Patient: Male, 57 years old.
Hospital "A"
Chief complaint: Continuous cough for 1 month
History of the present illness: Pneumonitis (for which differential diagnosis of pulmonary tuberculosis was needed) was diagnosed by plain chest radiography carried out in a nearby hospital due to continuous cough for 1 month. The patient visited the Division of Pulmonology at the "A" University Hospital on the same day and was hospitalized.
Past medical history: No special findings.
Personal history and family disease: The patient had been smoking a pack of cigarettes daily for 40 years, and did not drink alcohol. There was no notable family disease.
Physical examination: Enlarged cervical lymph nodes were found bilaterally.
Blood test: Hemoglobin (Hb) was measured to be 12.6 g/dl in the complete blood cell count (CBC), which was a slightly decreased concentration, while the total proteins and albumin were in the normal range. The erythrocyte sedimentation rate (ESR) increased to 73 mm/h.
Tumor marker: Carcinoembryonic antigen (CEA) was 0.66 ng/ml, which was at the normal level, while neuron-specific enolase (NSE) increased to 19.31 ng/ml.
Chest images: In the plain chest x-ray, potential pneumonitis or pulmonary tuberculosis was found bilaterally in the upper lobes of the lungs (discernment of a lung tumor on the right upper lobe was required) (Figure 1-A). Pneumonitis was most suspicious bilaterally on the upper part of the lungs from the chest computed tomography (CT). Based on the imaging study, we concluded that complicated silicosis was accompanied by pneumonitis. Sarcoidosis or pulmonary tuberculosis had to be considered if this pneumonitis was to be classified as a tumor.
Findings from thyroid and cervical ultrasound: There were no abnormal findings in the thyroid. The cervical level IV and VI lymph nodes and supraclavicular lymph nodes on both sides were enlarged, which raised a suspicion of cancer metastasis (Figure 2).
Findings in excision biopsy of cervical lymph nodes: Excision biopsy of the enlarged lymph nodes showed reactive hyperplasia and anthracosis.
Bronchoscopic findings: No endobronchial lesions were observed. The bronchial washing test gave negative results for acid-fast bacillus (AFB), AFB polymerase chain reaction (PCR), AFB culture test, and microscopic cytology. In the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), atypical cells were observed on the right bronchial tubes. Immunohistochemistry (IHC) on the reactive lymphoid tissue of 2 lymph nodes produced negative results for CD 56, chromogranin A, and synaptophysin.
CT-guided percutaneous needle biopsy (PCNB): In a biopsy of the lungs, malignant neoplasm was not found while fibrosis and anthracosilicosis were observed.
Pulmonary function test: The forced vital capacity (FVC) was 67%, and forced expiratory volume in one second (FEV1) 59%, and FEV1/FVC (%) 64%, indicating a mixed ventilatory defect.
Diagnosis and progress: Lung cancer was suspected, accompanied by pneumonitis. As the dyspnea symptoms had improved somewhat, the patient was discharged and positron emission tomography - computed tomography (PET-CT) was planned as an outpatient follow-up examination. However, the patient has not returned to Hospital "A" since then.
Hospital "B" (7 months later)
Chief complaints: cough, dyspnea (repeated worsening and improving for 7 months)
History of the present illness: The patient had been discharged from Hospital "A" voluntarily without a definitive diagnosis during the medical evaluation he was undergoing due to continuing symptoms of dyspnea, cough, and fatigue during exercise that had started 7-8 months before. Then he visited the Department of Pulmonology of Hospital "B" in August 2012 with repeated worsening of symptoms.
Physical examination: At the time of admission, his body temperature was 36.5 C, pulse 98 beats/min, blood pressure 105/60 mmHg, respiration rate 20 breaths/min, and with decreased bilateral respiratory sounds in the lungs. While his nutritional status was good and mental status was normal, he looked chronically ill and his whole body was weak. He had difficulty in breathing even when sitting still, and the symptoms worsened when he lay on the left side. He had lost 5 kg:from 55 kg to 50 kg:since January 2012.
Chest images: Small opacities were observed throughout the whole lung in plain chest radiographic images, and a large opacity was observed in the right upper lung, interpreted to be pneumoconiosis (ILO classification u/u, 2/3, A) (Figure 1-B). Pneumonic infiltration was observed around the large opacity. Pneumoconiosis (silicosis pattern) accompanied by progressive massive fibrosis, along with reactive lymph nodes, were found in the chest CT, which, in addition, required the discernment of lung cancer. Nodules characteristic of silicosis were observed in the centrilobular and subpleural parts of the lung in the chest high resolution CT (HRCT) (Figure 1-D).
