Since January 1993, the Massachusetts Department of Public Health

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Since January 1993, the Massachusetts Department of Public Health ...

    A project of the Massachusetts Department of Public Health’s Occupational Health Surveillance Program,

    the Massachusetts Thoracic Society, and the Massachusetts Allergy Society

Massachusetts Department of Public Health, Occupational Health Surveillance Program, 6th floor, 250 Washington Street,

     Boston, MA 02108, Tel: (617) 624-5632, Fax: (617) 624-5696

     April 1997

Dear Physicians,

     never having worn respiratory protection equipment. In the evaluation of the Bulletin conducted last summer, He had no other known occupational exposures. He many of you indicated that you would like us to provide smoked cigars in his 20’s on rare occasions, but had interesting case studies illustrating the difficulties in never smoked cigarettes. diagnosing occupational lung diseases. This month we

    present a case study written by two occupational medicine After his retirement, the patient developed mild residents from Harvard School of Public Health describing adult-onset diabetes mellitus but was otherwise healthy. asbestosis in a retired carpenter. He continued to lead an active and normal life dividing As many as 10,000 workers employed in Massachusetts his time between Massachusetts and Florida. Not only shipyards during the 1950’s and 1960’s may have been was he able to maintain the lawns on his properties, but exposed to asbestos. Other industries in the state with

    potential asbestos exposures include construction, plumbing, he also continued to take brisk daily walks. In 1994, textile manufacturing, and asbestos abatement. the patient noted an increase of exertional dyspnea Since 1992, SENSOR has received 122 reports of during his half-mile walks. In 1995, he experienced asbestosis in Massachusetts. Because the lag time between some difficulty while mowing his lawn. By 1996, his initial asbestos exposure and the onset of disease can be as

    exercise tolerance changed from being able to actively long as 40 years, the number of individuals with asbestos

    related diseases continues to grow each year despite the walk and climb stairs to experiencing shortness of reduction in asbestos exposures in recent years. It is breath after walking a few blocks or climbing less estimated that a minimum of 3600 Massachusetts workers will than one flight of stairs. Mowing his lawn became develop asbestos related lung diseases between 1991 and extremely difficult. 2010. It is important that physicians continue to recognize the

    health problems associated with asbestos exposure and to In addition to the increase in symptoms, the patient understand the challenges in diagnosing asbestos related was noted to have a rapidly declining Forced Vital diseases. Capacity (FVC) (see graph below). From 1988 through 1996, his Diffusion Capacity (DLCO) also Sincerely, decreased from 23.15 ml/min./mmHg to 14.03 Catharine M. Tumpowsky, MPH

    Occupational Lung Disease Surveillance Project ml/min./mmHg. His arterial blood gas in 1996 was pH = 7.39, pCO2 = 45 and pO2 = 66. At rest, his room

    air oxygen saturation was 92% but after walking 3

    minutes, his room air oxygen saturation declined to

    88%. Rapidly Progressing Pulmonary Fibrosis in a Actual and Predicted Pre-Bronchodilator FVC Over Time 1988-96

    Retired Shipyard Worker 4.5FVC-actual 4FVC-pred3.5E.V. Moy, MD, MPH and Arvin Chin, MD, MPH 32.5 Liter2 A 70 year old male carpenter retired in 1988 at the 1.51age of 62. Based on the findings of diffuse interstitial 0.5fibrosis and pleural plaques found on a screening chest 0888990919293949596x-ray, and his history of direct asbestos exposure, his Yearphysician raised concerns about asbestosis. The

    patient had worked in various shipyards for the previous 40 years from the 1950’s through the 1980’s. His work REPORT FEBRUARY AND MARCH renovating and building ships placed him in direct CASES NOW contact with asbestos. Although the patient recalled By April 30th, report all occupational lung disease cases working in clouds of airborne asbestos dust, he reported seen for the first time in February and March 1997. If

     continued on other side SENSOR: Sentinel Event Notification System for Occupational Risk. Massachusetts SENSOR is funded by the National Institute for Occupational Safety and Health.

