Extrinsic Allergic Alveolitis

  • Samuel P. Hammar

Abstract

The lung is the site of a variety of complex inflammatory reactions. In many instances the inflammation is a normal reaction against various infectious agents, such as bacteria and viruses, or is a response to necrotic tissue, such as infarcted lung parenchyma or degenerating tumor. In extrinsic allergic alveolitis, the inflammatory reaction characteristic of this condition is thought to represent a hypersensitivity process mediated by immunoglobulins, lymphokines, and immune effector cells. Although the four immunologic responses described by Gell and Coombs1 (Fig. 18-1) are often used in characterizing various inflammatory reactions in the lungs, the immunopathogenesis of extrinsic allergic alveolitis remains poorly understood. Extrinsic allergic alveolitis, also referred to as hypersensitivity pneumonitis or microgranulomatous hypersensitivity reaction, is a predominantly chronic inflammatory disease of the peripheral gas-exchanging portion of the lung resulting from sensitization and subsequent exposure to a variety of organic dusts. The condition was first described in 1932 in farmers exposed to moldy hay.2 Initially it was considered a mycotic process.3,4 Pepys and colleagues5,6 elucidated some of the initial immunologic mechanisms though to be operative in the disease. Williams7,8 demonstrated that the disease could be produced in sensitized farmers by the inhalation of extracts of moldy hay. Farmer’s lung disease was found to result from a hypersensitivity reaction against a species of thermophilic actinomyces, Thermoactinomyces vulgarus, that proliferated as the hay became overheated in the process of becoming moldy.9,10 Numerous organic antigens have now been recognized as causing hypersensitivity reactions in the lung, and these are usually named after the occupation in which the patient was exposed to the organic antigen. The term extrinsic allergic alveolitis was coined by Pepys11 to refer to the entire group of similar reactions to organic dusts.

Keywords

Idiopathic Pulmonary Fibrosis Bronchoalveolar Lavage Fluid Hypersensitivity Pneumonitis Open Lung Biopsy Organic Dust 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Gell RRA, Coombs PGH. Classification of allergic reactions responsible for clinical hypersensitivity disease. In: Gell PGH, Coombs RRA, eds. Clinical aspects of immunology. 2d Ed. Oxford, Blackwell, 1968: 575–596.Google Scholar
  2. 2.
    Campbell JM. Acute symptoms following work with hay. 22. Br Med J 1932; 2: 1143–1144.Google Scholar
  3. 3.
    Fawcitt R. Fungoid conditions of the lung. Br J Radiol 1936;9: 172–195; 354–378.Google Scholar
  4. 4.
    Tornell E. Thresher’s lung. Acta Med Scand 1946; 125: 191–219.CrossRefGoogle Scholar
  5. 5.
    Pepys J, Riddell RW, Citron KM, Clayton YM. Precipitins against extracts of hay and moulds in the serum of 24. patients with farmer’s lung, aspergillosis, asthma and sarcoidosis. Thorax 1962; 17: 366–374.CrossRefGoogle Scholar
  6. 6.
    Pepys J, Longbotton JL, Jenkins PA. Vegetable dust 25. pneumoconiosis. Am Rev Respir Dis 1964; 89: 842–858.PubMedGoogle Scholar
  7. 7.
    Williams JV. Inhalation tests with hay and fungi in patients with farmer’s lung. Acta Allergol 1961; 16: 77–78.CrossRefGoogle Scholar
  8. 8.
    Williams JV. Inhalation and skin tests with extracts of hay and fungi in farmer’s lung. Thorax 1963; 18: 182–196.PubMedCrossRefGoogle Scholar
  9. 9.
    Corbaz R, Gregory PH, Lacey ME. Thermophilic and 27. mesophilic actinomycetes in mouldy hay. J Gen Microbiol 1963; 32: 449–454.PubMedCrossRefGoogle Scholar
  10. 10.
    Gregory PH, Fetenstein GN, Lacey ME, Skinner FA, Pepys J, Jenkins PA. Farmers lung disease: The develop- 28. ment of antigens in moulding hays. J Gen Microbiol 1964; 36: 429–439.PubMedCrossRefGoogle Scholar
  11. 11.
    Pepys J. Hypersensitivity to inhaled organic antigens. J Coll Physicians 1967; 2: 42–28.Google Scholar
  12. 12.
