Introduction: Hypersensitivity pneumonitis is known as an immune-mediated lung disease presenting as Interstitial Lung Disease in susceptible individuals after an environmental exposure. Definitive diagnostic guidelines have been examined and proposed by several governing organizations. Hypersensitivity pneumonitis presents a challenge when identifying exact related exposures.

Case Presentation: 67 year-old female with past medical history of hypertension, acid reflux, diabetes mellitus type 2, obstructive sleep apnea and remote breast cancer presented with chronic shortness of breath. Pulmonary Function Tests were essentially normal with a mildly reduced Forced Vital Capacity. Bronchoscopy was performed, during which she was found to have a membranous tracheal defect and was referred for surgical repair. During repair of tracheal defect, a palpated abnormality in the right basal segment was found which was resected. She remained short of breath unrelieved by a course of diuretics and presented back to the hospital with a pleural effusion prompting therapeutic and diagnostic thoracentesis.

Immune related labs were negative. Negative viral and bacterial studies. HSR panel also negative for related pathogens. BAL which cultured negative and showed predominant lymphocytosis. Lung tissue pathology reported subpleural scarring with early honeycomb change accompanied by patchy peribronchiolar inflammation and rare non-necrotizing granuloma with rare fibroblast foci accompanied by airway centric inflammation and peribronchiolar metaplasia. HRCT chest: Scattered ground glass opacity and interlobular septal thickening. More superiorly along the pleural space there is new nodularity. Diffuse interstitial thickening present.

Final Diagnosis: Patient was diagnosed with Fibrotic Hypersensitivity Pneumonitis given pulmonary wedge resection histopathology results and radiographic findings. Given the new findings on CT after patient endorsed a year long history of clay inhalation, this is assumed to be the exposure causing her hypersensivity pneumonitis.

Management: This patient with evidence of HSP was prescribed a course of steroids and has been managed as an outpatient. She was advised to refrain from any pottery activities and avoid other related exposures. Physicians may see pandemic related exposures causing a variety of respiratory diseases in coming years.