Identical Twins, Matching Symptoms: Hypersensitivity Pneumonitis

PRESENTATION Shortness of breath was first attributed to the patient’s extensive history of cardiac ills, but a detailed environmental history pointed to the true source. A 58-year-old Caucasian woman presented with a 12-month history of dyspnea, nonproductive cough, and wheezing. She had been born with Ebstein’s anomaly, for which she had undergone tricuspid valve replacement with a prosthetic valve and repair of a coexisting atrial septal defect. In addition, she had an implanted pacemaker for complete heart block. Her cardiologist was considering biventricular pacing as an intervention for her dyspnea and requested a pulmonary evaluation before proceeding. The patient, who was married and a nurse, had an unremarkable pulmonary history. None of her medications posed a risk for lung toxicity. She never smoked, drank alcohol, or used illicit drugs. An identical twin sister, who lived in Texas, had similar pulmonary complaints and a presumptive diagnosis of pulmonary fibrosis. The sister’s medical records were brought to the consultation due to concern for a genetic predisposition for this progressive lung disease.