Egyptian Journal of Chest Diseases and Tuberculosis (2015) xxx, xxx–xxx

HO ST E D BY

The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

www.elsevier.com/locate/ejcdtwww.sciencedirect.com

ORIGINAL ARTICLE

Idiopathic pulmonary fibrosis (IPF) in upper Egypt,

a single center study

* Corresponding author.

Peer review under responsibility of The Egyptian Society of Chest

Diseases and Tuberculosis.

http://dx.doi.org/10.1016/j.ejcdt.2015.05.0070422-7638 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and TubeThis is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: M. Alaa Rashad, A.K. Ibrahim, Idiopathic pulmonary fibrosis (IPF) in upper Egypt, a single center study, Egypt. J. CTuberc. (2015), http://dx.doi.org/10.1016/j.ejcdt.2015.05.007

M. Alaa Rashad a,*, Ahmed K. Ibrahim b

a Department of Chest Diseases and Tuberculosis, Faculty of Medicine, Assiut University, Assiut, Egyptb Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt

Received 2 December 2014; accepted 10 May 2015

KEYWORDS

Interstitial pulmonary

fibrosis;

Epidemiology;

Upper Egypt

Abstract Aim of work: Idiopathic pulmonary fibrosis (IPF) is the second most common cause of

admission to Chest Department at Assiut University hospital, the pattern of presentation, method

for diagnosis and Co-morbidities need further studies.

Aim: To explore demographic data and pattern of presentation of patients with IPF in upper

Egypt and to study the difference from international data.

Methods: A total of 568 patients with final diagnosis of IPF were studied, retrospective study

was done using the available hospital database for all patients admitted at Assiut University hos-

pital (Tertiary hospital for all upper Egypt Governorates) during the period from 2007 to 2012.

Patients with incomplete data were excluded from study, all patients underwent chest X-ray, high

resolution computed tomography, spirometry, arterial blood gases, in addition to routine labora-

tory investigation. Patients with clinical or laboratory evidence of collagen vascular disease or

extrinsic allergic alveolitis were excluded from current study.

Results: The current study included 568 patients, 191 males and 377 females, mean age

44 ± 12 years. In all cases diagnosis was made according to clinical, spirometry and HRCT chest,

no one was subjected to thoracoscopic or bronchoscopic lung biopsy. Most cases were house wife or

farmer, 76% of cases were non-smokers, 17% ex-smokers and 7% current smokers, 86% of cases

have restrictive spirometry. Usual interstitial pneumonia was the most common high resolution

chest computed tomography pattern (51%) (Fig. 5). 39% of cases have at least one Co-morbid dis-

ease such as systemic hypertension, ischemic heart disease, pulmonary embolism and/or diabetes

mellitus.

There was a significant difference between male and female patients with IPF with regard to

smoking status (P value < 0.005) and HRCT pattern (P< 0.01).

Conclusion: IPF in upper Egypt has a different age and sex distribution compared to interna-

tional data. Domestic air pollution, indoor exposures or other environmental factors may account

for this difference. Lack of local resources for lung biopsy and lack of national guidelines for IPF

rculosis.

hest Dis.

Figure 1 Sex dis

2 M. Alaa Rashad, A.K. Ibrahim

Please cite this article in press as: M. Alaa RTuberc. (2015), http://dx.doi.org/10.1016/j.ej

may also account for this difference. It is highly recommended to establish a national database for

patients with IPF in order to plane for national guidelines.

ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest

Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Idiopathic pulmonary fibrosis (IPF) is a chronic progressivedisease with unclear etiology and pathophysiology [1,2]. Its

prognosis is poor; survival time after initial diagnosis is only2.5–3.0 yr. There is currently no effective therapy known toimprove survival [3,4].

Numerous studies on the etiology of IPF have identified

many possible inciting factors including saw dust, metal parti-cles, smoking, gastroesophageal reflux, and viruses [1]. SinceIPF is more prevalent in the aged population, it has been

hypothesized that the development and progression of IPFmay be affected by age-related diseases such as diabetes melli-tus (DM), metabolic syndrome, obesity, and cardiovascular

disease [5–8].Criteria for the diagnosis of IPF were set forth in an

international consensus statement formulated by members

of the American Thoracic Society (ATS) and the EuropeanRespiratory Society (ERS) [9]. In the absence of biopsyevidence of usual interstitial pneumonia, a constellation oftypical clinical findings may be used to support the diagnosis

of IPF. However, the extent to which these diagnosticguidelines are followed in actual clinical practice isunknown [9].

Median survival among persons with IPF is believed to befrom 3 to 5 yr. Respiratory failure is the most frequent cause ofdeath, and has been reported to account for over 80% [10,11–

15].Surprisingly, little is known about the epidemiology of IPF

in the United States. Initial estimates of its prevalence, basedlargely on case series from pulmonary clinics and tertiary-

care hospitals, ranged from 3 to 6 cases per 100,000 persons[16].

Substantially higher rates of prevalence (20 per 100,000

among men, 13 per 100,000 among women) and incidence(11 and 7 per 100,000, respectively) were reported in a studybased on the adult population of Bernalillo County, New

Mexico [17]. It is unclear, however, whether these rates are

tribution.

ashad, A.K. Ibrahim, Idiopathic pulmocdt.2015.05.007

generalizable to the present-day United States as a whole,because they are based on data more than 15 yr old and comefrom an area of the United States known to attract personswith chronic lung diseases [18].

Although more recent estimates of disease prevalence(range, 1–24 cases per 100,000) are available from severalEuropean studies, their generalizability to the United States

is not clear [19–23].

