to anti-inflammatory therapy in individual patients are unanswered questions. Since the evidence and validation of testing generally performed during the diagnostic work-up and longitudinal monitoring of HP is feeble at best, the viewpoints discussed are not intended to resolve current controversies but rather to provide a conceptual framework for evaluating discordant information when evaluating and caring for patients with HP.

Keywords

hypersensitivity pneumonitis - occupational lung disease - interstitial lung disease - pulmonary fibrosis
 

  • References

  • 1 Selman M, King TE, Pardo A. ; American Thoracic Society; European Respiratory Society; American College of Chest Physicians. Idiopathic pulmonary fibrosis: prevailing and evolving hypotheses about its pathogenesis and implications for therapy. Ann Intern Med 2001; 134 (02) 136-151
    PubMedGoogle Scholar
  • 2 Lacasse Y, Selman M, Costabel U. , et al; HP Study Group. Classification of hypersensitivity pneumonitis: a hypothesis. Int Arch Allergy Immunol 2009; 149 (02) 161-166
    CrossrefPubMedGoogle Scholar
  • 3 Johannson KA, Elicker BM, Vittinghoff E. , et al. A diagnostic model for chronic hypersensitivity pneumonitis. Thorax 2016; 71 (10) 951-954
    CrossrefPubMedGoogle Scholar
  • 4 Cramer C, Schlünssen V, Bendstrup E. , et al. Risk of hypersensitivity pneumonitis and interstitial lung diseases among pigeon breeders. Eur Respir J 2016; 48 (03) 818-825
    CrossrefPubMedGoogle Scholar
  • 5 Singh S, Collins BF, Sharma BB. , et al. Interstitial lung disease in India. Results of a prospective registry. Am J Respir Crit Care Med 2017; 195 (06) 801-813
    CrossrefPubMedGoogle Scholar
  • 6 Fernandez Perez ER, Brown KK. Fibrotic hypersensitivity pneumonitis. Curr Respir Care Rep 2014; 3: 170-178
    CrossrefPubMedGoogle Scholar
  • 7 Morell F, Villar A, Montero MA. , et al. Chronic hypersensitivity pneumonitis in patients diagnosed with idiopathic pulmonary fibrosis: a prospective case-cohort study. Lancet Respir Med 2013; 1 (09) 685-694
    CrossrefPubMedGoogle Scholar
  • 8 Tzilas V, Tzouvelekis A, Bouros E. , et al. Diagnostic value of BAL lymphocytosis in patients with indeterminate for UIP imaging pattern. Eur Respir J 2019
    PubMedGoogle Scholar
  • 9 Papali A, Hines SE. Evaluation of the patient with an exposure-related disease: the occupational and environmental history. Curr Opin Pulm Med 2015; 21 (02) 155-162
    CrossrefPubMedGoogle Scholar
  • 10 Taking the occupational history. Ann Intern Med 1983; 99 (05) 641-651
    PubMedGoogle Scholar
  • 11 Chew GL, Horner WE, Kennedy K. , et al. Procedures to assist health care providers to determine when home assessments for potential mold exposure are warranted. J Allergy Clin Immunol Pract 2016; 4: 417-422 e2
    CrossrefPubMedGoogle Scholar
  • 12 Hill AB. The environment and disease: association or causation? 1965. J R Soc Med 2015; 108 (01) 32-37
    CrossrefPubMedGoogle Scholar
  • 13 Millerick-May ML, Mulks MH, Gerlach J. , et al. Hypersensitivity pneumonitis and antigen identification--An alternate approach. Respir Med 2016; 112: 97-105
    CrossrefPubMedGoogle Scholar