    Sostman HD, Matthay RD, Putman CE. Cytotoxic drug-induced lung disease. Am J Med 1977; 62: 608–615.PubMedCrossRefGoogle Scholar
  13. 13.
    Farney RJ, Morris AH, Armstrong JD, Hammar S. Diffuse pulmonary disease after therapy with nitrogen mustard, vincristine, procarabazine and prednisone. Am Rev 31. Respir Dis 1977; 115: 135–145.Google Scholar
  14. 14.
    Winterbauer RH, Wilske KR, Wheelis RF. Diffuse pulmonary injury associated with gold treatment. N Engl J Med 1976; 294: 919–921.PubMedCrossRefGoogle Scholar
  15. 15.
    Higgins T, Niklasson PM. Hypersensitivity pneumonitis induced by trimethoprim. Br Med J 1990; 300: 1344.CrossRefGoogle Scholar
  16. 16.
    Soda K, Ando M, Shimazu K, Sakata T, Yoshida K, Araki 33. S. Different classes of antibody activities to Trichosporon cutaneum antigen in summer-type hypersensitivity pneumonitis by enzyme-linked immunosorbent assay. Am Rev 34. Respir Dis 1986; 133: 83–87.Google Scholar
  17. 17.
    Orriols R, Manresa J, Aliaga J, Codina R, Rodrigo M, 35. Morell F. Mollusk shell hypersensitivity pneumonitis. Ann Intern Med 1990; 113: 80–81.PubMedCrossRefGoogle Scholar
  18. 18.
    Gamboa PM, de las Marinas MD, Antepara I, Jauregui I, Sunz MML. Extrinsic allergic alveolitis caused by esparto 36. (Stipa tenacissima). Allergol Immunopathol 1990; 18: 331–334.Google Scholar
  19. 19.
    Banaszak EF, Theide WH, Fink JN. Hypersensitivity 37. pneumonia due to contamination of an air conditioner. N Engl J Med 1970; 283: 271–276.PubMedCrossRefGoogle Scholar
  20. 20.
    Fink JN, Banaszak EF, Thiede WH, Barboiak JJ. Interstitial pneumonitis due to hypersensitivity to an organism 39. contaminating a heating system. Ann Intern Med 1971; 74: 80–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Pickering CAC, Moore WKS, Lacey J, Holford-Stevens 40. VC, Pepys J. Investigation of a respiratory disease associated with an air conditioning system. Clin Allergy 1976; 6: 109–118.Google Scholar
  22. 22.
    Kumar P, Leech S. Hypersensitivity pneumonia due to contamination of a car air conditioner. N Engl J Med 1981; 305: 1531–1532.PubMedCrossRefGoogle Scholar
  23. 23.
    Friend JAR, Gaddie J, Palmer KNV, Pickering CAC, Pepys J. Extrinsic allergic alveolitis and contaminated cooling-water in a factory machine. Lancet 1977;i:297–300.Google Scholar
  24. 24.
    Woodward ED, Friedlander B, Lesher RJ, Font W, Kinsey R, Hearne FT. Outbreak of hypersensitivity pneumonitis in an industrial setting. JAMA 1988; 259: 1965–1969.CrossRefGoogle Scholar
  25. 25.
    Grant INB, Blyt W, Wardrop VE, Gordon RM, Pearson JCG, Mair A. Prevalence of farmer’s lung in Scotland: a pilot survey. Br Med J 1972: 1: 530–534.PubMedCrossRefGoogle Scholar
  26. 26.
    Madsen D, Klock LE, Wenzel FJ, Robbins JL, Schmidt CD. The prevalence of farmer’s lung in an agricultural population. Am Rev Respir Dis 1976; 113: 171–174.PubMedGoogle Scholar
  27. 27.
    Gruchow HW, Hoffman RG, Marx JJ, Emanuel DA, Rimm AA. Precipitating antibodies to farmer’s lung antigens in a Wisconsin farming population. Am Rev Respir Dis 1981; 124: 411–415.PubMedGoogle Scholar
  28. 28.
    Kreiss K, Hodgson MJ. Buildings associated epidemics. In: Walsh PJ, Dudney CS, Copenhaver ED, eds. Indoor air quality. Boca Raton, Florida: CRC Press, 1984: 87–108.Google Scholar
  29. 29.