Methods

A single center retrospective hospital-based study was carriedout in chest department, Assiut University hospital, AssiutEgypt (Tertiary hospital for all upper Egypt Governorates)

between January 2007 and December 2012.All patients with confirmed IPF admitted during the study

period to Chest department at Assiut University, who agreedto participate in the research, were included in this study.

The diagnosis of IPF was made based on the diagnostic criteriaof American Thoracic Society and the European RespiratorySociety by history taking, clinical examination, high-

resolution computerized tomography (HRCT) of the chestand pulmonary function testing (PFT). None of the casesaccepted to confirm the diagnosis by either thoracoscopic lung

biopsy or transbronchial lung biopsy. The presence of typicalclinical and HRCT features of IPF, when identified by expertclinicians and radiologists, is sufficiently characteristic to allow

a confident diagnosis and eliminate the need for surgical lungbiopsy. All cases had basal fine crackles in auscultation andpredominantly peripheral, sub-pleural, bi-basal fine reticularshadows and/or honeycombing, occasionally with traction

bronchiectasis on HRCT. All cases had also abnormal pul-monary function studies including evidence of restriction––re-duced vital capacity with increased FEV1/FVC ratio. There

was no evidence of either coexisting collagen-vascular diseaseor history of known occupational exposure to agents thatmight produce a clinical picture similar to that of IPF in any

of the cases.

Figure 2 Occupation.

nary fibrosis (IPF) in upper Egypt, a single center study, Egypt. J. Chest Dis.

Figure 5 Chest high resolution Computed tomography pattern

(UIP = usual interstitial pneumonia, NSIP = non-specific inter-

stitial pneumonia).

Idiopathic pulmonary fibrosis (IPF) in upper Egypt 3

The study was approved by the Research Ethics CommitteeAssiut Faculty of Medicine, Assiut University.

Results

The current study included 568 patients, 191 males (34%) and377 females (66%) (Fig. 1), mean age 44 ± 12 years. In all

cases diagnosis was made according to clinical, spirometryand HRCT chest, no one was subjected to thoracoscopic orbronchoscopic lung biopsy. Most cases were house wife 53%

or farmer 12% (Fig. 2), 76% of cases were non-smokers,17% ex-smokers and 7% current smokers (Fig. 3), 86% ofcases have restrictive spirometry, mixed 9% or normal 5%

(Fig. 4). Usual interstitial pneumonia was the most commonhigh resolution chest computed tomography pattern (51%),desquamative 20% and nonspecific 5% (Fig. 5). 39% of cases

have at least one Co-morbid disease such as systemic hyperten-sion, ischemic heart disease, pulmonary embolism and/or dia-betes mellitus (Fig. 6).

There was a significant difference between male and female

patients with IPF with regard to smoking status (Pvalue < 0.005) (Fig. 7) and HRCT pattern (Fig. 8) (P < 0.01).

Most females were non-smoker (97%).

Discussion

The current study included 568 IPF cases, showed that most

cases diagnosed with IPF in upper Egypt are middle aged

Figure 3 Smoking status.

Figure 4 Spirometry.

Figure 6 Co morbid Disease.

Please cite this article in press as: M. Alaa Rashad, A.K. Ibrahim, Idiopathic pulmoTuberc. (2015), http://dx.doi.org/10.1016/j.ejcdt.2015.05.007

female house wife, epidemiology of IPF in the united states

showed that IPF is more prevalent among aged males.In a population-based study in Bernalillo County, New

Mexico, Coultas et al. found a prevalence of ILD of 81 per105 in males and 67 per 105 in females, and an incidence of

32 per 105 per yr in males and of 26 per 105 per yr in females[24].

In another study, farming and raising birds with the poten-

tial exposures to dusts of animal feeds, products and waste aswell as pesticides were significant risk factors for the develop-ment of IPF among female workers. Also, the environmental

exposure to domestic birds and cats was positively associatedwith IPF development in both genders. These findings werein accordance with results of current study.

Agricultural workers are exposed to very high levels of dust

and aerosolized particulates from a variety of sources includ-ing feed grains, bedding, and livestock fecal material, [24]and tend to have a higher prevalence of lung fibrosis [25].

In Egypt, the poultry industry had expanded rapidly overthe past 25 years to provide approximately 55% of the per cap-ita animal protein consumption. Problems with raising birds in

Egypt include widespread roof-top and back-yard raising bird,unhygienic local marketing and home slaughtering as well asthe presence of approximately 40,000 poultry farms lacking

biosecure and hygienic production systems and unprotectedexposure to birds. 30, 31 these widespread unplanned andunprotected activities in raising birds and their environmentalimpacts help in magnifying the role of raising birds in IPF

nary fibrosis (IPF) in upper Egypt, a single center study, Egypt. J. Chest Dis.

Figure 7 Smoking status according to sex distribution.

Figure 8 Chest HRCT pattern according to sex distribution. (UIP = usual interstitial pneumonia, NSIP = non-specific interstitial

pneumonia).

4 M. Alaa Rashad, A.K. Ibrahim

development. In Egypt, women were found to be moreinvolved in raising birds than men and this may explain the ele-vated risk of IPF among women [24].

This study has several limitations. First, data from the med-ical records may be incomplete due to limited information.Second, this study was based on earlier, 2002 ATS-ERS guide-

lines for diagnosis of IPF and on retrospective study.Therefore, this study may have involved atypical IPF featureson HRCT. Third, the interpretation of HRCT images mayhave differed in quality among radiologists. Further prospec-

tive studies are needed to confirm our results using the newIPF guidelines. Fourth, the IPF in patients was not confirmedby lung tissue biopsy.

Conflict of interest

We have no conflict of interest to declare.

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