To identify clinical and radiologic findings that affect disease severity and short-term prognosis of humidifier disinfectant-associated lung injury in adults and to compare computed tomography (CT) findings between the patients with and without death or lung transplantation.
Fifty-nine adults (mean age, 34 years; M/F = 12:47) were enrolled in this retrospective study. Medical records and prospective surveillance data were used to assess clinical and radiological factors associated with a poor clinical outcome. Multivariate generalized estimating equation models were used to analyse serial CT findings. Overall cumulative major events including lung transplantation and mortality were assessed using the Kaplan–Meier method.
Almost half needed ICU admission (47.5 %) and 17 died (28.8 %). Young age, peripartum and low O2 saturation were factors associated with ICU admission. On initial chest radiographs, consolidation (P < 0.001) and ground-glass opacity (P = 0.01) were significantly noted in patients who required ICU admission. CT findings including consolidation (odds ratio (OR), 1.02), pneumomediastinum (OR, 1.66) and pulmonary interstitial emphysema (OR, 1.61) were the risk factors for lung transplantation and mortality.
Clinical and radiologic findings are related to the risks of lung transplantation and mortality of humidifier disinfectant-associated lung injury. Consolidation, pneumomediastinum and pulmonary interstitial emphysema were short-term prognostic CT findings.
• Young age, peripartum and low O 2 saturation were associated with ICU admission.
• Consolidation, pneumomediastinum and pulmonary interstitial emphysema were short-term prognostic CT findings.
• Consolidation and ground-glass opacity disappeared within 3 months and replaced by centrilobular nodules.
• Radiologic findings are related to the outcome of humidifier disinfectant-associated lung injury.
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acute respiratory distress syndrome
cryptogenic organizing pneumonia
intensive care unit
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The authors would like to thank all of the patients who participated in this study. We also thank the members of Humidifier Disinfectant Interstitial Lung Disease Surveillance and Research Team including the pulmonologists, pathologists and radiologists in our institution for their valuable help.
The scientific guarantor of this publication is Kyung-Hyun Do. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. This research was supported by the Environmental Health Center for Hazardous Chemical Exposure funded by the Ministry of Environment (2015-0510), Republic of Korea. One of the authors (Hwa Jung Kim) has significant statistical expertise. Institutional review board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study.
Seventeen patients from this were previously described (Hong S.B. et al. Thorax 69(8):694–702, 2014), as mentioned in the “Materials and methods” of this manuscript. Methodology: retrospective, observational, multicentre study.
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Pathologic findings in patients with four phases of lung injury from humidifier disinfectant use. (A) Acute phase: a transbronchial lung biopsy specimen showing organizing pneumonia pattern with proliferation of intra-alveolar fibroblastic polyps (hematoxylin and eosin, original magnification ×100). Wedge-resected specimens indicate the subacute phase (B), early chronic phase (C), and late chronic phase (D) (original magnifications ×40). The specimen showed a spectrum of fibro-inflammatory processes (arrows) with centrilobular distribution. Interestingly, the subpleural space was well preserved, even in the late chronic phase (arrowheads). (GIF 59 kb)
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Pathologic findings in the late chronic phase in patients who did not require intensive care (A and B) and who required intensive care (C and D). Both cases showed the typical pathologic findings of lung injury associated with humidifier disinfectant use. The fibro-inflammatory process showed a centrilobular distribution (arrow, A and C, original magnification ×40). Notably, the subpleural space was not involved, even in the end stage (arrowhead, A and C). Variable degrees of fibroblastic proliferation resulted in bronchiolar obliteration and peribronchiolar fibrosis (B, arrow, original magnification ×100). (D) In the case of the intensive care patient, the infiltration of numerous interstitial lymphoplasma cells in the background of pulmonary edema accompanied by bronchiolar obliteration could be identified (arrow, original magnification ×100). (GIF 70 kb)
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Koo, H.J., Do, KH., Chae, E.J. et al. Humidifier disinfectant-associated lung injury in adults: Prognostic factors in predicting short-term outcome. Eur Radiol 27, 203–211 (2017). https://doi.org/10.1007/s00330-016-4367-6