  • 14 Muñoz X, Sanchez-Ortíz M, Ojanguren I, Cruz MJ. Inhalation challenge in the differential diagnosis of usual interstitial pneumonia. Eur Respir Rev 2015; 24 (137) 542-544
    CrossrefPubMedGoogle Scholar
  • 15 Hodgson MJ, Parkinson DK, Karpf M. Chest X-rays in hypersensitivity pneumonitis: a metaanalysis of secular trend. Am J Ind Med 1989; 16 (01) 45-53
    CrossrefPubMedGoogle Scholar
  • 16 Lynch DA, Rose CS, Way D, King Jr TE. Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study. AJR Am J Roentgenol 1992; 159 (03) 469-472
    CrossrefPubMedGoogle Scholar
  • 17 Silva CI, Müller NL, Lynch DA. , et al. Chronic hypersensitivity pneumonitis: differentiation from idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia by using thin-section CT. Radiology 2008; 246 (01) 288-297
    CrossrefPubMedGoogle Scholar
  • 18 Christe A, Charimo-Torrente J, Roychoudhury K, Vock P, Roos JE. Accuracy of low-dose computed tomography (CT) for detecting and characterizing the most common CT-patterns of pulmonary disease. Eur J Radiol 2013; 82 (03) e142-e150
    CrossrefPubMedGoogle Scholar
  • 19 Hodnett PA, Naidich DP. Fibrosing interstitial lung disease. A practical high-resolution computed tomography-based approach to diagnosis and management and a review of the literature. Am J Respir Crit Care Med 2013; 188 (02) 141-149
    CrossrefPubMedGoogle Scholar
  • 20 Kazerooni EA. High-resolution CT of the lungs. AJR Am J Roentgenol 2001; 177 (03) 501-519
    CrossrefPubMedGoogle Scholar
  • 21 Murata K, Itoh H, Todo G. , et al. Centrilobular lesions of the lung: demonstration by high-resolution CT and pathologic correlation. Radiology 1986; 161 (03) 641-645
    CrossrefPubMedGoogle Scholar
  • 22 Rival G, Manzoni P, Lacasse Y. , et al. High-resolution CT predictors of hypersensitivity pneumonitis. Sarcoidosis Vasc Diffuse Lung Dis 2016; 33 (02) 117-123
    PubMedGoogle Scholar
  • 23 Travis WD, Costabel U, Hansell DM. , et al; ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2013; 188 (06) 733-748
    CrossrefPubMedGoogle Scholar
  • 24 Remy-Jardin M, Giraud F, Remy J, Copin MC, Gosselin B, Duhamel A. Importance of ground-glass attenuation in chronic diffuse infiltrative lung disease: pathologic-CT correlation. Radiology 1993; 189 (03) 693-698
    CrossrefPubMedGoogle Scholar
  • 25 Okada F, Ando Y, Yoshitake S. , et al. Clinical/pathologic correlations in 553 patients with primary centrilobular findings on high-resolution CT scan of the thorax. Chest 2007; 132 (06) 1939-1948
    CrossrefPubMedGoogle Scholar
  • 26 Hansell DM, Wells AU, Padley SP, Müller NL. Hypersensitivity pneumonitis: correlation of individual CT patterns with functional abnormalities. Radiology 1996; 199 (01) 123-128
    CrossrefPubMedGoogle Scholar
  • 27 Kligerman SJ, Henry T, Lin CT, Franks TJ, Galvin JR. Mosaic attenuation: etiology, methods of differentiation, and pitfalls. Radiographics 2015; 35 (05) 1360-1380
    CrossrefPubMedGoogle Scholar
  • 28 Chung JH, Zhan X, Cao M. , et al. Presence of air trapping and mosaic attenuation on chest CT predicts survival in chronic hypersensitivity pneumonitis. Ann Am Thorac Soc 2017; 14 (10) 1533-1538
    CrossrefPubMedGoogle Scholar
