Inadequate access to diagnostic resources: a case of unrecognized hypersensitivity pneumonitis

Objective: Hypersensitivity pneumonitis (HP) often goes unrecognized because of its relatively low incidence in the general population and it is frequently misdiagnosed as a respiratory infection or idiopathic interstitial lung disease. Methods: Through the analysis of a paradigmatic case of hypersensitivity pneumonitis, in which only symptomatic diagnosis and treatment were proposed, we argue that limiting the clinical process to generic diagnosis, without detection of the etiologic agent, makes it impossible to avoid exposure, hinders compensation and severely worsens the evolution of the disease. Results: In 1981, a previously healthy, 28-year-old female clerk developed respiratory symptoms. She was diagnosed as suffering from extrinsic bronchial asthma and was treated with steroids and broncho-dilators. Neither immunologic tests nor any environmental pathogen research were proposed until 2008, when precipitins analysis showed positivity to Thermoactynomyces vulgaris, which had presumably contaminated the centralized air-conditioning system. Conclusions: The diagnosis of HP is unlikely to be missed if, in all clinical settings, occupational or environmental causes are routinely considered in the differential diagnosis of any patient with a respiratory problem. This approach could provide a better clinical management of the disease and more effective programmes of primary prevention. Implicit rationing of healthcare resources by limiting diagnostic tests that are not readily accessible reduces patient autonomy and the benefits of medical care.