1. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 CASE PRESENTATION II ANDREW YOUN, MD, FRCPC CLINICAL CARE: MULTIDISCIPLINARY DIAGNOSIS NOVEMBER 14, 2015

2. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 FACULTY DISCLOSURE In accordance with the Accreditation Council for Continuing Medical Education, The France Foundation requires that all program faculty, content developers, CME approval committee, and medical writers in a position to control the content of this activity are expected to disclose any or not significant financial interest or other relationship with any proprietary entity producing health care goods or services, with the exemption of nonprofit or governmental organizations and non-health care related companies. Our goal is to ensure that there is no compromise of the ethical relationship that exists between those in a position to control the content of the activity and those attending the activity and their respective professional duties. All CME Educational Activities sponsored by The France Foundation are reviewed by our faculty CME committee to ensure a balanced and evidence-based presentation. Any potential conflict of interest among program faculty has been identified and resolved according to ACCME guidelines. Andrew Youn, MD, FRCPC, has no relevant disclosures. ©2015 Pulmonary Fibrosis Foundation. All rights reserved.2

3. Clinical Care: Multidisciplinary Diagnosis Case III Andrew Youn, MD FRCPC Clinical Fellow Interstitial Lung Disease University of Toronto

4. Case History Meds: 1.Prednisone 5mg PO OD 2.Imuran 50mg PO OD 3.Plaquenil 200mg PO OD 4.Atorvastatin 10mg PO QHS SHx: Life-time non-smoker Non-drinker No illicit drug use FHx: Negative for ILD, CTD ID: 69F PMHx: 1.SLE. Dx’ed 1974, clinically stable. 2.GERD 3.Hypercholesterolemia 4.Thrombocytopenia

5. Case History HPI: SLE initially diagnosed in 1974 – Clinically stable for past 20 years Beginning in early 2014, rheumatologist noticed presence of mild bibasilar crackles Referred to ILD clinic at TGH for assessment on April 2015 – MRC dyspnea class 2, intermittent dry cough Exposure History: No pneumotoxic drugs (including gold, MTX) No occupational exposures Significant for having parrot x 30 years, budgies x 5 years

6. Case History Autoimmune Serology (Oct 2014) – ANA 1:640 homogeneous – Anti-SSB (La) 1.2 AI units – Anti-chromatin >8.0 AI units – Anti-ribosomal P 1.0 AI units – Negative Anti-SSA (Ro), Anti- Sm, Anti –SmRNP, Anti-RNP, Anti-SCl70, Anti-Jo-1, ACA – Anti-dsDNA 28 U/mL – C3 0.72 g/L, C4 0.06 g/L Pulmonary Function Test (April 2015)

7. What’s going on? The main DDx at this point was… CTD-ILD versus Hypersensitivity Pneumonitis

8. HRCT (Nov 2014)

9. HRCT (Feb 2015)

10. VATS lung biopsy (RUL, RML) on May 2015

11. Pathology

15. Official pathology report: – “Mild to moderate mixed interstitial chronic inflammatory infiltrates associated with occasional non-necrotizing granulomas and scattered foamy macrophages. The inflammation and granulomas tend to show a centrilobular predominance…The lung parenchymal architecture is preserved without evidence of remodeling.”

16. Summary 69F with long history of SLE, with clear exposure to HP antigens Definite diagnosis of HP (secondary to avian antigens) After removal of birds (to humane society), significant improvement in symptoms No other changes to management

17. Thank you Dr. Charlene Fell Dr. Shane Shapera Dr. David Hwang Dr. Jeffrey Tanguay