    Salvaggio JE, Karr RM, Hypersensitivity pneumonitis. Chest 1979; 75 (Suppl): 270–274.PubMedGoogle Scholar
  30. 30.
    Hapke EJ, Seal RME. Thomas GO. Farmer’s lung: A clinical, radiographic and serological correlation of acute and chronic stages. Thorax 1968; 23: 451–468.PubMedCrossRefGoogle Scholar
  31. 31.
    Hargreave FE, Hinson KF, Reid L, Simon G, McCartney DS. The radiological appearances of allergic alveolitis due to bird sensitivity (bird fancier’s lung). Clin Radiol 1972; 23: 1–10.PubMedCrossRefGoogle Scholar
  32. 32.
    Mokare S, Ikonen M, Haahtela T. Radiologic findings in farmer’s lung: prognosis and correlation to lung function. Chest 1985; 87: 460–466.CrossRefGoogle Scholar
  33. 33.
    Silver SF, Muller NL, Miller RR, Lefroe MS. Hypersensitivity pneumonitis: evalutation with CT. Radiology 1989; 173: 441–445.PubMedGoogle Scholar
  34. 34.
    Fink JN. Hypersensitivity pneumonitis. J Allergy Clin Immunol 1984; 74: 1–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Hansen PJ, Penny R. Pigeon breeders disease. Study of the cell-mediated response to pigeon antigens by the lymphocyte culture technique. Int Arch Allergy Appl Immunol 1974; 47: 498–504.PubMedCrossRefGoogle Scholar
  36. 26.
    Fink JN, Moore VL, Barboriak JJ. Cell-mediated hypersensitivity in pigeon breeders. Int Arch Allergy Appl Immunol 1975; 49: 831–836.PubMedCrossRefGoogle Scholar
  37. 37.
    Pepys J. Hypersensitivity diseases of the lungs due to fungi and organic dusts. Monogr Allergy 1969; 4: 1–145.PubMedGoogle Scholar
  38. 38.
    Uhr JW. Delayed hypersensitivity. Physiol Rev 1966; 46: 359–419.PubMedGoogle Scholar
  39. 39.
    Fink JN, Tebo T, Baraboriak JJ. Characterization of human precipitating antibody to inhaled antigens. J Immunol 1969; 103: 244–251.PubMedGoogle Scholar
  40. 40.
    Fink JN, Barboriak JJ, Sosman AJ. Immunologic studies of pigeon breeder’s disease. J Allergy 1967; 39: 214–221.PubMedCrossRefGoogle Scholar
  41. 41.
    Moore VL, Fink JN. Immunologic studies in hypersensitivity pneumonitis: Quantitative precipitins and complement-fixing antibodies in symptomatic and asymptomatic pigeon breeders. J Lab Clin Med 1975; 85: 540–545.PubMedGoogle Scholar
  42. 42.
    Ojanen T. Class specific antibodies in serodiagnosis of farmer’s lung. Br J Ind Med 1992; 49: 332–336.PubMedGoogle Scholar
  43. 43.
    Reyes CN, Wenzel FJ, Lawton BR, Emanuel DA. The pulmonary pathology of farmer’s lung disease. Chest 60. 1982; 81: 142–146.CrossRefGoogle Scholar
  44. 44.
    Barrowcliff DF, Arbuster PG. Farmer’s lung: A study of an early acute fatal case. Thorax 1968; 23: 490–500.PubMedCrossRefGoogle Scholar
  45. 45.
    Ghose T, Bandrigan P, Milleen R, Dill J. Immunopathological studies in patients with farmer’s.Iung. Clin Allergy 1974; 4: 119–129.PubMedCrossRefGoogle Scholar
  46. 46.
    Calvanico NJ, Ambegaonkar SP, Schlueter DP, Fink JN. 62. Immunoglobulin levels in bronchoalveolar lavage fluid from pigeon breeders. J Lab Clin Med 1980; 96: 129–140.PubMedGoogle Scholar
  47. 47.
    Patterson R, Wang JLF, Fink JN, Calvanico JN, Roberts ME. IgA and IgG antibody activities of serum and bron- 63. choalveolar lavage fluids from symptomatic and asymptomatic pigeon breeders. Am Rev Respir Dis 1979; 120: 1113–1118.PubMedGoogle Scholar
  48. 48.
