title: Clinical case: Differential diagnosis of idiopathic pulmonary fibrosis.
abstract: BACKGROUND
  The diagnosis of idiopathic pulmonary fibrosis can be quite challenging, even after careful clinical evaluation, imaging and pathological tests. This case report intends to demonstrate and discuss these difficulties, especially those concerning the differential diagnosis with chronic hypersensitivity pneumonitis.
  
  
  METHODS
  A 58-year-old white male presented with shortness of breath, dry cough, fatigue and weight loss for two months. He was a former smoker and had regular exposure to a parakeet and poultry. Physical examination revealed bilateral basal crackles and chest imaging showed subpleural cystic lesions and traction bronchiectasis with a right side and upper level predominance. Auto-antibodies and IgG immunoglobulins to parakeet and fungal proteins were negative. Lung function tests displayed moderate restriction, low diffusion capacity and resting hypoxaemia. Bronchoalveolar lavage showed increased lymphocytes (28%) and neutrophils (12%) and surgical lung biopsy was compatible with a pattern of usual interstitial pneumonia. According to the possibility of either idiopathic pulmonary fibrosis or chronic hypersensitivity pneumonitis, treatment included prednisolone, azathioprine, acetylcysteine and avoidance of contact with the parakeet, but there was an unfavorable response and the patient was subsequently referred for lung transplant.
  
  
  CONCLUSIONS
  Chronic hypersensitivity pneumonitis and idiopathic pulmonary fibrosis can present with the same clinical and radiological manifestations In this case, despite careful evaluation, no definite diagnosis could be achieved.
authors.affiliation: Centre of Pulmonology of University of Coimbra, Portugal. carlos.crobalo@gmail.com
authors.forename: Carlos Robalo
authors.initials: CR
authors.lastname: Cordeiro
authors.forename: Tiago M
authors.initials: TM
authors.lastname: Alfaro
authors.forename: Sara
authors.initials: S
authors.lastname: Freitas
mesh_terms: D000111:Acetylcysteine / Q000627:therapeutic use; D000542:Alveolitis, Extrinsic Allergic / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology*; D001379:Azathioprine / Q000627:therapeutic use; D003937:Diagnosis, Differential; D019468:Disease Management; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology*; D054990:Idiopathic Pulmonary Fibrosis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology*; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011239:Prednisolone / Q000627:therapeutic use; D011656:Pulmonary Emphysema / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000473:pathology*; D011859:Radiography; D012907:Smoking
chemical_list: D011239:Prednisolone; D001379:Azathioprine; D000111:Acetylcysteine