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    Critique

    Items 88, 89, 90, 91 Answers: 88(D); 89(A); 90(E); 91(C)

    EDUCATIONAL OBJECTIVE: Recognize clinical features of asbestosis, sarcoidosis, diffuse parenchymal lung disease, and malignant mesothelioma.

    The health consequences of asbestos exposure are of concern to the public, health officials, and employers. Lung disease as a result of asbestos exposure occurs most commonly in persons in the occupations of asbestos mining and manufacturing; shipbuilding, repair, and refitting; general construction and insulation; automobile maintenance and brake repair; as well as electricians, plumbers, pipe fitters, and railroad engine repair workers. Asbestos-related lung disease can also occur in family members of asbestos workers (by handling the worker’s clothing), in workers employed in the vicinity of asbestos workers (bystander exposure), and in persons without apparent exposure to asbestos (environmental exposure). Asbestosis refers to parenchymal fibrosis and occurs in up to 75% of heavily exposed insulation workers. Asbestosis usually begins subpleurally in the lung bases and progresses to involve the lungs diffusely. Pleural disease (pleural fibrosis) is the most common form of asbestos-related lung disease. Pathologically, there are localized areas of pleural scarring, also known as pleural plaque. Pleural plaques are usually bilateral, involve the middle and lower third of the thoracic cage, and are generally found on the parietal pleural surface. Calcification, which may occur, appears to be related to the latency period. Calcification of diaphragmatic pleural plaques is a sine qua non of asbestos-related pleural disease.

    A variety of cancers are related to asbestos exposure. In addition to lung cancer and mesothelioma, there is an increased incidence of gastrointestinal cancers (gastric, colon, pharyngeal) and lymphomas. Although the pathogenesis of malignant mesothelioma is unclear, asbestos is the single most important causative agent of mesothelioma. Almost all patients with malignant mesothelioma are symptomatic at the time of diagnosis. Chest pain of a constant gnawing character, such as the dull ache reported by the 70-year-old insulation contractor, is the most frequent presenting symptom, present in 43% of patients; dyspnea (27%), cough (19%), weight loss (13%), and fever (7%) also occur. The physical examination frequently reveals evidence of pleural effusion, finger clubbing (< 5%), bibasilar crackles, and pleuropericardial rub. Pleuritic chest pain is, however, a rare occurrence.

    The diagnosis of malignant mesothelioma is often difficult; pleural fluid cytology is of limited value. Pleural biopsy or closed-chest needle biopsy may confirm the diagnosis but usually provides insufficient tissue. Thoracoscopic pleural biopsy and/or open thoracotomy (surgical pleural biopsy) is generally necessary for definitive diagnosis and is the diagnostic procedure of choice for the 70-year-old insulation worker. The pathologist may often have significant difficulty in making a diagnosis despite removal of substantial tissue mass.

    The prognosis of malignant mesothelioma is poor; aggressive surgical resection, radiation therapy, and chemotherapy have all yielded poor results. The average survival time of persons in most cases of mesothelioma is 6 to 12 months after diagnosis and 8 to 14 months after the onset of symptoms.

    Sarcoidosis is a disorder of unknown cause involving multiple tissues and systems. In the absence of infection, noncaseating granulomas in the affected tissue are the histologic hallmark for the diagnosis of sarcoidosis. The lungs and hilar lymph glands are the most common organs and tissue involved with histologic evidence of sarcoidosis. The most common radiologic feature of pulmonary sarcoidosis is bilateral hilar adenopathy. In truly asymptomatic patients with no risk factors associated with HIV infection, this radiologic presentation is most consistent with the diagnosis of sarcoidosis, and in this setting a histologic confirmation is not essential. Patients presenting with other radiologic stages require histologic confirmation of presumed sarcoidosis. Patients with sarcoidosis usually manifest anergy, and the positive tuberculin skin test is an unusual and unexpected finding in this 40-year-old woman working as a counselor for homeless adolescents. This does raise the concern for active tuberculous disease. This patient’s chest radiographic abnormalities are consistent with stage II sarcoidosis. The positive tuberculin skin test, the persisting symptoms, and the radiographic findings all warrant further diagnostic intervention. Transbronchial lung biopsy is indicated to confirm the diagnosis of sarcoidosis.

    Diffuse parenchymal lung disease (DPLD), with or without pleural involvement, can occur in collagen vascular diseases, including systemic lupus erythematosus (SLE), rheumatoid arthritis, mixed connective tissue disease, polymyositis, dermatomyositis, scleroderma, progressive systemic sclerosis, and Sjögren’s syndrome. In patients presenting with DPLD, a history of joint symptoms, pleural involvement, and systemic manifestations should raise the clinician’s suspicion for collagen vascular disease as the cause of the DPLD. The 25-year-old secretary with wrist and finger stiffness fits in this category.