    Reynolds NY, Fulmer JD, Kazmierowski JA, Roberts WC, 64. Frank MM, Crystal RG. Analysis of cellular and protein content of bronchoalveolar lavage fluid from patients with idiopathic pulmonary fibrosis and chronic hypersensitivity pneumonitis. J Clin Invest 1977; 59: 165–175.PubMedCrossRefGoogle Scholar
  49. 49.
    Daniele RP, Elias JA, Epstein PE, Rossman MD. Bronchoalveolar lavage: Role in the pathogenesis, diagnosis and management of interstitial lung disease. Ann Intern Med 66. 1985; 102: 93–108.Google Scholar
  50. 50.
    Richerson HB. Hypersensitivity pneumonitis: Pathology 67. and pathogenesis. Clin Rev Allergy 1983; 1: 469–486.PubMedGoogle Scholar
  51. 51.
    Richerson HB. Immune complexes and the lung: A 68. skeptical review. Sury Synth Pathol Res 1984; 3: 281–291.Google Scholar
  52. 52.
    Fournier E, Tonnel AB, Gosset Ph, Wallaer B. Ameisen JC, Voisin C. Early neutrophil alveolitis after antigen 69. inhalation in hypersensitivity pneumonitis. Chest 1985; 88: 563–566.PubMedCrossRefGoogle Scholar
  53. 53.
    McSharry C, Banham SW, Boyd G. Effect of cigarette smoking on the antibody response to inhaled antigens 70. and the prevalence of extrinsic allergic alveolitis among pigeon breeders. Clin Allergy 1985; 15: 487–494.PubMedCrossRefGoogle Scholar
  54. 54.
    Cormier Y, Gagnon L, Berube-Genest F, Fournier M. Sequential bronchoalveolar lavage in experimental ex 71. trinsic allergic alveolitis: The influence of cigarette smoking. Am Rev Respir Dis 1988; 137: 1104–1109.PubMedCrossRefGoogle Scholar
  55. 55.
    Kusaka H, Homma Y, Ogasawara H, et al. Five-year follow-up of Microspolyspora faeni antibody in smoking and 72. nonsmoking farmers. Am Rev Respir Dis 1989; 140: 695–699.PubMedCrossRefGoogle Scholar
  56. 56.
    Soda K, Ando M, Saka T, Sugimoto M, Nakashima H, 73. Araki S. Clq and C3 in bronchoalveolar lavage fluid from patients with summer-type hypersensitivity pneumonitis. Chest 1988; 93: 76–80.PubMedCrossRefGoogle Scholar
  57. 57.
    Caldwell JR, Pearce CE, Spencer C, Leder T, Waldman 74. RH. Immunologic mechanisms in hypersensitivity pneumonitis. J Allergy Clin Immunol 1973; 52: 225–230.PubMedCrossRefGoogle Scholar
  58. 58.
    Costabel U, Bross KJ, Marxen J, Matthys H. T lymphocy osis in bronchoalveolar lavage fluid of hypersensitivity pneumonitis: changes in profile of T-cell subsets during course of disease. Chest 1984; 85: 514–518.PubMedCrossRefGoogle Scholar
  59. 59.
    Cormier Y, Belanger J, Beaudoin J, Laviolette M, Beaudoin R, Hebert J. Abnormal bronchoalveolar lavage in asymptomatic dairy farmers. Study of lymphocytes. Am Rev Respir Dis 1984; 130: 1046–1049.PubMedGoogle Scholar
  60. 60.
    Cormier Y, Belanger J, Laviolette M. Persistent bronchoalveolar lymphocytosis in asymptomatic farmers. Am Rev Respir Dis 1986; 133: 843–847.PubMedGoogle Scholar
  61. 61.
    Keller RH, Swartz S, Schlueter DP, Bar-Sela S, Fink JN. Immunoregulation in hypersensitivity pneumonitis: Phenotypic and functional studies of bronchoalveolar lavage lymphocytes. Am Rev Respir Dis 1984; 130: 766–771.PubMedGoogle Scholar
  62. 62.
    Denis M, Cormier Y, Fournier M, Tardif J, Laviolette M. Tumor necrosis factor plays an essential role in determining hypersensitivity pneumonitis in a mouse model. Am J Respir Cell Mol Biol 1991; 5: 477–483.PubMedCrossRefGoogle Scholar
  63. 63.