  • 29 Salisbury ML, Gross BH, Chughtai A. , et al. Development and validation of a radiological diagnosis model for hypersensitivity pneumonitis. Eur Respir J 2018; 52 (02) 52
    CrossrefPubMedGoogle Scholar
  • 30 Chong BJ, Kanne JP, Chung JH. Headcheese sign. J Thorac Imaging 2014; 29 (01) W13
    CrossrefPubMedGoogle Scholar
  • 31 Barnett J, Molyneaux PL, Rawal B. , et al. Variable utility of mosaic attenuation to distinguish fibrotic hypersensitivity pneumonitis from idiopathic pulmonary fibrosis. Eur Respir J 2019; 54 (01) 54
    PubMedGoogle Scholar
  • 32 Mooney JJ, Elicker BM, Urbania TH. , et al. Radiographic fibrosis score predicts survival in hypersensitivity pneumonitis. Chest 2013; 144 (02) 586-592
    CrossrefPubMedGoogle Scholar
  • 33 Fernández Pérez ER. The role of computed tomography honeycombing in profiling disease progression in chronic interstitial lung disease. Ann Am Thorac Soc 2019; 16 (05) 546-548
    CrossrefPubMedGoogle Scholar
  • 34 Salisbury ML, Gu T, Murray S. , et al. Hypersensitivity pneumonitis: radiologic phenotypes are associated with distinct survival time and pulmonary function trajectory. Chest 2019; 155 (04) 699-711
    CrossrefPubMedGoogle Scholar
  • 35 Jacob J, Odink A, Brun AL. , et al. Functional associations of pleuroparenchymal fibroelastosis and emphysema with hypersensitivity pneumonitis. Respir Med 2018; 138: 95-101
    CrossrefPubMedGoogle Scholar
  • 36 Chiba S, Tsuchiya K, Akashi T. , et al. Chronic hypersensitivity pneumonitis with a usual interstitial pneumonia-like pattern: correlation between histopathologic and clinical findings. Chest 2016; 149 (06) 1473-1481
    CrossrefPubMedGoogle Scholar
  • 37 Fernández Pérez ER, Kong AM, Raimundo K, Koelsch TL, Kulkarni R, Cole AL. Epidemiology of Hypersensitivity pneumonitis among an insured population in the United States: a claims-based cohort analysis. Ann Am Thorac Soc 2018; 15 (04) 460-469
    CrossrefPubMedGoogle Scholar
  • 38 Fernández Pérez ER, Sprunger DB, Ratanawatkul P. , et al. Increasing hypersensitivity pneumonitis-related mortality in the United States from 1988 to 2016. Am J Respir Crit Care Med 2019; 199 (10) 1284-1287
    CrossrefPubMedGoogle Scholar
  • 39 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 (05) 1644-1651
    CrossrefPubMedGoogle Scholar
  • 40 Walters GI, Mokhlis JM, Moore VC. , et al. Characteristics of hypersensitivity pneumonitis diagnosed by interstitial and occupational lung disease multi-disciplinary team consensus. Respir Med 2019; 155: 19-25
    CrossrefPubMedGoogle Scholar
  • 41 Iijima Y, Sugiyama Y, Suzuki E, Nakayama M, Yamasawa H, Bando M. The relationship between the incidence of summer-type hypersensitivity pneumonitis and environmental factors in Southern Tochigi Prefecture. Intern Med 2017; 56 (09) 1023-1027
    CrossrefPubMedGoogle Scholar
  • 42 Fernández Pérez ER, Yilmaz M, Jenad H. , et al. Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease. Chest 2008; 133 (05) 1113-1119
    CrossrefPubMedGoogle Scholar
  • 43 Adegunsoye A, Oldham JM, Bonham C. , et al. Prognosticating outcomes in interstitial lung disease by mediastinal lymph node assessment. An observational cohort study with independent validation. Am J Respir Crit Care Med 2019; 199 (06) 747-759
