Journal List > Ann Occup Environ Med > v.32(1) > 1141584

Nam, Park, Suh, Ham, Son, Kim, and Kim: Problems with diagnostic criteria for humidifier disinfectant lung injury (HDLI): two cases of radiologically improved HDLI

Abstract

Background

In Korea, to investigate the casual relationship between humidifier disinfectant and lung disease, four rounds of investigation and judgment were conducted. During this investigation, two adults who performed lung biopsy were recognized for their relevance between humidifier disinfectants and lung disease. At first, we did not think of the relationship to humidifier disinfectant because chest computed tomography (CT) finding of 2 cases were improved. However, they performed lung biopsy and it showed typical humidifier disinfectant lung injury (HDLI) pathologic findings, they could be recognized as HDLI. We report these cases here.

Case presentation

We selected 2 cases from the fourth-round investigation at Kangbuk Samsung Hospital. Patient of case 1 used humidifier disinfectants since September 2010. The patient was admitted 6 months later to the intensive care unit (ICU) due to severe dyspnea. Pathology following a lung biopsy revealed typical HDLI finding which was determined to be due to humidifier disinfectant exposure. Patient of case 2 used humidifier disinfectant from 2001 to 2008 for about 3 months each winter. The patient's cough and sputum production symptoms began in December of 2007. The patient was admitted to the respiratory medicine department due to worsening dyspnea. Pathology following a lung biopsy revealed typical HDLI finding. This was determined to have been caused by humidifier disinfectant exposure.

Conclusions

Because the typical radiologic findings associated with HDLI can improve over time, it is necessary to consider the revision of current diagnostic criteria that the presence of radiologic findings is important.

References

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Fig. 1.
(A) Case 1 chest HRCT (at the time of first hospital visit): It shows the appearance of an acute diffuse interstitial lung disease such as acute eosinophilic pneumonia, hypersensitivity pneumonitis, diffuse alveolar damage, or interstitial pneumonia. Symmetrically distributed GGOs and small centrilobular nodules were observed. (B) A chest HRCT of case 1 (taken 6 years after discontinuing humidifier disinfectant at Kangbuk Samsung Hospital): Symmetrically distributed GGOs, small centrilobular nodules of both lungs at the initial CT were disappeared. HRCT: high resolution computed tomography; GGO: ground glass opacity; CT: computed tomography.
aoem-32-e1f1.tif
Fig. 2.
(A) Initial chest HRCT of case 2 (at the time of first hospital visit): It shows diffuse ground glass opacity, centrilobular ground glass opacity and nodules, and mild fibrosis in right upper lobe with calcified nodules. (B) Chest HRCT of case 2 (taken 9 years after discontinuing humidifier disinfectant use at Kangbuk Samsung Hospital): Centrilobular GGOs and peribronchial GGOs that were initially present in both lungs were disappeared. A postinfectious granuloma of RUL and diffuse air trapping in both lungs were observed. HRCT: high resolution computed tomography; GGO: ground glass opacity; RUL: right upper lobe.
aoem-32-e1f2.tif
Fig. 3.
Case 2 lung pathology (February 15, 2008). Diffuse alveolar damage is present.
aoem-32-e1f3.tif
Table 1.
Radiologic criteria for humidifier disinfectant lung injury classification [6]
Classification Features
Definite Initially multifocal, patchy consolidation sparing subpleural areas, then with disappearance of consolidation followed by progression to diffuse, centrilobular, ground-glass opacity. No evidence of air trapping or reticular opacity.
Probable Persistent, diffuse, and extensive centrilobular ground-glass nodular opacities with no evidence of air trapping on follow-up computed tomography.
Possible Subtle features of diffuse and extensive centrilobular ground-glass opacities or other similar features.
Unlikely No evidence of diffuse and extensive centrilobular ground-glass opacity.
Table 2.
General evaluation classification and definition for HDLI levels [5]
Level Injury classification
Definite A confirmed case of humidifier disinfectant exposure, can be verified with centrilobular radiologic findings, typical clinical findings on the basis of clinical disease course and/or pathologic findings; HDLI (disease of the terminal bronchiole caused by humidifier disinfectant exposure) is almost certain or highly probably with no other potential lung disease causes.
Probable A confirmed case of humidifier disinfectant exposure, can be verified with centrilobular radiologic findings, typical clinical findings on the basis of clinical disease course and/or pathologic findings; HDLI (disease of the terminal bronchiole caused by humidifier disinfectant exposure) is probable or somewhat likely even though other causes cannot be completely ruled out.
Possible A confirmed case of humidifier disinfectant exposure, suspected due to existing findings, typical clinical findings on the basis of clinical disease course and/or pathologic findings that are not in line with typical HDLI; HDLI (disease of the terminal bronchiole caused by humidifier disinfectant exposure) is unlikely but other causes cannot be ruled out.
Unlikely A confirmed case of humidifier disinfectant exposure, case does not include typical radiologic findings, typical clinical findings on the basis of clinical disease course of and/or pathologic findings; almost certainly not HDLI (disease of the terminal bronchiole caused by humidifier disinfectant exposure) because other causes are suspected.

HDLI: humidifier disinfectant lung injury.

Table 3.
Case 1 and case 2 PFT results
Case Date FVC FEV1 FEV1/FVC DL CO
Case 1 2011.3.30 1.92 L (56.3%) 1.73 L (58.3%) 89.8% 42.6%
2017.10.27 3.42 L (94.0%) 2.99 L (96.0%) 88.0% 63.0%
Case 2 2008.2.12 1.81 L (57.0%) 1.36 L (56.0%) 75.0% 57.0%
2017.12.20 2.94 L (95.0%) 2.32 L (90.0%) 79.0% 69.0%

PFT: pulmonary function test; FVC: forced vital capacity; FEV1: forced expiratory volume in 1 second; D L CO: carbon monoxide diffusing capacity.

Table 4.
Comparison of first hospital and Kangbuk Samsung Hospital visit of case 1 patient
Variables First hospital visit Kangbuk Samsung Hospital visit (6 years after discontinuing humidifier disinfectant)
Symptom Cough, dyspnea, weight loss Improved
PFT FVC, 56.3%; FEV1/FVC, 89.8%; D L CO, 42.6% FVC, 94.0%; FEV1/FVC, 88.0%; D L CO, 63.0%
Radiologic finding Systemically distributed GGOs, centrilobular nodules Improved
Pathologic finding Acute and chronic inflammation with interstitial fibrosis Not performed

PFT: pulmonary function test; FVC: forced vital capacity; FEV1: forced expiratory volume in 1 second; D L CO: carbon monoxide diffusing capacity; GGO: ground glass opacity.

Table 5.
Comparison of first hospital and Kangbuk Samsung hospital visit of case 2 patient
Variables Symptom First hospital visit Cough, sputum, dyspnea Kangbuk Samsung Hospital visit (9 years after discontinuing humidifier disinfectant) Improved
PFT FVC, 57.0%; FEV1/FVC, 75.0%; D L CO, 57.0% FVC, 95.0%; FEV1/FVC, 79.0%; D L CO, 69.0%
Radiologic finding Diffuse GGOs, Centrilobular GGO and nodules Improved
Pathologic finding Diffuse alveolar damage Not performed

PFT: pulmonary function test; FVC: forced vital capacity; FEV1: forced expiratory volume in 1 second; D L CO: carbon monoxide diffusing capacity; GGO: ground glass opacity.

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