key: cord-0832986-afbd1m91
authors: Bringgold, Will; Halliday, Stephen
title: THE CHEESE WHIZ LUNG: HYPERSENSITIVITY PNEUMONITIS IN AN IMITATION CHEESE FACTORY WORKER
date: 2020-10-31
journal: Chest
DOI: 10.1016/j.chest.2020.08.1578
sha: 9ae12865a427f7a529f8755e4b686767323a1d2b
doc_id: 832986
cord_uid: afbd1m91

nan

CASE PRESENTATION: She was first seen in 2015 for frequent exacerbations of cough and dyspnea requiring steroids, initially thought to be due to smoking and asthma. She developed progressive dyspnea on exertion, and a chest CT showed ILD, prompting an extensive work up including BAL, EBUS and full rheumatologic evaluation; which all returned normal. The patient underwent a lung biopsy in 2019 that demonstrated "airway centered inflammation and fibrosis, occasional multinuclear giant cells suggesting the possibility of chronic hypersensitivity pneumonitis (HP)". She was initiated on prednisone in late 2019 and referred to our pulmonary clinic. She worked in a factory producing cheese products and imitation cheeses where she had significant un-masked exposure to organic dusts, but denied other significant exposures. Several colleagues stopped working due to breathing issues and she consistently felt better away from work. Physical exam was unremarkable. Pertinent labs included a CRP of 2.5, a high CCP of 61.7 and a homogeneous ANA at 1:40. Spirometry showed a restrictive pattern and her chest CT was overread as "slowly progressive, upper lobe predominant, fibrosis consistent with fibrotic HP". She was diagnosed with chronic HP and was initiated on mycophenolate (MMF) with a steroid taper. At last check, the patient was on MMF 1g BID and tapered to 10mg of prednisone daily. She had not been working due to isolation from the spreading COVID-19 virus and feels that her breathing has continued to improve.

There are over 300 reported causes of HP. We believe our patient has "cheese worker/washer's lung," a rare form of HP, from her 15þyr occupation at an imitation cheese factory, which uses many organic ingredients in manufacturing. An extensive literature review found only a small collection of cases that reported respiratory symptoms including cough, dyspnea and asthma-like presentations from cheese factory workers(1). Two articles, from Guglielminetti(2) and Campbell(3), report hypersensitivity pneumonitis from exposure to different penicillium strains (roqeforti, verrucosum, casei) or aspergillus. There were no reports of imitation cheeses causing HP when using search mesh terms including "artificial, substitute or imitation cheese" and "lung, respiratory or disease." Other aerosolized components of imitation cheese include starches, emulsifiers, and non-starch carbohydrates whose aerosolized components potentially contributed to her lung pathology.

Respiratory syndrome very similar to extrinsic allergic alveolitis due to Penicillium verrucosum in workers in a cheese factory

We report a case of chronic hypersensitivity pneumonitis related to imitation cheese manufacturing. This report adds to the literature by demonstrating that "cheese worker's lung" is a real disease, even if the "cheese" is fake.Reference #1: Torrijos MD P, Elisa Gómez, Rodriguez MD, García C, et al. Occupational allergic respiratory disease (rinoconjunctivitis and asthma) in a cheese factory worker. Journal of Allergy and Clinical Immunology. 2018;Volume 6(Issue 4).