    CrossrefPubMedGoogle Scholar
  • 44 Chung JH, Montner SM, Adegunsoye A. , et al. CT findings associated with survival in chronic hypersensitivity pneumonitis. Eur Radiol 2017; 27 (12) 5127-5135
    CrossrefPubMedGoogle Scholar
  • 45 Ley B, Torgerson DG, Oldham JM. , et al. Rare protein-altering telomere-related gene variants in patients with chronic hypersensitivity pneumonitis. Am J Respir Crit Care Med 2019; 200 (09) 1154-1163
    CrossrefPubMedGoogle Scholar
  • 46 Ley B, Newton CA, Arnould I. , et al. The MUC5B promoter polymorphism and telomere length in patients with chronic hypersensitivity pneumonitis: an observational cohort-control study. Lancet Respir Med 2017; 5 (08) 639-647
    CrossrefPubMedGoogle Scholar
  • 47 Newton CA, Batra K, Torrealba J. , et al. Telomere-related lung fibrosis is diagnostically heterogeneous but uniformly progressive. Eur Respir J 2016; 48 (06) 1710-1720
    CrossrefPubMedGoogle Scholar
  • 48 Alqalyoobi S, Adegunsoye A, Linderholm A. , et al. Circulating plasma biomarkers of progressive interstitial lung disease. Am J Respir Crit Care Med 2019; (e-pub ahead of print) DOI: 10.1164/rccm.201907-1343LE.
    CrossrefPubMedGoogle Scholar
  • 49 Earis JE, Marsh K, Pearson MG, Ogilvie CM. The inspiratory “squawk” in extrinsic allergic alveolitis and other pulmonary fibroses. Thorax 1982; 37 (12) 923-926
    CrossrefPubMedGoogle Scholar
  • 50 Flaherty KR, King Jr TE, Raghu G. , et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis?. Am J Respir Crit Care Med 2004; 170 (08) 904-910
    CrossrefPubMedGoogle Scholar
  • 51 de Gracia J, Morell F, Bofill JM, Curull V, Orriols R. Time of exposure as a prognostic factor in avian hypersensitivity pneumonitis. Respir Med 1989; 83 (02) 139-143
    CrossrefPubMedGoogle Scholar
  • 52 Allen DH, Williams GV, Woolcock AJ. Bird breeder's hypersensitivity pneumonitis: progress studies of lung function after cessation of exposure to the provoking antigen. Am Rev Respir Dis 1976; 114 (03) 555-566
    PubMedGoogle Scholar
  • 53 Zacharisen MC, Schlueter DP, Kurup VP, Fink JN. The long-term outcome in acute, subacute, and chronic forms of pigeon breeder's disease hypersensitivity pneumonitis. Ann Allergy Asthma Immunol 2002; 88 (02) 175-182
    CrossrefPubMedGoogle Scholar
  • 54 Gimenez A, Storrer K, Kuranishi L, Soares MR, Ferreira RG, Pereira CAC. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. Thorax 2018; 73 (04) 391-392
    CrossrefPubMedGoogle Scholar
  • 55 Kokkarinen JI, Tukiainen HO, Terho EO. Effect of corticosteroid treatment on the recovery of pulmonary function in farmer's lung. Am Rev Respir Dis 1992; 145 (01) 3-5
    CrossrefPubMedGoogle Scholar
  • 56 Morisset J, Johannson KA, Vittinghoff E. , et al. Use of mycophenolate mofetil or azathioprine for the management of chronic hypersensitivity pneumonitis. Chest 2017; 151 (03) 619-625
    CrossrefPubMedGoogle Scholar
  • 57 Adegunsoye A, Oldham JM, Fernández Pérez ER. , et al. Outcomes of immunosuppressive therapy in chronic hypersensitivity pneumonitis. ERJ Open Res 2017; 3 (03) 3