    Denis M, Cormier Y, Laviolette M. Murine hypersensitivity pneumonitis: A study of cellular infiltrates and cytokine production and its modulation by cyclosporin A. Am J Respir Cell Mol Biol 1992; 6: 68–74.PubMedCrossRefGoogle Scholar
  64. 64.
    Denis M, Cormier Y, Laviolette M, Ghadirian F. T cells in hypersensitivity pneumonitis: Effects of in vivo depletion of T cells in a mouse model. Am J Respir Cell Mol Biol 1992; 5: 183–189.CrossRefGoogle Scholar
  65. 65.
    Allen DH, Basten A, Woolcock AJ. HLA and bird breeder’s hypersensitivity pneumonitis. Monogr Allergy 1977; 11: 45–54.PubMedGoogle Scholar
  66. 66.
    Flaherty DK, Iha T, Chmelik F, et al. HLA-8 and farmer’s lung disease. Lancet 1975;ii:507.Google Scholar
  67. 67.
    Rittner C, Sennekamp J, Vogel F. HLA-B8 in pigeon fancier’s lung. Lancet 1975;ii:1303.CrossRefGoogle Scholar
  68. 68.
    Rodey GF, Rink J, Koethe S, et al. A study of HLA-A, B, C and DR specificities in pigeon breeder’s disease. Am Rev Respir Dis 1979; 119: 755–759.PubMedGoogle Scholar
  69. 69.
    Benacerraf B, Katz DH. The nature and function of histocompatibility-linked immune response genes. In: Benacerraf B, ed. Immunogenetics and immunodeficiency. Baltimore: University Park Press, 1975: 117–178.CrossRefGoogle Scholar
  70. 70.
    Allen EM, Moore VL, Stevens JO. Strain variation in BCG-induced chronic pulmonary inflammation in mice. I. Basic model and possible genetic control by non-H-2 genes. J Immunol 1977; 119: 343–347.PubMedGoogle Scholar
  71. 71.
    Ando M, Hirayama K, Soda K, Okubo R, Araki S, Sasazuki T. HLA-DQw3 in Japanese summer-type hypersensitivity pneumonitis induced by Trichosporon cutaneum. Am Rev Respir Dis 1989; 140: 948–950.PubMedCrossRefGoogle Scholar
  72. 72.
    Salvaggio JE, Phanuphak P, Stanford R, Bice D, Claman H. Experimental production of granulomatous pneumonitis. J Allergy Clin Immunol 1975; 56: 364–380.PubMedCrossRefGoogle Scholar
  73. 73.
    Harris JD, Bice D, Salvaggio J. Cellular and humoral bronchopulmonary immune responses of rabbits immunized with thermophilic actinomycete antigen. Am Rev Respir Dis 1976; 114: 29–43.PubMedGoogle Scholar
  74. 74.
    Larson K, Eklund A, Malmberg P, Bjermer L, Lundgren R, Belin L. Hyaluronic acid (Hyaluronan) in BAL fluid distinguishes farmers with allergic alveolitis from farmers with asymptomatic alveolitis. Chest 1992; 101: 109–114.CrossRefGoogle Scholar
  75. 75.
    Pesci A, Bertorelli G, Oliver D. Mast cells in bronchoalveolar lavage fluid and transbronchial biopsy specimens of 88. patients with farmer’s lung disease. Chest 1991; 100: 1197–1202.PubMedCrossRefGoogle Scholar
  76. 76.
    Berrens L, Guikers CLH, vanDijk A. The antigens in 89. pigeon breeders disease and their interaction with human complement. Ann NY Acad Sci 1974; 221: 153–162.PubMedCrossRefGoogle Scholar
  77. 77.
    Rylander R, Haglind P, Lundholm M, Mattsby I, Stenquist I. Humidifier fever and endotoxin exposure. Clin 90. Allergy 1978; 8: 511–516.Google Scholar
  78. 78.
    Edwards JH, Barboriak JJ, Fink JN. Antigens in pigeon breeders disease. Immunology 1970; 19: 729–734.PubMedGoogle Scholar
  79. 79.
    Dickie HA, Rankin J. Farmer’s lung: An acute granulo-matous interstitial pneumonitis occurring in agricultural workers. JAMA 1958; 167: 1069–1076.CrossRefGoogle Scholar
  80. 80.