Pulmonary function test: The forced vital capacity (FVC) was 57%, and forced expiratory volume in one second (FEV1) 47%, and FEV1/FVC (%) 66%, indicating a mixed ventilatory defect. The carbon monoxide diffusing capacity (DL,CO) was decreased to 61%.
Findings from electrocardiogram and echocardiography: The ejection fraction (EF) was normal at 60-64%, and there were no specific findings regarding cardiomobility.
Blood test: HB was slightly below normal at 11.9 g/dl, and the erythrocyte sedimentation rate (ESR) was 120 mm/h and c-reactive protein (CRP) 4.31 mg/dL.
Bronchoscopic findings: The segmental bronchi within the right middle, right upper, and left upper lobes had become narrower (Figure 3), and a malignant cell test, AFB smear and culture tests, and AFB PCR test in broncho-alveolar lavage fluid were performed, all of which were negative.
Job history and work environment (based on personal statement): The patient was referred to the Division of Occupational and Environmental Medicine and applied for occupational accident coverage since silicosis was suspected after excluding lung cancer. The patient's job history showed that he had been working in rice farming and greenhouse strawberry farming until 1992, and at the time, there had been no facilities that could expose him to dust, such as a cement factory or mine near the residence or farmland. For approximately 20 years since then, he had been engaged in the task of blending raw materials for manufacturing glass containers, and he stopped working in glass manufacturing after being admitted to Hospital "A".
His main task was to put silicon dioxide, the major material comprising glass containers, along with additives including soda and calcium carbonate, into an automatic mixer, and to operate the machine 1-2 times a day for about 10 minutes. He was also engaged in other tasks such as product packaging and transport in addition to blending work, while neither grinding nor cutting glass was included in the manufacturing process.
The blender was placed indoors and the ceiling of the workshop was partially open. The workers used a dust mask onto which a handkerchief was attached during work.
Diagnosis and progress: The patient had been diagnosed with silicosis, and was discharged since the dyspnea symptoms had improved. He received outpatient treatment at the Division of Pulmonology and underwent a consultation on the occupational accident in the Department of Occupational and Environmental Medicine.
Hospital "B" (12 months later)
Chief Complaint: Acute dyspnea had occurred a week earlier.
History of the present illness: The patient presented to the emergency room because acute dyspnea had occurred while having suffered a severe cough due to a cold for 4:5 days.
Past medical history: The patient had been undergoing regular examinations due to pneumoconiosis (silicosis) accompanied by progressive massive fibrosis.
Physical examinations: When the patient came to the emergency room, he was clearly conscious with the temperature of 36.2 C, a pulse rate of 102 beats/min, blood pressure of 110/70 mmHg, a respiration rate of 20 breathes/min, 97% oxygen saturation of arterial blood. The height was 164 cm and the weight 48 kg, which had been reduced by 2 kg since August 2012.
Arterial blood gas analysis (emergency room): The analysis showed that the pH was 7.419, pO2 69.8 mmHg, pCO2 32.7 mmHg, bicarbonate 20.7 mEq/L, O2 saturation 93.3%, and base excess -3.0 mEq/L.
Chest Images: In the chest X-ray images, pneumothorax on the right side and pneumoconiosis were observed (Figure 1-C). In the chest CT, pneumothorax on the right side, localized pulmonary edema in various sites, complicated pneumoconiosis accompanied by progressive massive fibrosis, and mediastinal reactive lymph nodes were observed.
Examination findings: An AFB smear examination of sputum, AFB culture test, and sputum culture test all gave negative results.
Pulmonary function test (after treating pneumothorax): The FEV1/FVC (%) was 63.8%, FVC 75.0%, and FEV1 59.1%, indicating mixed ventilatory defects
Clinical progress: Pneumothorax and other symptoms have been improved by the oxygen therapy, and thus the patient was discharged after the 7 days of hospitalization. Follow-up examinations ensued, and the patient applied for occupational accident rehabilitation coverage.
Chest X-ray. C. Pneumothorax, right. Underlying complicated pneumoconiosis, progressive massive fibrosis. HRCT.