    CrossrefPubMedGoogle Scholar
  • 58 Jinta T, Miyazaki Y, Kishi M. , et al. The pathogenesis of chronic hypersensitivity pneumonitis in common with idiopathic pulmonary fibrosis: expression of apoptotic markers. Am J Clin Pathol 2010; 134 (04) 613-620
    CrossrefPubMedGoogle Scholar
  • 59 Coalson JJ. The ultrastructure of human fibrosing alveolitis. Virchows Arch A Pathol Anat Histol 1982; 395 (02) 181-199
    CrossrefPubMedGoogle Scholar
  • 60 King Jr TE, Bradford WZ, Castro-Bernardini S. , et al; ASCEND Study Group. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014; 370 (22) 2083-2092
    CrossrefPubMedGoogle Scholar
  • 61 Richeldi L, du Bois RM, Raghu G. , et al; INPULSIS Trial Investigators. Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. N Engl J Med 2014; 370 (22) 2071-2082
    CrossrefPubMedGoogle Scholar
  • 62 Flaherty KR, Wells AU, Cottin V. , et al; INBUILD Trial Investigators. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med 2019; 381 (18) 1718-1727
    CrossrefPubMedGoogle Scholar
  • 63 Bang KM, Weissman DN, Pinheiro GA, Antao VC, Wood JM, Syamlal G. Twenty-three years of hypersensitivity pneumonitis mortality surveillance in the United States. Am J Ind Med 2006; 49 (12) 997-1004
    CrossrefPubMedGoogle Scholar
  • 64 Coultas DB, Zumwalt RE, Black WC, Sobonya RE. The epidemiology of interstitial lung diseases. Am J Respir Crit Care Med 1994; 150 (04) 967-972
    CrossrefPubMedGoogle Scholar
  • 65 Madsen D, Klock LE, Wenzel FJ, Robbins JL, Schmidt CD. The prevalence of farmer's lung in an agricultural population. Am Rev Respir Dis 1976; 113 (02) 171-174
    PubMedGoogle Scholar
  • 66 Rittig AH, Hilberg O, Ibsen R, Løkke A. Incidence, comorbidity and survival rate of hypersensitivity pneumonitis: a national population-based study. ERJ Open Res 2019; 5 (04) 5
    PubMedGoogle Scholar
  • 67 Duchemann B, Annesi-Maesano I, Jacobe de Naurois C. , et al. Prevalence and incidence of interstitial lung diseases in a multi-ethnic county of Greater Paris. Eur Respir J 2017; 50 (02) 50
    CrossrefPubMedGoogle Scholar
  • 68 Barber CM, Wiggans RE, Carder M, Agius R. Epidemiology of occupational hypersensitivity pneumonitis; reports from the SWORD scheme in the UK from 1996 to 2015. Occup Environ Med 2017; 74 (07) 528-530
    CrossrefPubMedGoogle Scholar
  • 69 Hyldgaard C, Hilberg O, Muller A, Bendstrup E. A cohort study of interstitial lung diseases in central Denmark. Respir Med 2014; 108 (05) 793-799
    CrossrefPubMedGoogle Scholar
  • 70 Hanley A, Hubbard RB, Navaratnam V. Mortality trends in asbestosis, extrinsic allergic alveolitis and sarcoidosis in England and Wales. Respir Med 2011; 105 (09) 1373-1379
    CrossrefPubMedGoogle Scholar
  • 71 Karakatsani A, Papakosta D, Rapti A. , et al; Hellenic Interstitial Lung Diseases Group. Epidemiology of interstitial lung diseases in Greece. Respir Med 2009; 103 (08) 1122-1129
    CrossrefPubMedGoogle Scholar
  • 72 Fenclová Z, Pelclová D, Urban P, Navrátil T, Klusácková P, Lebedová J. Occupational hypersensitivity pneumonitis reported to the Czech National Registry Of Occupational Diseases in the period 1992-2005. Ind Health 2009; 47 (04) 443-448
