A 61-year-old female with...

A 61-year-old female was referred to an ILD clinic for undifferentiated ILD in 2014. She had a history of dyspnoea after developing a respiratory illness 8 years prior, and her symptoms worsened after initially responding well to inhaled corticosteroid therapy. Her CT scan suggested nonspecific inflammation and bronchoscopy results were presumed to be non-diagnostic. She was treated with a 6-month course of corticosteroids and remained asymptomatic until 1 year before evaluation when she noted decreased exercise tolerance. The patient's home had visible mold during her initial presentation but this has since been remediated. Her HRCT showed upper lobe predominant peribronchovascular and peripheral fibrosis. Her transbronchial biopsy revealed a chronic interstitial inflammatory infiltrate. The patient was diagnosed with fibrotic hypersensitivity pneumonitis caused by an unknown antigen, possibly the mold in her home, and was treated with a prolonged course of corticosteroids and immunosuppressants. After four years, her symptoms recurred, and her lung function tests declined. Prednisone was restarted with the addition of mycophenolate sodium, but her disease continued to progress on imaging (as given in image), and nintedanib was added to her treatment regimen two years later.