     In this patient, the exposures were both

    prolonged and direct. A diagnosis of asbestosis is

     His chest x-rays showed mild progression of interstitial suggested based on this patient’s occupation and fibrosis from 1988 to 1992 and more rapid progression exposure histories, linear opacities on chest x-ray, and

     from 1992 to 1996. A chest CT showed evidence of pleural plaques. However, the unusually rapid 2

    you have NOT seen any cases, it is not necessary to return interstitial fibrosis and circumscribed pleural fibrosis progression of interstitial fibrosis raises the question of the report form. (plaque). a secondary cause for the interstitial fibrotic process.

     Although an open lung or transbronchial biopsy would

     Asbestos is a mineral made of hydrated fibrous be helpful in identifying a secondary process, the silicates. Its physical properties, including high tensile patient’s low pulmonary reserve precluded such a

    strength and acid heat resistance, make it an important procedure. manufacturing material. From 1940 to 1979, over 27 Besides asbestos, specific known causes of million workers were exposed to asbestos in the United interstitial inflammatory lung disease include: drugs States. The spectrum of pulmonary diseases associated (antibiotics) and chemotherapeutic agents, radiation, with asbestos includes bronchogenic cancer, aspiration pneumonia, and post-Adult Respiratory mesothelioma, pleural plaques, and asbestosis Distress Syndrome and other occupational exposures, (characterized by interstitial fibrosis). As a result of such as silica (rounded opacities), mixed dust (silica and the increased recognition of the hazardous nature of asbestos) pneumonitis and farmer’s lung asbestos, there is at present less exposure to asbestos in (hypersensitivity pneumonitis). These causes should the workplace and in the environment. Although the be readily apparent from the history. annual production of asbestos in the United States has Some of the less obvious causes include collagen decreased since the 1970s as a result of stricter vascular diseases, pulmonary hemorrhage syndromes, regulatory standards and product liability litigation lymphocytic infiltrative disorders, inherited diseases, related to its health effects, the use of asbestos is on the gastrointestinal/liver diseases and Graft vs. host rise in developing countries. disease. In addition, there is the general classification

     Of the non-malignant diseases, pleural plaques are of idiopathic pulmonary fibrosis (usual interstitial relatively common among asbestos exposed workers and pneumonitis), a term that is invoked when a cause can be readily diagnosed on a chest x-ray. On the other cannot be determined. hand, asbestosis is less common and results in greater The identification of these other diseases is decline in pulmonary function. The diagnosis of important because therapy and prognosis differ from asbestosis cannot be made solely on the grounds of that for asbestosis. Some of the idiopathic diseases interstitial fibrosis on a chest x-ray, because many listed above may respond to corticosteroids and conditions result in the same end-organ changes. responses to therapy may also provide diagnostic clues.

     The standard for diagnosis of asbestosis is the Hence, this patient meets the criteria for a diagnosis presence of one or more asbestos bodies in lung tissue of asbestosis with rapid acceleration of the disease or with interstitial and peribronchiolar fibrosis. Biopsies, asbestosis with superimposed usual interstitial however, are not often obtained. The clinical diagnosis pneumonitis. of asbestosis is based on an appropriate exposure history, a long latency period of 15 or more years, and References for this article are available on request by calling

    Catharine Tumpowsky at 617-624-5637. other supportive signs of asbestos exposure such as the

     radiographic presence of linear opacities and pleural

    plaques and lung function tests which may reveal a Number of Lung Disease Cases Reported to MA restrictive defect, mixed restrictive-obstructive defect or SENSOR, March 1992-January 1997

    an obstructive defect. December January Total to Date The evaluating physician should take a careful 1996 1997 (3/92-1/97) sequential history of all occupational exposures. 35 14 460 Asthma Asbestosis is associated both with the magnitude and the 0 0 12 Silicosis duration of exposure to inhaled asbestos. Prolonged 0 0 122 Asbestosis direct or indirect occupational contact provides a strong Chemical indication of high exposure. There is no evidence that 0 0 15 Pneumonitis casual or background urban exposures, which can occur in the general population, are likely to cause asbestosis. Total

    35 14 609 Number of


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