    CrossrefPubMedGoogle Scholar
  • 73 Kornum JB, Christensen S, Grijota M. , et al. The incidence of interstitial lung disease 1995-2005: a Danish nationwide population-based study. BMC Pulm Med 2008; 8: 24
    CrossrefPubMedGoogle Scholar
  • 74 Solaymani-Dodaran M, West J, Smith C, Hubbard R. Extrinsic allergic alveolitis: incidence and mortality in the general population. QJM 2007; 100 (04) 233-237
    CrossrefPubMedGoogle Scholar
  • 75 Xaubet A, Ancochea J, Morell F. , et al; Spanish Group on Interstitial Lung Diseases, SEPAR. Report on the incidence of interstitial lung diseases in Spain. Sarcoidosis Vasc Diffuse Lung Dis 2004; 21 (01) 64-70
    PubMedGoogle Scholar
  • 76 Schweisfurth H. Report by the Scientific Working Group for Therapy of Lung Diseases: German Fibrosis Register with initial results [in German]. Pneumologie 1996; 50 (12) 899-901
    PubMedGoogle Scholar
  • 77 Agostini C, Albera C, Bariffi F. , et al; Registro Italiano Pneumopatie Infiltrative Diffuse. First report of the Italian register for diffuse infiltrative lung disorders (RIPID). Monaldi Arch Chest Dis 2001; 56 (04) 364-368
    PubMedGoogle Scholar
  • 78 Thomeer M, Demedts M, Vandeurzen K. ; VRGT Working Group on Interstitial Lung Diseases. Registration of interstitial lung diseases by 20 centres of respiratory medicine in Flanders. Acta Clin Belg 2001; 56 (03) 163-172
    CrossrefPubMedGoogle Scholar
  • 79 Dalphin JC, Debieuvre D, Pernet D. , et al. Prevalence and risk factors for chronic bronchitis and farmer's lung in French dairy farmers. Br J Ind Med 1993; 50 (10) 941-944
    PubMedGoogle Scholar
  • 80 Malmberg P, Rask-Andersen A, Höglund S, Kolmodin-Hedman B, Read Guernsey J. Incidence of organic dust toxic syndrome and allergic alveolitis in Swedish farmers. Int Arch Allergy Appl Immunol 1988; 87 (01) 47-54
    CrossrefPubMedGoogle Scholar
  • 81 Terho EO, Heinonen OP, Lammi S, Laukkanen V. Incidence of clinically confirmed farmer's lung in Finland and its relation to meteorological factors. Eur J Respir Dis Suppl 1987; 152: 47-56
    PubMedGoogle Scholar
  • 82 Terho EO, Heinonen OP, Lammi S. Incidence of farmer's lung leading to hospitalization and its relation to meteorological observations in Finland. Acta Med Scand 1983; 213 (04) 295-298
    PubMedGoogle Scholar
  • 83 Hendrick DJ, Faux JA, Marshall R. Budgerigar-fancier's lung: the commonest variety of allergic alveolitis in Britain. BMJ 1978; 2 (6130): 81-84
    CrossrefPubMedGoogle Scholar
  • 84 Grant IW, Blyth W, Wardrop VE, Gordon RM, Pearson JC, Mair A. Prevalence of farmer's lung in Scotland: a pilot survey. BMJ 1972; 1 (5799): 530-534
    CrossrefPubMedGoogle Scholar
  • 85 Boyd DH. The incidence of farmer's lung in Caithness. Scott Med J 1971; 16 (05) 261-262
    CrossrefPubMedGoogle Scholar
  • 86 Musellim B, Okumus G, Uzaslan E. , et al; Turkish Interstitial Lung Diseases Group. Epidemiology and distribution of interstitial lung diseases in Turkey. Clin Respir J 2014; 8 (01) 55-62
    CrossrefPubMedGoogle Scholar
  • 87 Alhamad EH. Interstitial lung diseases in Saudi Arabia: a single-center study. Ann Thorac Med 2013; 8 (01) 33-37
    CrossrefPubMedGoogle Scholar