    All components of the respiratory system, including the pulmonary parenchyma, airways, pleura, and respiratory muscles, can be primarily involved by collagen vascular disease. In patients with SLE, pleurisy and pleural effusion (which occur in up to 60% of patients) represent the most frequent noninfectious complications. Lupus-related effusions are exudates that contain both acute and chronic inflammatory cells. These effusions are characterized by high titers of antinuclear antibody and low pleural fluid complement concentrations. Pleural effusions are also the most common noninfectious pulmonary complication of rheumatoid arthritis. Rheumatoid pleural effusion are exudative with mixed inflammatory cell populations and typically have low pleural fluid glucose concentration (< 30 mg/dL). Among the collagen vascular diseases, pleuritis and effusions occur most commonly in patients with SLE, mixed connective tissue disease, and rheumatoid arthritis.

    This patient’s history of joint symptoms, pleuritic chest pain, pleural effusion, and renal involvement (abnormal urinalysis) point to the diagnosis of collagen vascular disease (likely SLE); therefore, the most appropriate next diagnostic steps are laboratory tests for erythrocyte sedimentation rate, antinuclear antibodies, and rheumatoid factor.

    There are over 150 clinical situations and causes associated with DPLD. Clinicians confronted with patients presenting with suspected DPLD must be aware of several acute and chronic medical problems. Elicitation of a thorough, detailed medical history is essential in the diagnostic evaluation of patients presenting with unexplained exertional dyspnea, diffuse pulmonary infiltrates, and restrictive lung defect.

    In the interview with the 32-year-old pregnant woman, after eliciting the history that she had experienced intermittent dysuria a few weeks before the onset of DPLD, the clinician should inquire into further details regarding that history. For example, had she seen a physician? If so, what diagnostic and therapeutic interventions were done? Was an antibiotic prescribed? Such a detailed elicitation will bring out otherwise subtle and occult facts that may, indeed, be relevant to the diagnosis of DPLD. For this patient, a careful review of her medication history is the most appropriate of the diagnostic options presented.

    For patients similar to the one in the question, a common antibiotic, nitrofurantoin (Macrodantin), is often prescribed by obstetricians/gynecologists for urinary tract infection. Nitrofurantoin is commonly used during pregnancy to treat symptomatic and asymptomatic bacteriuria and urinary tract infection; it is also used as suppressive therapy following recurrent urinary tract infections or pyelonephritis.

    Acute and chronic pulmonary reactions to nitrofurantoin are well known side effects. Acute pulmonary toxicity to nitrofurantoin is an uncommon side effect of therapy and can cause minor or life-threatening pulmonary dysfunction. Acute nitrofurantoin-induced interstitial pneumonitis may be one of the most commonly reported drug-induced pulmonary diseases. Acute pulmonary reactions to nitrofurantoin can be associated with fever, chills, cough, pleuritic chest pain, and dyspnea. Rarely, pleural effusion and/or pulmonary hemorrhage may occur. The acute reaction usually begins within a few hours to several days of beginning the drug, and it may manifest as a form of noncardiac pulmonary edema in addition to the interstitial reaction. This reaction generally resolves rapidly. Blood eosinophilia and a small pleural effusion occur in 10% to 20% of patients. The reaction does not appear to be dose related.

    Chronic nitrofurantoin pneumonitis mimics all clinical features of idiopathic pulmonary fibrosis, although cessation of further use of nitrofurantoin is associated with good prognosis.

    Bibliography

    1. Light RW. Benign and malignant mesotheliomas. In: Pleural Diseases. Baltimore: Williams & Wilkins; 1995;117-28.
    2. Neuman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med. 1997;336:1224-34.
    3. ***** G. Interstitial lung disease: a diagnostic approach. Are CT scan and lung biopsy indicated in every patient? Am J Respir Crit Care Med. 1995;151:909-14.
    4. Boggess KA, Benedetti TJ, ***** G. Nitrofurantoin-induced pulmonary toxicity during pregnancy: a report of a case and review. Obstet Gynecol Surv. 1996;51:367-70.
    5. Segal AM, Reardon EV. Systemic lupus erythematosus. In: Cannon GW, Zimmerman GA, eds. The Lung in Rheumatic Disease. New York: Basel; 1990;261-78.


    From MKSAP 11 Electronic. Copyright 1998 American College of Physicians. All Rights Reserved.

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    health consequence

    i agree with you The health consequences of asbestos exposure are of concern to the public, health officials, and employers. Lung disease as a result of asbestos exposure occurs most commonly in persons in the occupations of asbestos mining and manufacturing; shipbuilding, repair, and refitting; general construction and insulation; automobile maintenance and brake repair; as well as go to http://www.allyourpills.com for great deals and all electricians, plumbers, pipe fitters, and railroad engine repair workers. Asbestos-related lung disease can also occur in family members of asbestos workers (by handling the worker’s clothing), in workers employed in the vicinity of asbestos workers (bystander exposure), and in persons without apparent exposure to asbestos (environmental exposure). Asbestosis refers to parenchymal fibrosis and occurs in up to 75% of heavily exposed insulation workers. Asbestosis usually begins subpleurally in t http://www.allyourpills.com he lung bases and progresses to involve the lungs diffusely. Pleural disease (pleural fibrosis) is the most common form of asbestos-related lung disease. Pathologically, there are localized areas of pleural scarring, also known as pleural plaque. Pleural plaques are usually bilateral, involve the middle and lower third of the thoracic cage, and are generally found on the parietal pleural surface. Calcification

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