You are presented a case of a 34-year-old previously healthy woman who presents
to the ER with progressive shortness of breath, dry cough, and fatigue for 3 weeks.
She also reports intermittent low-grade fevers and unintentional weight loss (~5 lbs).
She denies chest pain or hemoptysis. She works in a small bakery and has no recent
travel. She has two cats and a dog and has had no recent travel or known exposure
to ifectious illnesses.
Physical examination reveals a well developed woman who appears her stated age. Her
temperature is 99.5°F, heart rate 102 beats per minute, and respiratory rate 20 breaths
per minute. Her blood pressure is 118/76 mm Hg. Her SpO2 is 91% on room air. Pertinent
findings include bibasilar inspiratory crackles without dullness. The physical examination
is otherwise normal.
Pertinent laboratory findings include a mild leukocytosis and an elevated CRP. A chest
x-ray shows a diffuse increase in interstitial markings. Tests for COVID, influenza
and HIV are negative. Results of an ANA and rheumatoid factor are pending.
DIAGNOSIS: Hypersensitivity pneumonitis ("Bakers lung") due to chronic inhalation of moldy
flour or thermophilic actinomycetes in the bakery environment.
Teaching points: 1. Occupational exposure clues are critical; 2. Subacute hypersensitivity pneumonia
can mimic viral or autoimmune pneumonia; 3. Early recognition and removal from exposure
can be curative; and 4. BAL lymphocytosis and autoimmune IgG precipitins to the offending
fungus/fungi are diagnostic.