    Totten RS, Reid DHS, Davies HO, Moran TJ. Farmer’s lung. Am J Med 1958; 25: 803–809.CrossRefGoogle Scholar
  81. 81.
    Frank RC. Farmer’s lung: A form of pneumoconiosis due to organic dusts. AJR 1958; 79: 189–215.Google Scholar
  82. 82.
    Seal RMF, Thomas GO, Griffiths JJ. Farmer’s lung. Proc 93. R Soc Med 1963; 56: 271–273.Google Scholar
  83. 83.
    Seal RMF, Hapke EJ, Thomas GO, Pathology of the acute and chronic stages of farmer’s lung. Thorax 1968; 23: 94. 469–489.PubMedCrossRefGoogle Scholar
  84. 84.
    Hammar S, Bockus D, Remington F, Friedman S. The 95. widespread distribution of Langerhans’ cells in pathologic tissues: An ultrastructural and immunohistochemical study. Hum Pathol 1986; 17: 894–905.PubMedCrossRefGoogle Scholar
  85. 85.
    Liebow AA, Carrington CB. Diffuse pulmonary lym- 96. phoreticular infiltration associated with dysproteinemia. Med Clin North Am 1973; 57: 809–843.PubMedGoogle Scholar
  86. 86.
    Perreault C, Cousineau S, D’Angelo G, et al. Lymphoid interstitial pneumonia after allogeneic bone marrow 97. transplantation: A possible manifestation of chronic graft-versus-host disease. Cancer 1985; 55: 1–9.PubMedCrossRefGoogle Scholar
  87. 87.
    Strimlan CV, Rosenow EC III, Divertie MB, Harrison EG Jr. Pulmonary manifestations of Sjögren’s syndrome. Chest 1976; 70: 354–361.PubMedCrossRefGoogle Scholar
  88. 88.
    Grieco MH, Chinoy-Acharya P. Lymphocytic interstitial pneumonia associated with acquired immune deficiency syndrome. Am Rev Respir Dis 1985; 131: 952–955.PubMedGoogle Scholar
  89. 89.
    Solal-Celingny T, Couderc LJ, Herman D, et al. Lymphoid interstitial pneumonitis in acquired immunodeficiency syndrome-related complex. Am Rev Respir Dis 1985; 131: 956–960.Google Scholar
  90. 90.
    Guillon J, Autran B, Denis M, et al., Human immunodeficiency virus-related lymphocytic alveolitis. Chest 1988; 94: 1264–1270.PubMedCrossRefGoogle Scholar
  91. 91.
    Travis WD, Fox CH, Devaney KO, et al. Lymphoid pneumonitis in 50 adult patients with human immunodeficiency virus: Lymphocytic interstitial pneumonitis versus nonspecific interstitial pneumonitis. Hum Pathol 1992; 23: 529–541.PubMedCrossRefGoogle Scholar
  92. 92.
    Rom WN, Travis WD. Lymphocyte-macrophage alveolitis in non-smoking individuals occupationally exposed to asbestos. Chest 1992; 101: 779–786.PubMedCrossRefGoogle Scholar
  93. 93.
    Hammar SP, Hallman KO. Localized, acute, or unusual pulmonary disease in persons occupationally exposed to asbestos. Chest (in press).Google Scholar
  94. 94.
    Morell F, Orriols R, Molina C. Usefulness of skin test in farmer’s lung. Chest 1985; 87: 202–205.PubMedCrossRefGoogle Scholar
  95. 95.
    Costabel V, Bross KJ, Marxen MA, Matthys H. T-lymphocytosis in bronchoalveolar lavage fluid of hypersensitivity pneumonitis: Changes in profile of T-cell subsets during the course of disease. Chest 1984; 85: 514–518.PubMedCrossRefGoogle Scholar
  96. 96.
    Anttinen H, Terho EO, Myllyla R, Savolainen E. Two serum markers of collagen biosynthesis as possible indicators of irreversible pulmonary impairment in farmer’s lung. Am Rev Respir Dis 1986; 133: 88–93.PubMedGoogle Scholar
  97. 97.
    Braun SR, doPico GA, Tsiatis A, Horvath E, Dickie HA, Rankin J. Farmer’s lung disease: Long-term clinical and physiologic outcome. Am Rev Respir Dis 1979; 119: 185–191.PubMedGoogle Scholar

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© Springer Science+Business Media New York 1994

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  • Samuel P. Hammar

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