Arthritis and BRIEF CLINICAL OBSERVATIONS Hypergamma- - globulinemic Purpura in Hypersensitivity Pneumonitis

CASE REPORTS Case I A 51-year-old man was admitted because of dyspnea, thoracic pain, dry cough, and weight loss of 1 month duration. He had been holding parakeets for 40 years, Physical examination revealed dorsobasal pulmonary r-ales, palpable purpura on the legs, and swelling of both knees and the right ankle. Besides an erythrocyte sedimentation rate (ESR) of 80 mm/h, standard laboratory tests were normal. The serum protein concentration was elevated (85 g/L) due to hypergammaglobulinemia with raised immunoglobulin A &A) (13.3 g/L) and IgG (44.9 g/L). There were circulating immune complexes and complement activation. Antinuclear antibody and rheumatoid factor were negative. The arterial blood gas was unremarkable. Chest roentgenogram demonstrated fine reticulonodular shadows throughout both lungs. Antibodies to parakeet antigen were strongly positive. Pulmonary function tests revealed decreases in volume and diffusion capacity. The bronchoalveolar lavage (BAL) fluid showed 60% lymphocytes with a CD4XD8 ratio of 1. Transbronchial biopsies demonstrated interstitial pneumonitis. Biopsy of the purpura revealed a perivascular infiltrate and extravasation of erythrocytes. Joint fluid of the right knee showed 0.2 X 10a/mm3 leucocytes, and synovial biopsy showed a hyperplastic synovium. The diagnosis bird-breeder’s lung was made. After cessation of the exposure, the clinical signs disappeared. The chest roentgenogram and the pulmonary function tests improved after starting prednisone.