It's Time to Blame the Birds

Abstract

INTRODUCTION: Bird Fancier's Lung (BFL) is one of the most common forms of hypersensitivity pneumonitis; however, patients can be quite heterogeneous and have varying clinical presentations. We present a case of a 51-year-old man with exposure to multiple parakeets at his home with 12 years of recurrent symptoms.CASE PRESENTATION: Over a period of 12 years, the patient had experienced recurrent episodes of shortness of breath and cough productive of white sputum clumps and plastic-looking casts of his airways. He was diagnosed on several occasions with right middle and lower lobe pneumonia with radiologic findings of interstitial and nodular infiltrates that improve with steroids and antibiotics, but would eventually recur. Bronchoscopy at that time was nondiagnostic and he underwent VATS lung biopsy (at an outside institution) of a right lower lobe infiltrate a year after initial onset of symptoms. Pathology demonstrated mild bronchiolitis and chronic inflammation and minimal fibrosis without evidence of active infectious pneumonia. This is unusual since biopsy findings of BFL typically include loosely formed granulomas, giant cells, lymphoplasmacytic interstitial infiltrate in addition to some degree of fibrosis that may be present. It is unknown if he was on steroids at the time of his biopsy. His only persistent finding over the years was a significantly elevated IgE level around 1000 IU/ml (normal 0-180 IU/ml). Diagnosis was established 12 years after onset of symptoms following a bronchoscopy and bronchoalveolar lavage which showed 60% lymphocytes and a Bird Fancier Profile Panel which was positive for IgG antibodies to parakeets but negative for IgE. He had initial improvement of symptoms and radiographic infiltrates with prednisone but managed to maintain extended relief after eliminating exposure to all but one of his birds at home in addition to twice daily fluticasone/salmeterol inhaler. DISCUSSION: A high grade of suspision is required to diagnose BFL. Exposure history and symptom resolution with elimination of antigen exposure were critical in this case.CONCLUSIONS: This case illustrates the importance of exposure history to diagnose hypersensitivity pneumonitis despite the absence of definitive initial workup.